Mid-Week MOT: Ankle Sprains
If I had a pound for every time I've gone over on my ankle I would indeed be rather rich by now.
I am not sure I know anyone that hasn't sprained their ankle at some point in their lives.
It is a very common injury but is not always diagnosed or treated correctly.
The sprained ankle can cause problems for a long time after the injury and result in lower leg instability, joint weakness and chronic pain.
What is a sprain? How does it differ from a strain?
Where two bones meet at a joint, they are held in place by fibrous, inelastic, collagen bands (ligaments) firmly attached to each bone. They have a notoriously bad blood supply and can take a long time to heal.
A sprain, therefore, is where the ligaments are either stretched or ruptured (partially or fully) as a result of trauma to the area where the joint is forced beyond its normal range. There may be pain, swelling, bruising, loss of function and inability to weight bear. A full rupture may not heal on its own and could need surgical repair.
This injury can also be accompanied by a fracture, due to the extreme forces involved, and it is often very difficult to differentiate between the two. Therefore, if in doubt, a visit to A&E or a Minor Injuries Unit is advised so that a health care professional can assess the damage.
A strain happens at the muscle or tendon that attaches the muscle to the bone. When you "pull" a hamstring, you have a strain. The muscle fibres again, may be stretched or partially torn and there is often pain, swelling, bruising, loss of power and decreased function. The muscle can become completely detached which may then be a job for the surgeons.
Lets have a look at the anatomy of the foot and ankle ligaments.....
You can see how thick and wide the ankle ligaments are, stabilising the inside and outside aspect of the foot/ankle. There are at least three on either side of the ankle and when a sprain occurs, it is usually just one or two that are affected in varying degrees. If a ligament holds out, it may actually take off the piece of bone it is attached to causing an avulsion fracture.
The diagram shows the big heel bone (calcaneus) and the tibia (shinbone) above it on the medial side, and the fibula (smaller outside ankle bone) all joined nicely with the white ligaments.
The most common type of ankle sprain happens when you go over down a kerb or uneven surface and the sole of your foot turns in. This is an inversion sprain, and will stretch the lateral ankle ligaments. There may also be some compressive damage to the medial or inside aspect of the ankle where the bones have approximated. These lateral ligaments are slightly thinner and longer than the medial ones leaving them more injury prone. Eversion injuries or turning the sole of the foot outwards, are less common due to the stability of the thicker deltoid ligaments and their weight bearing function.
We grade sprains according to the amount of damage done as follows:
(From the American Association of Orthopaedic Surgery - www.orthoinfo.aaos.org)
Grade One - mild damage to a ligament where they are perhaps stretched. No instability in the joint.
Grade Two - a partial tear to the ligament and some resulting instability as the joint is more lax.
Grade Three - complete tear of ligament with substantial instability at the joint.
It is important to note that the degree of swelling, bruising and pain is not always a good indicator of the level of damage at a joint.
(I have seen more significant effects from a grade 2 ankle sprain then a fractured ankle!)
Treatment and Rehab....
This is an acronym for Protection, Rest, Ice, Compression and Elevation in the first 24-48 hours post injury.
Early treatment for sprains is all about stopping activity and preventing the condition from worsening. The joint needs protecting from sudden movements and particularly from lateral movements which caused the injury in the first place. Weight bearing is a good idea but keep the joint in alignment. From Grade Two onwards, crutches may be given and the ankle immobilised in a cast or plastic boot. It is important that this treatment is not prolonged as we need to preserve the muscle function and joint range.
Applying an ice compress for 10 mins every hour, over a tubular bandage, will lessen the bruising and reduce swelling.
According to the current NICE guidelines (www.cks.nice.org.uk/sprains-and-strains) the use of paracetamol and topical anti-inflammatory medications such as ibuprofen or diclofenac based gels, are advocated routes for analgesia.
Referral for physiotherapy is not actually indicated for ankle sprains, however, there are some steps you can take to rehabilitate your ankle and prevent recurrence.
Keep the joint active by doing gentle circular movements or drawing the alphabet with your toes. Work within pain free limits. When you can, try to weight bear as soon as possible but support the ankle with a tubular bandage or similar.
After about a week, and if the swelling and bruising are subsiding, you can begin to do some more challenging exercises such as calf raises and rocking back and forth on your toes and heels.
The recurrence rate of ankle sprain is quite high. This is due to disruption of the body's ability to maintain joint position when you over stretch or tear ligaments. This ability is called proprioception, and it is a feedback mechanism helping your brain to know where you are in space so that it can adjust muscular tone and position quickly and efficiently to keep you upright and out of danger.
When symptoms are almost gone, you can begin to work on the proprioception of the joint by standing on the one bad leg barefoot and balancing. When this is too easy, close your eyes (make sure you can hold onto something as you may wobble a bit).
After that, introduce a thin pillow or folded towel to make the floor more unstable and then balance again, working up to closing your eyes for longer each time and increasing the pillow thickness.
This exercise is useful for strengthening the foot and ankle and calf muscles too.
Ankle sprains are very common and very easy to rehab and treat. If you get it right in the first few days and weeks, then you can expect a full recovery.
If symptoms worsen, however, and you are not getting better then you should speak to your GP or practice nurse for referral to an orthopaedic department or at least for a plain x-ray.
Follow the simple steps outlined above, keep the area moving but do not overdo it.
In future, try to keep active, warm up before activity, wear appropriate footwear and maintain a normal weight and you will reduce your chance of injury.
For osteopathy in High Wycombe or beyond, call Lucy from OsteoFusion on 07833 321604 or visit www.OsteoFusion.co.uk
Thanks for reading.