Ankle Sprains - One Step at a Time

One of the most common sports related injury is the Ankle Sprain. The mechanics of kicking the ball causes this to be a significant injury in soccer. To properly treat a sprain the structures and the extent of damage to such structures must be properly assessed. Most sprains do not involve breaks or fractures of the bones. The rule is the ones you do not x-ray are usually fractured. Depending on your insurance plan, I suggest getting to your favorite orthopedic surgeon for a quick x-ray followed by therapy with a physical therapist or athletic trainer.

Most sprains are inversion sprains (ankle rolls inwards) with the anterior talofibular ligament being the one most commonly damaged. Sprains to this ligament respond well to therapy and can be supported with taping or bracing for continued play. Posterior ankle sprains (forced plantar flexion) and high ankle sprains (plantar flexion or forced heel plant) do not respond as quickly to traditional rehab. In posterior ankle sprains it is not uncommon to fracture the posterior process of the talus and this should be ruled out. In high ankle sprains, a front view x-ray should be taken to rule out separation of the fibula and tibia at the maleoli (anklebones). Sprains are rated as first, second and third degree with third being the worst. Swelling, discoloration, pain and point tenderness are good indications of the severity of the sprain. In severe sprains, a ligament laxity test will indicate if surgery will be necessary but testing may be postponed until after rehab due to swelling and tenderness limiting test results. The MRI is another method of assessing tissue damage.

Treatment for ankle sprains has evolved over the years. In the old days, ankle sprains were put in a cast and on crutches. Only when ligament damage is so severe as to warrant surgery should casting be a method of treatment. The most significant innovation in ankle rehab evolved out of Dallas in the 1980's with the invention of the fracture boot by 3-D orthopedics. Originally, this boot was invented for stable ankle fractures that were able to partial or full weight bear. The Dallas independent school district Athletic Trainers were asked by 3-D to evaluate some sample boots on athletic ankle sprains. The findings were remarkable. Wearing the fracture boot cut the rehab time in half. After studying the biomechanical and physiological results, the reasons were quite obvious. Biomechanically, the damaged ligament is held in a neutral position to allow the tightest possible ligament healing position but just enough stress to build a higher grade of scar tissue. Physiologically, due to position of the ankle to the heart, blood flow is minimal in a non-weight bearing state. Blood pressure out of your heart is normally 120 over 80 millimeters of mercury. The pressure of the blood coming out of your ankle back to your heart is 7 millimeters of mercury. The body uses the muscles in the lower leg to force the blood against gravity toward the heart with each contraction. Normal blood flow is necessary to bring the building blocks of healing to the damaged ankle. Discard the brace when you can walk normally without pain.

Another big problem with sprains is the body's defense mechanism of disrupting proprioception (brain to muscle communication) to the ankle muscle structure. We must re-teach the muscles when to contract and relax at the right time. Single leg stand on an unstable surface is a good teaching tool (see picture 1). The mechanics of running is a series of single leg jumps. It only makes sense you should be able to stand on one leg with stability. A good test for returning to play is jumping up and down on one leg without pain. Kicking the soccer ball while standing on the injured ankle is a good functional exercise for rehab. (See picture 2) Taping the ankle is thought to help with proprioception as well as support.

The most common cause of re-injury is atrophy to the anterior tibial compartment. If you did not go through a comprehensive rehab program after an ankle sprain then you will have this weakness. A good diagnostic tool is called the ÒParker signÓ (see picture 3). Have the injured person sit with both legs in full extension without socks or shoes. Have them pull their toes up to put the ankle in full dorsiflexion. Compare the extensor digitorum longus tendons on each ankle. The injured ankle will be less prominent than the uninjured. The best exercise for this muscle is resistive dorsiflexion (see picture 4) with an elastic band or a comparable resistance. More functional exercises will be added at the end of rehab such as running, cutting and jumping.

Buying shoes to match the turf will help prevent ankle sprains as well. Most indoor turfs warrant flat-soled shoes but a new generation of turf is much more like natural grass. Even with the new softer turf, I would hesitate to wear molded-soled shoes and prefer the turf shoes (multiple small nubs) to help protect the ankle from rollovers. Save the molded and screw in type studs for wet or soft outdoor fields.

Ankle sprains are a common injury in many sports and especially in soccer. Proper training and rehab will help prevent that dreaded recurrent ankle sprain.

The player pictured is Dallas Sidekick Fabinho rehabbing from ankle surgury.

Questions: Sports-Med-Central.com