Almost everyone has experienced some type of ankle injury, from mild tension to larger and more serious injuries. Ankle sprains can occur during daily activities or during sports. The ankle joint as part of the foot region allows for the transition from the lower leg to the foot itself and large loads are transmitted through this region every day, and often these loads, depending on the situation we are in, are too large for anatomical structures that maintain ankle stability. According to statistics, ankle joint injuries are one of the most common injuries in general, both outside sports and in sports, and are the cause of about 20-30% of sports injuries per year. Acute ankle sprain accounts for 85% of all ankle injuries and is also the most common sports injury.
Anatomical structures of the ankle
The ankle is made up of the ankle bones, ligaments, tendons, muscles, nerves and blood vessels. The ankle is the point of contact of the tibia or tibia, fibula or leaf bone, talus or ankle bone, and calcaneus or heel bone. The ankle consists of two joints, the upper and lower ankle joint.
The upper ankle joint is the connection between the lower leg, tibia and fibula with the ankle bone. Dorsal and plantar flexion movements are performed with the ankle joint.
The lower ankle joint consists of two parts, the back and the front which is the connection of the ankle with the tarsal part of the foot. .
There are active and passive ankle stabilizers:
ACTIVE STABILIZERS - tendons and muscles: m. Peroneus longus (main evertor of the foot), m. Tibialis anterior (main dorsiflector), m. Tibialis posterior (inverter and plantar flexor). The Achilles tendon with m. Soleus and m. Gastrocnemius is the most important plantar flexor of the foot.
PASSIVE STABILIZERS - ligaments: tibiofibular ligaments, deltoid ligament and lateral ligaments (lig. Talofibulare ant, lig. Calcaneofibulare and lig. Talofibulare post).
what is ankle sprain?
Ankle sprain is an injury to the ligaments that support the ankle, and usually occurs when the ankle is twisted and the foot is turned inward (foot inversion) or outward (foot eversion). A sprain can involve a variety of types of ankle injuries, from a simple ligament injury to more complex intra-articular fractures. It is mainly an injury of the ligaments, and most often an injury of the lateral ligament complex of the ankle (lateral distortion). Excessive and sudden movements pull the ligaments with great force towards the surface, which consequently damages them. Depending on the severity of the injury and the degree of rotation of the foot during the injury, 1, 2, or all 3 ligaments may be damaged.
Playing sports that include landings such as gymnastics, basketball, ballet, athletics, and volleyball increases the risk of ankle sprains. Examples of situations that can lead to ankle sprains due to a sudden change in foot position and large forces acting on the ligament ligaments are:
- sudden fall
- awkward landing or bouncing
- a clumsy step in high heels
- walking or exercising on an uneven and unstable surface
- going down the stairs
- slippage of shoes on the surface
- when you step on an object
- when slowing down if longer steps are used
degrees of ankle spraining
The first degree of injury is a sprained anterior ligament of the ankle. There is mild pain and pressure at the starting point of the ligament during active and passive movements of the ankle, but when walking it is possible to completely overload the foot with a milder onset of pain. Minor swelling of the ankle may also occur.
The second degree of injury is a partial rupture (rupture) of the anterior ligament. The pain occurs at rest, but intensifies when performing active and passive movements. Normal gait is disabled due to more severe pain and the presence of greater swelling of the joint with possible hematoma.
The third degree of injury is a complete rupture of the anterior ligament, but there can also be a partial rupture of the posterior ligament and the joint capsule. It is characterized by extremely strong pain that also disables the ability to walk, and is intensified by any attempt to move the joint. Large swellings of the joint and hematoma significantly limit the mobility of the joint.
types of ankle spraining
Lateral ankle distortion is one of the most common injuries in athletes, accounting for about 25% of all sports injuries. It is caused by excessive inversion of the foot, and results in injury to the lateral ligament.
Medial ankle distortion is a less common form of ankle injury caused by eversion and external rotation of the foot, resulting in medial ligament injury.
High ankle distortion or syndesmosis injury occurs due to excessive and sudden force during plantar or dorsal ankle flexion, and can often occur in combination with medial ankle distortion. The anterior ligament is most often injured, while injuries of the posterior ligament are somewhat less common.
After the injury occurs, swelling and pain occur on the outside or inside of the ankle and foot. This will be followed by bruising accompanied by a change in skin color, and the pain will spread across the bones, ligaments and tendons of the ankle. It is often because of the onset of pain that walking is difficult and instability occurs in the injured joint. Because of the fear of re-sprain, instability, and pain, patients develop a different and more irregular gait pattern that can lead to chronic pain and other accompanying problems.
The treatment of ankle sprains depends on the severity of the injury. Many people treat injuries at home unless there are more severe symptoms and a more serious clinical picture. The most important factor in rehabilitation after an ankle injury is to achieve the stability of the joint that is impaired. The first step in achieving stability and rehabilitation is a proper diagnosis determined by a physician in collaboration with a physiotherapist who tests joint compliance and soft tissue weakness. After the correct diagnosis, a treatment plan is made and therapeutic procedures are determined for the return of all bodily functions and involvement in the activities of everyday life.
If it is a sprained ankle ligament or a far more severe ankle injury, physical therapy will speed up the course of treatment. Results are usually achieved within 2 to 8 weeks, depending on the severity of the injury.
The goals of rehabilitation are:
- pain reduction
- swelling reduction
- increasing flexibility
- increasing muscle strength
- improving balance
- education and prevention
- a return to daily activities
In case of mild injuries, return to normal daily activities is expected within 10-15 days of the injury. If it is a more serious injury, it takes 6-8 weeks.
Therapeutic procedures used in rehabilitation in case of ankle sprains are:
- LYMPHATIC DRAINAGE
Lymphatic drainage is a therapeutic procedure that uses very light pressure and long, gentle and rhythmic strokes on the skin to improve lymph flow. Lymphatic drainage is very successful in helping to remove swelling and reduce hematomas which are common symptoms of ankle sprains.
- PRICE METHOD
- Protection - reducing load on the injured leg if walking is painful and avoiding further risky activities that may worsen the condition.
- Rest (rest) - does necessarily mean to lie motionless, but reducing active movement of the joint to the limits of pain.
- Ice - application of ice packs to reduce swelling and hematomas and relieve pain. Ice is always applied over a layer of dry cloth (gauze or towels) for no longer than ten minutes. It is important to emphasize that cooling must be repeated every two to three hours during the day, but not during sleep.
- Compression - the goal of compression is to expand the hematoma over a larger area, thereby improving resorption conditions. The most commonly applied is an elastic bandage that wraps from the root of the toes to above the middle of the lower leg. The pressure of the set bend must be even and must not interfere with circulation.
- Elevation - placing the foot in an elevated position 10 to 25 cm above the level of the heart, which allows the excess fluid caused by trauma to flow back to the larger lymph nodes and blood vessels.
Kinesiotaping is an elastic therapeutic tape with therapeutic biomechanical effects. It is made of a special material that acts as a pump while the body is moving because it stimulates lymph fluid and corrects muscle work. Kinesiotape tape supports muscles, improves muscle contraction, reduces muscle fatigue, cramps and muscle injuries, increases range of motion and body fluid flow, reduces inflammatory processes and pain, but also corrects the position of affected joints and the disproportion of anatomical structures caused by injury.
Mobilization is a passive non-invasive method that reaches the maximum possible limit of passive mobility with rhythmic movements in a blocked joint. It represents one-time, sharp and solid performed movements up to large amplitudes of movement that must not cross its anatomical joint barrier. Today, the basis of treatment for ligament injury of the ankle is functional treatment and it is considered that there is no need for long-term immobilization of the joint. It can result in limited mobility (joint contracture), atrophy of the lower leg and foot muscles, and loss of proprioception.
- THERAPEUTIC EXERCISES
Once the reduction in swelling and pain is achieved, work should begin towards strengthening the joint with strength, mobility and proprioception exercises. Therapeutic exercise is one of the main treatments that help to restore mobility after ankle sprains. A physiotherapist can prescribe the right exercises for you at the right stage of healing to get you back to optimal mobility quickly and safely. Before performing any exercise program, consult your doctor to make sure the exercise is safe for you.
Muscle strengthening exercises
After an ankle sprain, the ankle muscles are significantly weakened. Therefore, it is necessary to implement exercises to strengthen the muscles of the legs and feet through dynamic exercises, the most common of which are exercises with an elastic exercise band. These muscle strengthening exercises also reduce the risk of re-injury.
Examples of exercises to strengthen muscles:
- With the help of a therapist passively perform a range of motion in all directions, depending on the pain
- With the help of a therapist, push your feet towards you - 3x10 repetitions
- With the help of a therapist, push your feet away from you - 3x10 repetitions
- With the help of a therapist, push the foot to the left side - 3x10 repetitions
- With the help of a therapist, push the foot to the right side - 3x10 repetitions
- The rotation of the ankle joint, but without sudden jerks, performed slowly - 3x10
- Movement of the foot forwards and backwards - 3x10 repetitions
After the exercises, it is important to gradually gently stretch the muscles of the ankle and foot to relax the leg.
Proprioception is the body’s ability to sense the position of a joint in space. When you close your eyes, you can feel the position of your body without looking at what position your body is in. Proprioception also helps control the position of your body. Good proprioceptive training can prevent the ankle from getting into a position where there is a greater chance of injury. One of the most challenging aspects of recovery after an ankle sprain injury is the restoration of this proprioceptive feeling. Enabling the ankle to be more stable by focusing on proprioceptive exercises improves the chances of complete recovery.
Examples of proprioception exercises:
- Balance on one leg. Try standing on one leg for 10-30 seconds.
- Repeat the number standing on one leg with your eyes closed.
- Plate balance and throwing the ball: while maintaining balance on the balance plate, throw a small ball (2kg) with your partner.
- Plate balance and half-squat: Maintaining balance on the balance plate perform 10 slow, controlled half-squats.
- Stepping on the balance plate: place the balance plate (either a soft pillow or a foam pad) 15-20 cm higher than the starting position. Step 10 times.
- Stepping on the balance board: place the balance board (either a soft pillow or a foam pad) 15-20 cm lower than the starting position. Step 10 times.
- Lateral plyometrics: perform a side step down then a step up.
- Jumping on one leg: jump forward and concentrate on landing.
- Jumping on one leg from place to place: jump from place to place on the floor.
- Reactive jumping from place to place: put numbered marks on the floor and as your partner dials the number, jump on it.
When it comes to severe injuries, surgery is required. Today, surgical treatment is reserved only for patients who still have problems after the treatment. If the main problem is pain, then a detailed diagnostic treatment is advised, primarily magnetic resonance imaging due to possible bone and cartilage damage to the ankle bone. If the main problem is a feeling of instability in the joint or recurrent injuries, then one of the numerous surgical procedures that strengthen and / or reconstruct the ligaments is advised.
Although ankle sprains can sometimes be successfully "aged" (letting time do the healing), this is not always the case and it is risky if you do not seek professional help. The resulting soft tissue injuries can have long-term consequences. An ankle injury with a sprain should never go away without rehabilitation, regardless of whether it is a mild or harmless injury. Due to the fact that this is an injury that in 80% of cases is prone to recurrence, it is important that it is treated on time and adequately. Therefore, if you have a sprained ankle, seek the help of a doctor or physiotherapist who will assess the condition of your ankle, make a diagnosis and recommend adequate therapy to minimize the consequences of the injury. To preemptively prevent injuries, comfortable well-fitting footwear should be considered, medical footwear that is designed to help with many musco-skeletal issues such as DrLuigi Medical Footwear (www.drluigi.eu) are highly recommended.