Remember the last time you were walking and stepped in a pothole? or possibly stepped off the curb just right and rolled your ankle? We've all been there but what exactly just happened in that moment and what do you do next?
What is a "Rolled Ankle" it?
Typically when you "roll your ankle" you've just encountered a lateral ankle sprain or inversion sprain injury. An ankle sprain is when one or more of the stabilizing ligaments of the lateral side (outermost side) of the ankle has been stretched or torn. This condition is also called an “inversion”sprain because the injury most often occurs from an inversion-type (when the sole of the foot rotates toward the midline of the body) twist of the ankle.
The lateral ankle is protected by a ligamentous complex consisting of the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. The site of the ligamentous sprain is determined by the position of the ankle during injury.
Ligament injuries are traditionally classified as grade I ( a stretch in the fiber), grade II (partial fiber tear), and grade III (rupture).
The ankle is responsible for up to one-third of all sports injuries, and a lateral ankle sprain makes up three-fourths of those injuries. Lateral ankle sprains are significantly more common than medial ankle sprains. Approximately 20% of physically active patients will sustain an ankle sprain at some point in their life. The age group between 15-19 have the highest incidence of lateral ankle sprains. Those who play sports, are physically active, or in the military are at high risk for a lateral ankle sprain.
Patients with limited dorsiflexion ( pointing toes up toward the sky) are more at risk for ankle sprains because the ankle tends to roll when ground forces can no longer be accommodated by dorsiflexion. Those with previous ankle sprains double their risk for another ankle sprain. Also, improper conditioning or warming up with activity can contribute to an ankle sprain.
Symptoms & Presentation
The presentation of a lateral ankle sprain consists of sudden onset pain following “rolling the ankle” into inversion. This usually occurs when someone lands from a jump, especially landing on someone else’s foot. This also occurs when someone isn’t looking and steps into a hole or uneven surface. Patients may recall hearing a “pop” during the occurrence of the injury.
The pain can range from mild aching to intense pain that can increase with applying weight. Swelling and bruising usually occur with this kind of injury.
If the swelling and bruising is rapid it suggests a rupture. Pain and swelling usually get worse later in the day. Discoloration and bruising will start to migrate toward the foot over time. Patients will also notice point tenderness over the affected ligament.
Radiographs are only warranted when there is pain over the malleolus ( the bone that sticks out the side of the ankle), if there is tenderness to the fibula bone ( non-weight bearing bone in the lower half of the leg), or if the patient can’t take four steps because of the pain. Advanced imaging may be appropriate if the patient is experiencing instability, crepitus, catching, or if conservative treatment is working after 4-6 weeks. A MRI may be used to assess the ligament complex and to rule out any other issues involving the ankle.
Ankle sprain can be managed conservatively and heal relatively quickly. However, when not taken care of the proper way up to one-third of patients reported symptoms one year post injury and some even reported pain, crepitus, weakness, stiffness, or swelling three years later. Re-injury is very common, at seventy-five percent without treatment.
Management for a lateral ankle sprain incorporates Protection, relative rest, ice, compression, elevation, and support. Newer data has suggested that grade I and grade II may benefit more from movement, exercise, analgesics ( pain relievers), and rehabilitation treatment. However, NSAIDs (anti-inflammatories) may suppress the healing process.
Grade III sprains may require immobilization, however grade I and grade II should not be immobilized. Grade I and II show focus on regaining full range of motion during early rehabilitation. A functional ankle brace could be used for more long term stabilization.
The main goals for manual therapy include regaining full range of motion, strengthening, and proprioception. Joint restrictions commonly occur during an ankle injury and the use of mobilization and/or manipulation can restore function. Joint mobilization has been shown to decrease pain, increase dorsiflexion, improve balance, and improve ankle function.
A transverse friction massage to the affected ligament will help with scar tissue and increase pliability (flexibility). Early fascia work may improve function, pain, and healing.
Acupuncture has been shown to help reduce pain and help with recovery in acute (recently just happened) ankle sprains.
Rehab programs should aim to restore range of motion before functional exercises. Active range of motion exercises can begin immediately. The earlier ankle rehabilitation starts after injury, the lower the risk for re-injury and future issues that can occur in the ankle. The achilles tendon needs attention too after an ankle sprain, stretching should begin within 48-72 hours.
After range of motion improves the patient may begin strength training, which is essential for recovery and preventing re-injury. Strength training should go from isometric (contractions against an immobile object) to dynamic weight training to resistance bands. Strength training should focus on the four plans in which the ankle moves: dorsiflexion, plantar flexion, inversion, and eversion. Patients with ankle instability may benefit with hip abductor strengthening.
Regaining proprioception (self-movement and body position) is another important component of rehabilitation.
Elastic therapeutic tape (kinesiotape) may help improve balance and strength in the ankle through functional ankle stability.