Where Does it Hurt? Ankle

Sprained ankles have been estimated to constitute up to 30% of injuries seen in sports medicine clinics and are the most frequently seen musculoskeletal injury seen by primary care providers.  Most of us have, at some point in our lives, rolled an ankle.  95% of all ankle sprains (rolls) occur in a direction called inversion.  This means that the heel will roll towards the opposite foot during the injury.  When your foot and toes are pointed down the position is called plantar flexion.  The opposite - when the foot and toes are pointed up - is called dorsiflexion.  These are pertinent because they can dictate the severity of an ankle sprain.  In the dorsiflexed position the ankle joint or mortise joint is in a close-packed position which adds a fair degree of stability.  Any inversion in this position is usually aggressive and can potentially cause a “high” ankle sprain.  More about this later.  In the plantar flexed position the opposite is true.  This is why most inversion sprains occur in the plantar flexed and inverted positions.  This type of injury stresses the ligaments and tendons surrounding the joint.

A “high” ankle sprain is when in the two leg bones (tibia and fibula) are wedged apart by the ankle bone (talus) during the inversion position.  This can also be called a syndesmotic sprain because the tibia and fibula form a syndesmosis.  The definition is a joint that has little movement.  Typical recovery from a high ankle sprain is significantly longer than that of a traditional sprain.  This type of injury usually occurs when an athlete jumps up and lands on someone else's foot.

There are three grades to ankle sprains and many times an on-field assessment can ascertain the severity prior to any imaging studies.  

Grade I - This is technically not a tear at all.  It is a stretching of the ATF ligament, also known as the anterior talofibular ligament.  It is named by its location and the bony structures it attaches to.  The patient usually has minimal swelling and bruising and can ambulate or walk with little to no limp.  This can usually be identified on the field by the athlete stumbles but catches themselves without necessarily going to ground and then limps around for a bit, and “walks-it-off.”  

Grade II - This is a partial tearing of the ATF ligament.  You will notice a greater degree of swelling and bruising.  This can be identified by the athlete who goes down to the ground and is visibly uncomfortable, but is able to walk with a moderate-severe limp.

Grade III - This is a complete tearing of the ATF.  It is sometimes accompanied by a fracture of the lateral maleolus aka. outside ankle.  It can also be associated with a fracture of the talar dome.  This sprain will present with a great degree of swelling and bruising.  The patient will often times go down on the field and most likely not want to get up without assistance.   

These “on-field” observations are only a guideline and are in no way an absolute.  We do see exceptions to these every day.  

If you or your child has ever suffered from an ankle sprain during sports, there is a very good possibility that it was not an isolated incident.  The recurrence rate has been reported as high as 80%.  Other sources report the likelihood of a second sprain being 4-5 times following the first.  The main reason for these staggering numbers is a poor rehabilitative strategy.  Most athletes can compete with some type of support, i.e. taping or bracing, etc with little to no drop in performance.  They typically cease their rehabilitation once they are able to play.  They should understand that the supportive device is only designed to allow them to play with their still-healing injury, and that their rehabilitation should continue to the point when the bracing is no longer needed. 

Ankle taping is the most common of all supportive taping that is performed by trainers and coaches alike.  In fact, there are many individuals who routinely get their ankles taped as a prophylactic measure even without any inherent stability deficiencies.  Whether this is a good idea or not is up for debate.  Taping has been proven to add little long term stability to the joint.  Interestingly enough, the most aggressive taping which is done skin-on-skin, and uses spray rosin and no pre-wrap has been shown to provide support for about 10-15 minutes maximum.  It does however add a significant proprioceptive feedback mechanism for the taped athlete.  This essentially means that the tape provides the athlete with a sensation that will make them more aware of their ankle, in turn subconsciously recruiting better muscular control of the area.  In fact, taping provides the same feedback in any joint when it is applied appropriately.  

The take-home of this piece is essentially to get evaluated by a Sports Medicine professional after sustaining the injury.  It can be the trainer, Sports Chiropractor, Physical Therapist, or Medical Doctor.  Have the injury graded, follow and COMPLETE a systematic rehabilitation strategy for a healthy return to play.