Background
Of the many functions of the ankle joint, one allows the body to adapt to uneven terrain during ambulation. Failure to compensate for uneven footing may result in an ankle injury.
Eighty-five percent of ankle injuries are sprains, and 85% of those are lateral inversion sprains (Garrick, 1982; Balduini, 1982). Most ankle sprains occur on the lateral aspect of the ankle. Although athletes usually recover quickly from ankle sprains, failure to rehabilitate appropriately imposes an increased risk for future injury.
Frequency
United States
The most common ankle injury is a lateral sprain caused by inversion of the foot, with more than 25,000 occurring each day in the United States (Pfeffer, 2001). They are also the most commonly seen sports injury, comprising 14-21% of sports injuries (Liu, 1999; Renstrom, 1994). Athletes participating in basketball, volleyball, soccer, and football are at especially high risk for ankle sprains, comprising 25-45% of injuries in these sports (Renstrom, 1994).
International
In the United Kingdom's general population, the prevalence of ankle sprains is reportedly 52.7 cases per 10,000 patients (Bridgman, 2003).
Functional Anatomy
The bony and soft tissue anatomy of the ankle place the lateral side of the ankle at higher risk than the medial side. The distal end of the fibula (ie, the lateral malleolus) extends further inferiorly than the distal end of the tibia (ie, the medial malleolus). This discrepancy in length gives the medial ankle superior stability by improving bony resistance to eversion.
The ligaments of the medial ankle, collectively known as the deltoid ligament complex, form a broad strong ligamentous stability to prevent eversion. On the lateral side, there is only minimal bony stability. Ligamentous stability comes from 3 relatively small ligaments, the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The deltoid ligament is a complex of very strong thick ligaments, which provides medial ankle stability. The syndesmotic ligament complex consists of the anterior tibiofibular ligament, the posterior tibiofibular ligament, and the distal interosseus membrane between the tibia and the fibula. A sprain of the syndesmotic ligament complex is sometimes called a "high ankle sprain" and often presents with anterior ankle pain.
In plantar flexion, the talus of the ankle is more susceptible to inversion forces compared to dorsiflexion when the talus is more stable with bony stabilization in the mortise. In plantar flexion, the ATFL is under tension and is susceptible to injury.
Although, many classification systems for grading lateral ankle sprains exist, perhaps the most common system is based on the clinical examination. In this system, Grade I ankle sprains are painful, but they have no increased laxity when compared to the uninjured side. This correlates with mild stretching of the ATFL. Grade II ankle sprains are painful with increased laxity on testing. This correlates with complete tear of the ATFL and partial tear of the CFL. Grade III ankle sprains usually are painful with an unstable ankle joint on examination. This correlates with complete ruptures of both the ATFL and CFL.
Sport Specific Biomechanics
Jumping, cutting, and pivoting place the ankle at risk for inversion injuries. Close body contact between athletes also places the athlete's ankle at risk for inversion injury (eg, stepping on the opponent's foot).
Treatment
Rest, ice, compression, and elevation (ie, RICE) are the mainstays of the acute treatment of lateral ankle sprains (see Other Treatment section below). The goal of acute treatment is to control pain and to maintain or regain range of motion (ROM). Athletes are encouraged to take their ankle out of the brace and move it through a pain-free ROM. Aggressive pain-free ROM is recommended. Having the athlete spell the letters of the alphabet with his/her foot and ankle several times per day is one simple activity to recommend even in an acute care setting. Pain control is the initial treatment goal. Acute Phase
Rehabilitation Program
Physical Therapy
Medical Issues/Complications
Surgical intervention may be considered for the treatment of third-degree ankle sprains in high-level athletes and for chronic ankle instability. In most cases normal biomechanical function is not completely restored; but for most patients with chronic ankle instability, satisfactory results can be obtained with various surgical procedures (Kaikkonen, 1997; Tohyama, 1997; Rosenbaum, 1997). Rest, ice, compression and elevation are the mainstays of treatment; rest is especially critical. Athletes must modify activities that aggravate the condition; this modification may be as simple as decreasing the amount, frequency, or intensity of activity. Often, athletes are more compliant with a decreased level of activity, if they are allowed to increase other non-aggravating activities (Quillen, 1996).Surgical Intervention
Other Treatment
The treatment plan during the recovery phase is aimed at regaining full ROM, strength, and proprioceptive abilities. Strengthening is started with isometric exercises and advanced to the use of elastic bands or surgical tubing (see Media File 4). Strengthening is performed in the following 4 cardinal ankle motions: dorsiflexion, plantar flexion, eversion, and inversion. Strengthening of the peroneals, which act as dynamic stabilizers of the ankle, is critical. Recovery Phase
Rehabilitation Program
Physical Therapy
Surgical intervention may be considered for the treatment of third-degree ankle sprains and for chronic ankle instability. In most cases, normal biomechanical function is not completely restored; but for most patients with chronic ankle instability, satisfactory results can be obtained with various surgical procedures (Kaikkonen, 1997; Tohyama, 1997; Rosenbaum, 1997). Symptoms of chronic instability may include chronic pain and instability despite a course of adequate physical therapy. A maintenance program of ankle strengthening, stretching, and proprioception exercises helps decrease the risk of future ankle sprains, particularly in individuals with a history of multiple ankle sprains or of chronic instability (Lephart, 1997; Sitler, 1994; Osborne, 2003; Stasinopoulos, 2004; Verhagen, 2004).Surgical Intervention
Maintenance Phase
Rehabilitation Program
Physical Therapy
Medication
The use of nonsteroidal anti-inflammatory drugs in acute musculoskeletal injuries is somewhat controversial (Stanley, 1998). NSAIDs may or may not be beneficial to the physiologic processes of soft tissue healing. They have been found to be useful in controlling pain and allowing more rapid progression in physical therapy. Disadvantages of NSAIDs include the risk of gastrointestinal bleeding, gastric pain, and renal damage (McCarthy, 1998).
Drug Category: Nonsteroidal anti-inflammatory drugs
These agents are used to control acute inflammation and pain. They may also be used for pain control as an adjunct to physical therapy.
Drug Name | Ibuprofen (Ibuprin, Advil, Motrin) |
---|---|
Description | Member of the propionic acid group of NSAIDs. Available in low dose form as an over-the-counter medication. Highly protein bound, metabolized in liver and eliminated primarily in urine. May reversibly inhibit platelet function. |
Adult Dose | 600-800 mg PO tid/qid |
Pediatric Dose | Recommended maximum daily dose: 40 mg/kg PO divided tid/qid |
Contraindications | Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding |
Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
Pregnancy | B - Usually safe but benefits must outweigh the risks. |
Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy |
Drug Name | Naproxen (Aleve, Naprelan, Naprosyn, Anaprox) |
---|---|
Description | Member of the propionic acid group of NSAIDs. Available in low dose form as an over-the-counter medication. Highly protein bound, metabolized in liver and eliminated primarily in urine. May reversibly inhibit platelet function. |
Adult Dose | Dose range: 250-550 mg PO bid/tid; maximum 1100 mg/d when used for pain control and acute musculoskeletal injury; maximum daily dose is 1650 mg for all conditions |
Pediatric Dose | 10 mg/kg PO divided bid recommended |
Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency |
Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
Pregnancy | B - Usually safe but benefits must outweigh the risks. |
Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug |