Sprained ankle

The sprain of the ankle (ankle joint distortion) is an injury that occurs during a violent or too fast rotation of the ankle joint; it is one of the most common sports injuries and occurs mainly in volleyball, basketball and football.

It is generally believed that sprain means overstretching of the ligaments and inflammation of the ankle joint.

In reality, however, the ligaments are extremely robust and it is much more likely that the “twisting” of the foot will cause a tear-off fracture of the ankle, i.e. that the ligament remains uninjured, but pulls so violently on the bone that a piece of it breaks off.

It is an uncontrolled rotational load on the foot that leads to overstretching or tearing of the joint capsule, tendons and blood vessels. In more severe cases, muscles and nerves can also be injured.

With a mild sprain, with proper treatment, in most cases complete healing occurs, but sometimes instability, pain or stiffness remain, in addition, relapses are possible.

The pain is noticeable in the upper outer and sometimes also in the interior of the foot, in rare cases at the level of the Achilles tendon, because its appearance corresponds to the position of the injured ligaments.

The anterior anterior ankle-fibula ligament (anterior talofibular ligament) is very resistant; a distortion-related overstretching can cause a fibula fracture, which means that the ligament breaks off a piece of the bone.


How are ankle distortions classified?

For anatomical reasons, the sprain of the ankle joint occurs in most cases with supination (inversion or supination trauma). The fibula is lower than the shin and with an inward edging of the foot (pronation) this bone barrier is quickly reached; the outward edging (supination), on the other hand, is limited only by the strength of the belts.

In general, the following ligaments can be affected: the anterior ankle-fibula ligament (ligamentum talofibular anterius) is always injured, the posterior ankle-fibula ligament (ligamentum talofibular posterius) is overstretched only in fairly severe cases and the heel bone-fibula ligament (ligamentum calcaneofibulare) is injured only in more severe cases.

Sprains can be classified according to the severity of the injury:

Grade 1: overstretching of ligaments and tendons without lesions;
Grade 2: incomplete tear of ligaments;
Grade 3: complete rupture of at least one ligament.

What are the causes of a sprained ankle?

The sprain occurs when the foot is placed on the outer edge and causes a violent outward rotation and supination of the ankle joint (inversion), i.e. the foot “bends” outwards. It is extremely rare for overstretching due to eversion, i.e. the ankle joint to be turned inwards.

The following factors can favor ankle distortion:

  1. Instability due to previous injuries.
  2. Touching down after a jump.
  3. A traumatic collision during sports (football).
  4. Insufficient training condition of the athlete.
  5. Uneven surface.
  6. Non-sport shoes.
  7. Inadequate warm-up training.
  8. Incorrect placement of the foot.

In severe sprains, a tendon of the fibula muscles on the outer lower leg can be injured or inflammation of the peroneal tendons can develop. The calf muscles (short, long and third fibula muscles) are pulled in a classic inversion trauma of the ankle joint.

A sprained ankle occurs mainly in children, young athletes and young women with heels, but can theoretically affect anyone.

What are the symptoms typical of sprained ankles?

With a sprained ankle, the following symptoms may occur:

  • mild to unbearable pain in the front outer side of the foot, between the outer ankle and the last three toes;
  • instability when walking;
  • decreased functioning of the foot;
  • Limp;
  • swelling of the foot and ankle;
  • Inability to strain the foot (in severe cases).

How is a sprained ankle diagnosed?

The diagnosis is made clinically, an anamnesis is carried out, in which the patient describes the course of the accident in detail; in most cases, this is already sufficient for the doctor.
The only “special cases” I have experienced in my time as a physiotherapist are patients who complain of foot pain whose injury was already 6 months ago. The reason for the complaints in this case can have various causes.

In the physical examination, the painful area is searched for when palpating the ankle.
The foot is swollen and in the post-acute phase bruises may be seen, corresponding to the bruise caused by the injured blood vessels.

After that, the doctor will assess the foot movement; in most cases, there is a restriction in dorsiflexion (movement of the foot towards the back of the foot) and supination (lifting the inside of the foot).
The patient is usually unable to walk on tiptoe, but may walk on his heels.

Only in severe cases, the doctor prescribes a skeletal muscle ultrasound to check if tendons and ligaments are injured or torn.

How is a sprained ankle treated?

One problem I face practically every day is the general assumption that sprains heal by immobilizing and relieving the foot for two weeks. I often deal with athletes who cannot put their foot on and move it even 10-15 days after the injury, as if it were splinted.
Cooling by ice is also rather harmful after a few days, because the joint becomes even stiffer in this way.

Each distortion is a case in itself and must therefore be treated individually; only general guidelines are given here.
The first aid is carried out using the PECH rule: break, ice (cold), compression (compression) and raising the injured foot so that the fluid produced during the ignition can be reabsorbed.
Damp clay compresses reduce the swelling.
Natural remedies for relieving inflammation and pain are arnica cream, devil’s claw ointment and aloe gel.
In the case of a swollen ankle, a zinc bandage helps in the acute phase to reduce the swelling.
The ice treatment should be done three times a day for about 20 minutes, but the ice must not come into direct contact with the skin; better is an ice pack, which is filled with 3-4 ice cubes and a little water and can be placed directly on the skin.

Cold treatment (cryotherapy) has an anesthetic effect, lowers muscle tone and has a vasoconstrictive effect; in this way, the effects of the inflammatory process are significantly reduced.
It continues as long as the foot is reddened and overheated, usually up to 24-36 hours after the injury; after that, the ice would only slow down the healing process of the tissues.

For pain, inflammation and swelling, the doctor may prescribe nonsteroidal anti-inflammatory drugs, such as ibuprofen (Dolormin®), diclofenac (Voltaren®), ketoprofen (Fastum Gel®, Alrheumun®) or naproxen (Aleve®).

When does surgery have to be performed?

When rehabilitating after a sprain, it is important to start careful mobilization as early as possible, because it has been scientifically proven that exercise accelerates healing, while immobilization slows it down or even blocks it. If there is a complete ligament rupture, opinions differ about the need for surgery.

Proponents of surgery believe that residual instability remains with physiotherapy alone.
Proponents of rehabilitation in the form of physical therapy and physiotherapy believe that surgical intervention entails avoidable dangers and contraindications, and also leads to the formation of adhesions.

Kinesio Taping

Kinesio taping for sprained and swollen ankles: Effect:
draining. Shape: two fan-shaped stripes. Length: 25 cm. Attach the strips so that they form a double fan that crosses at the ankle. Apply the tape without tension while stretching the ankle.

The functional tape bandage is intended to give stability to the ankle joint and give the athlete the opportunity to become competitive again as early as possible; in addition, it very effectively prevents further distortions.
Taping has a mechanical, pain-reducing and psychological effect, restricts certain dangerous movements because it is “superior” to the injured ligaments and thus reduces the risk of relapses.

The federation helps athletes who want to start running again before the ankle is completely healed, otherwise it will not be needed, on the contrary, it would delay the recovery process.

Often patients come to my practice and ask me why they still feel pain in the foot 2 or 4 weeks after the sprain.

It is quite normal that the pain persists despite being spared; the problem lies in the joint blockage, which makes correct movement of the ankle joint impossible.

Physiotherapy for sprained ankles

The immobilization phase must not last long because it does not contribute to healing, unsettles the patient and makes the joint stiff.

Once immobilization has ended, physiotherapy has the following treatment goals:

  1. Relieving or eliminating pain in order to be able to resume daily activities: work, driving, sports, etc.
  2. Return to the full range of motion of the joint.
  3. Improvement of muscle tone, which means strengthening the stabilizing lower leg muscles so that the joint can be better controlled.
  4. Regaining proprioceptive skills, which means foot training for optimal posture and movement control.

In the vast majority of cases, physiotherapy consists of manual therapy, i.e. manipulations to unlock the joints, especially the upper ankle joint between the shin/fibula and ankle, but it has also happened that I have had to manipulate the knee and heel to heal the patients.

For 3rd degree distortions, it is sometimes necessary to wear a plaster boot or orthosis for 3-4 weeks, because many doctors believe that surgery can be avoided. Many patients do not undergo surgery, nor do they wear plaster casts or bandages; they resume their sporting activities after about 2-3 months.
Those who undergo surgery must then complete a rehabilitation program lasting 5-8 weeks, and after 4 months at the earliest, training of high-risk sports (football, volleyball, basketball, etc.) can be resumed.

The return to competitive ability must be gradual and the ankle joint is supported by a functional bandage for the first 6 months.

While the ankle joint is plastered or splinted, isometric (d.h.in absence of movement) contractions must be performed, lasting about 5-10 seconds; in this way, the loss of muscular trophy caused by immobility is limited.
Not only the muscles of the foot, but also those of the thigh and hip must be strengthened.

The initial phase lasts up to 1 to 2 weeks from the accident or removal of the plaster, if it was applied for immobilization.
Depending on the severity of the distortion, the injured leg may only be partially loaded during this period in order to avoid aggravation of the situation and relapses.
The doctor may recommend the use of walking aids (walking stick or forearm crutches).

The proprioceptive training program

In proprioceptive rehabilitation, the ability to perceive the body’s movement and position in space is promoted; In this way, the patient improves his sense of balance and regains the usual confidence in the execution of everyday movements and sports activities.

The ankle joint can be described as a sensory organ because it contains a large number of receptors, i.e. sensory cells of the tendons, muscles and joints. These sensory cells transmit the information received at the ankle joint regarding posture to the central nervous system and ensure that the posture is adapted to everyday and sporting activities.

Proprioceptive training is fundamental, for some physiotherapists it is practically the only form of treatment for ankle distortion.

After a traumatic injury, such as a sprain or a broken bone, it is not enough to regain elasticity and muscle strength of the lower extremities, balance and static and dynamic postural control must also be improved to avoid relapse. For this purpose, proprioceptive training has been developed, in which, with the help of assistive devices, positions are taken and exercises are performed that make it difficult to maintain balance; in this way, the body is accustomed to coping with situations of instability as they occur in daily life and sports.

As soon as the ankle joint is again loadable by half the body weight, the first training phase begins, in which proprioceptive exercises are performed on the floor, on seesaw boards or soft cushions.

When satisfactory stability is achieved, the level of difficulty of the exercises can be increased.

Building muscle and regaining range of motion

The initial phase of rehabilitation should include gentle stretching exercises to maintain the flexion/extensor movement of the joint.

To strengthen muscles, the calf and back muscles must be isometrically tensed and free exercises must also be performed.

It is important to observe the pain threshold when practicing physiotherapy exercises; an exaggerated exercise behavior can revive the pain and make the treatment unbearable for the patient.

Alternating temperature baths can be performed; The foot is first immersed in a bowl of 16°C cold water and then in a bowl of 41°C warm water.
This treatment acts like a pump due to the alternating vasoconstrictive and vasodilating effect, which promotes blood circulation and accelerates tissue repair.

The second rehabilitation phase lasts about 2 to 4 weeks and is expanded according to the progress made:

1. more difficult exercises for balance and proprioception;
2. Muscle strengthening with greater load;
3. Walking exercises with changes of pace and direction.In the proprioceptive exercises, the rectangular rocking board is replaced by a round one.
You have to try to stand on only one leg with your eyes closed; those who can, stand only on tiptoe or on the heel.

The muscle building is initially carried out by strengthening exercises of the three-headed calf muscle (gastrocnemius and soleus) in closed kinetic chain; helpful here are leg press, toe stand or exercises against the resistance of elastic bands.

To improve coordination and balance, walking exercises on the heels and tiptoes with changes of direction and pace are on the program.

The rehabilitation period also includes sports activities that do not involve any particular risks, such as cycling, swimming or rowing.

The resumption of sport must take place individually through gradual and sport-specific preparation.

How long are the healing times?

Often patients come to my practice and ask me why they still feel pain in the foot 2 or 4 weeks after the sprain.
It is quite normal that the pain persists despite being spared; the problem lies in the joint blockage, which makes correct movement of the ankle joint impossible.

When the ability to compete can be achieved again depends on the severity of the distortion and the form of treatment.
A slightly sprained ankle heals within a few days, for more serious injuries special manual treatment is necessary.

If only physical therapies are used, such as lasermagnetic and ultrasound therapy, complete healing is difficult, and the risk of relapse is high.

I have achieved the best results with manual therapy and osteopathy accompanied by proprioceptive rehabilitation; in this way, a patient who could not put his foot on because of all the pain could walk, jump and gradually resume training after 2 weeks.

An untreated ankle sprain does not always heal with rest and care.

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