Lesson 1, Topic 1
In Progress

Ankle injury

The injury mechanism provides an important clue to the diagnosis. The typical mechanism, for a more simple ankle sprain, involves inversion and plantar flexion. The ability to weight-bear following injury is very helpful for distinguishing been an ankle sprain and a fracture.

Mechanism of the injury

The mechanism of injury is one of the key considerations when assessing an injured ankle. Lateral ligament sprains (and acute peroneal tendon injuries) generally occur after an ankle inversion injury. Inversion may occur when cutting, running on uneven ground or landing on an opponent’s foot. Deltoid ligament injuries typically occur after ankle eversion.

Examination

One of the initial goals of the physical examination is to decide whether the patient has a lateral ligament injury or a more significant injury that may require immobilisation or referral to an orthopaedic surgeon to consider surgical management.

Treatment

Non-operative management of lateral ligament injuries is generally recommended, even if there is evidence of a combined injury to the anterior talofibular and calcaneofibular ligaments. In most cases, functional treatment provides the quickest recovery of full range of motion and return to play, does not compromise mechanical stability any more than other treatments, and is safer and less expensive. Surgery is therefore not indicated as the primary treatment of uncomplicated ankle sprains

Acute Treatment

The goals of a functional treatment programme are to minimise the symptoms associated with the initial injury. Limiting the swelling and pain will permit early restoration of range of motion, muscle strength and neuromuscular control. A sport-specific exercise programme follows before a full return to training and competition. Analgesics can be used to provide pain relief, but acetylsalicylic acid (aspirin) and other non-steroidal anti-inflammatory medications can prolong bleeding and should be avoided if possible. Simple analgesia is useful and may accelerate recovery by permitting earlier achievement of full active range of motion and weight-bearing, resulting in an earlier return to training and competition

Rehabilitation

After the initial bleeding phase is over, the goal of treatment is to regain normal, pain-free range of motion. Increased range of motion can be achieved through passive, active or active-assisted stretching exercises as well as by submaximal exercise on a stationary bike. The exercise programme should progress (according to the improvement in function and degree of symptoms) from progressive linear movements (e.g. toe-raises, squats, jogging, jumping in place on two legs, then one, skipping-rope jumping) to cutting movements (e.g. running figures of eight, sideways jumping, sideways hurdle jumps). The goal of this progression of exercises is to gradually progress towards sport-specific exercises.

An important goal in the successful rehabilitation of an ankle sprain injury is the re-establishment of neuromuscular control of the ankle through a programme of balance exercises. Proprioceptive function is impaired in patients with residual functional instability after previous sprains, which can be improved by balance board exercises. Strengthening exercises are, also an important part of the rehabilitation program. These should be done with the ankle in a plantar flexion position. The ankle is least stable in planter flexion and this is the position where more ankle inversion injuries occur. Such programmes can reduce the risk off re-injury to the level of a previously uninjured ankle. Neuromuscular training should be carried out for six to ten weeks after an acute injury.