The document provides information about ankle injuries, including the anatomy of the ankle joint, types of ankle injuries (strains, sprains, and fractures), classification of ankle sprains (grades I-III), and treatment and rehabilitation for different grades of ankle sprains. It describes how grade I sprains involve minimal ligament tearing, grade II partial tearing, and grade III complete tearing. Treatment involves RICE (rest, ice, compression, and elevation) followed by progressive rehabilitation exercises over 2-4 weeks for grade I, 4-8 weeks for grade II, and 8-12 weeks for grade III sprains.
6. •The ankle is a complicated joint and is commonly injured. When mankind was evolved to walk on two legs the
ankle was given quite a lot of extra work to do, both in weight bearing and in balance.
•It is a joint where three bones meet- the tibia and fibula of the lower leg and the talus of the
foot, which sits on top of the heel bone (calcaneus). Ligaments, strong bands of fibrous tissue
capable of only slight stretch, hold the bones together.
Explanation :
•Tendons attach muscles to the bones to move the ankle joint, and are softer and more
stretchy.
Any of these structures- the bones, ligaments and the tendons can be injured.
7. What is an ankle injury?
An ankle injury can be a strain, sprain, and a fracture.
A strain refers to a painful condition of the ankle joint
brought about by inflammation, overuse or simply
awkward use. It includes inflammation of muscles and
tendons such as achilles tendon at the back of the heel.
A sprain is an injury to the band which connects two
or more bones to a joint. This band is called a
ligament. A sprain is usually caused by the joint being
suddenly forced outside its usual range of movement.
8. A fracture is break in one of the bones which make up
the ankle joint. Depending upon the cause of the fracture,
one or more bones may be involved. Fractures cause
sudden pain and usually cause significant swelling.
Stress fractures are smaller cracks in the bone which also
cause intense pain but with less dramatic swelling.
10. Lateral ankle sprains
These account for 85% of all ankle sprains, most commonly due to inversion of
the plantar flexed foot.[9]
Ankle sprains are classified from grade I to grade III depending on their
severity:
•Grade I injuries - the ligament is stretched, with microscopic (but not
macroscopic) tearing. Swelling is mild, with little or no functional loss and no
joint instability. The patient bears weight at least partially.
•Grade II injuries - the ligament is stretched with partial tearing. Swelling is
moderate-to-severe, with ecchymosis.There is moderate functional loss and
mild-to-moderate joint instability. Patients usually have difficulty bearing
weight.
•Grade III injuries - the ligament is completely ruptured. Swelling is
immediate and severe, with ecchymosis. The patient usually cannot bear
weight (or not without severe pain). There is moderate-to-severe instability of
the joint.
Ankle sprains – classification
11. Grade I ankle sprain
The
ligaments
have been
stretched or
torn
minimally
12. Grade II ankle sprain
Some of the
fibers of the
ligaments
are torn
completely.
13. Grade III ankle sprain
When
entire
ligament
is torn
and there
is
instability
of ankle
joint.
14. Syndesmotic (high ankle) sprain
This is caused by dorsiflexion and eversion of the ankle with
internal rotation of the tibia - eg, during skiing or football. The
syndesmotic ligaments are the combination of the interosseous
ligament and lower tibiofibular ligaments which normally stabilize
the mortise joint and fix the fibula in the fibular notch.
•Look for widening of the mortise (tibiofibular gap should be <5
mm measured 1 cm above the joint line on AP and mortise views).
•Squeeze test, side-to-side test and forced external rotation all
cause pain at the syndesmosis.
•Healing takes longer than standard lateral sprains - consider the
diagnosis in those with continuing pain more than six weeks after the
original injury.
15.
16. Treatment of ankle injuries.
PRICE
Protect from further injury (for example, by a support or high-top
high-lace shoes).
Rest the ankle joint for 48-72 hours following injury. For example,
consider the use of crutches when wanting to be mobile. Need to protect
the injured ankle from further injury. For example, use a bandage and/or
ankle support, or a boot with high sides. It is important that the ankle is
not rested for too long as this may delay recovery.
Ice should be applied as soon as possible after injury, for 10-30
minutes. (Less than 10 minutes has little effect. More than 30
minutes may damage the skin.) Make an ice pack by wrapping ice
cubes in a plastic bag or towel, or by using a bag of frozen peas. Do
not put ice directly next to skin, as it may cause ice burn.
continued……
17. …Gently press the ice pack on to the injured part. The cold is
thought to reduce the blood flow to the damaged ligament. This
may limit pain, inflammation and bruising. Some doctors may
advise re-applying of ice after every two hours for 15 minutes for
the first 8-72 hours.
Compression with a bandage will limit swelling, and help to rest
the joint. A tubular compression bandage or an elastic bandage can
be used. The bandage should not be too tight - mild pressure that is
not uncomfortable and does not stop blood flow is the aim. A
pharmacist will advise on the correct size. Remove the bandage
before going to sleep. May be advised to remove the bandage for
good after 48 hours, so that the joint can move.
18.
19. Elevation aims to limit and reduce any swelling. For
example, keep the foot up on a chair to at least hip
level when patient is sitting. (It may be easier to lie on
a sofa and to put the foot on some cushions.) When
the patient is in bed, put the foot on a pillow.
20. What should be avoided ?
•Heat - for example, hot baths, saunas, heat packs. Heat encourages
blood flow which will tend to increase bruising and inflammation. So,
heat should be avoided when inflammation is developing. However,
after about 72 hours, no further inflammation is likely to develop and
heat can then be soothing.
•Alcohol, which can increase bleeding and swelling and decrease
healing.
•Running, which may cause further damage.
•Massage, which may increase bleeding and swelling. However,
after 72 hours, gentle massage may be soothing.
HARM
21. When should you see a doctor?
•You suspect a bone may be broken or a ligament is ruptured.
•You have a lot of tenderness over a bone
•The leg or joint looks out of shape (deformed) rather than just
swollen. This may mean there is a break (fracture) or dislocation
which needs urgent treatment
•There is loss of circulation in the foot (a numb, cold foot with pale
or bluish skin). If this occurs, treatment is urgent.
•The pain is severe
•You cannot walk or weight bear because of the injury.
•Bruising is severe.
•The joint does not seem to work properly or feels unstable after the
pain and swelling have gone down. This may be a sign of an
additional injury such as a torn tendon.
22. •Symptoms and swelling do not gradually settle. Most sprains
improve after a few days, although the pain often takes several
weeks to go completely, especially when you use the injured
joint.
23. Rehabilitation programme:
Grade 1 Ankle Sprain
•Stage 1: 0 – 72 hours post injury
Protect the ankle from further injury by resting.
Resting the ankle from dynamic activities such as playing
sport or running is essential in this stage to allow healing to
commence.
Ice or cold therapy should be applied throughout the rehabilitation
process. Apply ice for 15 minutes every hour initially for the first day
then reduce this to 4 to 5 times a day from then on as required.
Compression will help reduce and prevent swelling and can be
applied immediately after injury at pitch side but only for 10
minutes at a time to avoid cutting of circulation to the area.
24. •Stage 2: Days 3 to day 7
If the pain is settling and the ankle is feeling comfortable then start
some of the Ankle mobility exercises very gently, 3-5 times a day.
The exercise recommended would be active plantar flexion and dorsi-
flexion. Strengthening exercises including the resisted plantar flexion
and dorsiflexion and isometric eversion and inversion.
Electrotherapy such as ultrasound may be used at this stage and
can be beneficial in reducing swelling and relaxing the muscle –
always performed by a professional therapist). Continue to rest from
any aggravating activities.
Continue with P.R.I.C.E. Continue to wear a compression bandage
or calf support. Basic proprioception exercises can begin – standing
on one leg (eyes open and eyes closed, arms out and in). If you are
being treated by a therapist, he/she may decide at this stage to use
alternating hot and cold therapy to further improve healing and reduce
swelling.
25. •Stage 3: Day 8 +
A healing ligament does needs a certain amount of stress to heal
properly so it is important that the rehabilitation process is
progressive and slowly introduces stress to the ligament. However,
doing too much exercise or putting too much stress on the healing
ligament in the early stages can be detrimental so this needs to be
finely balanced. Rehabilitation is both an art and a Science.
•Continue with PRICE and plantar and dorsiflexion mobility
exercises.
•Now introduce the active inversion/eversion exercise to improve the
range of movement of he ankle and flexibility of the ligaments.
•Begin more advanced strengthening exercises such as resisted
eccentric inversion and calf raises.
26. •More advanced proprioception exercises such as standing on an
unstable surface and hopping can be commenced. When hopping
exercises are performed confidently then jogging can commence.
•Progress from jogging to sprinting in straight lines as long as the
ankle remains pain free and does not swell up.
•Finally introduce twisting and turning activities.
The overall rehabilitation time frame for a grade 1 ankle
sprain is between 2 and 4 weeks. If the ankle is still
swollen or painful after this length of time, then
definitely recommended to seek professional opinion.
27.
28. Grade 2 Ankle Sprain
•Stage 1: Day 0 - 7
It is important to protect the ankle from further injury by resting it.
Avoid excessive weight bearing (use crutches if necessary) and wear
an ankle support that allows forwards and backwards movement but
not lateral/sideways movement. ankle taping can be used as an
alternative to an ankle support but this does need replacing on a daily
basis.
Rest from sporting activities is essential - a healing ligament needs
a certain amount of stress to heal properly but overdoing it early on
in the rehabilitation process can delay or even prevent healing. Full
weight bearing should be introduced as soon as pain allows but not
before. Avoid sideways ankle movements which are likely to stress
the injured ligaments.
29. Compression will help reduce and prevent swelling and
can be applied immediately after injury at pitch side but
only for 10 minutes at a time to avoid stopping the
circulation. A tube grip or elastic ankle support can
provide mild compression throughout the healing
process to help reduce swelling.
Elevation by raising the leg will help swelling drain
away from the site of the injury. Elevate the leg while
icing and for 10 minutes after.
30. •Stage 2: Day 8 to 21
• Continue with P.R.I.C.E.
• Continue to rest from any aggravating activities.
•Continue to wear a compression bandage or calf support.
• If the ankle is feeling comfortable then start some of the Ankle mobility
exercises very gently, 3-5 times a day. The exercise recommended would be
active plantar flexion and dorsi-flexion.
•Strengthening exercises including the resisted plantar flexion and dorsiflexion
and isometric eversion and inversion.
• Electrotherapy such as ultrasound may be used at this stage and can be beneficial
in reducing swelling and relaxing the muscle – always performed by a professional
therapist).
• Basic proprioception exercises can begin – standing on one leg (eyes open and
eyes closed, arms out and in)
• If you are being treated by a therapist, he/she may decide at this stage to use
alternating hot and cold therapy to further improve healing and reduce swelling.
31. •Stage 3: Days 22+
• Continue with PRICE and plantar and dorsiflexion mobility
exercises.
• Now introduce the active inversion/eversion exercise to improve the
range of movement of he ankle and flexibility of the ligaments.
• Ankle massage can be performed to improve the healing of the
damaged ligaments.
• Begin more advanced strengthening exercises such as resisted
eccentric inversion and calf raises
• Start functional exercises
• More advanced proprioception exercises such as standing on an
unstable surface and hopping can be commenced. When hopping
exercises are performed confidently then jogging can commence.
• Progress from jogging to sprinting in straight lines as long as the
ankle remains pain free and does not swell up.
• Finally introduce twisting and turning activities.
32. The overall rehabilitation time frame for a grade 2 ankle
sprain is between 4 and 8 weeks. If the ankle is still
swollen or painful after this length of time, then we
definitely recommend seeking a professional opinion.
33. Grade 3 injury
•This is very severe injury of the ankle and are often associated with
other injuries .We strongly advise you seek a professional opinion
before rehabilitating this severity of injury.
•Stop playing and rest immediately. If you are concerned that there
may be an associated injury, go straight to a Doctor or Hospital.
Once you have been fully assessed and allowed to progress
rehabilitation, follow the same program as for a grade 2 injury
with the following modifications;
•Initially use crutches for assisted weight bearing and do not walk
un aided until the ankle is pain free.
34. •Prolong the 1st stage of rehabilitation including
P.R.I.C.E. and gentle mobility exercises (plantar flexion
and dorsiflexion only) for the first 2 weeks and do not be
tempted to progress.
The overall rehabilitation time for a grade 3 injury is 8 to
12 weeks with most taking at least 10 weeks to fully
recover.
