Lateral Ankle Injury & Instability

Did you know the following about sprained ankle treatment?

Lateral ankle ligament sprains are reported as 25% of all musculoskeletal injuries

Of the reported injuries, 50% are related to sport injuries

Lateral ankle ligament sprains are reported as 85% of all ankle sprains

20% of patients develop chronic ankle instability after a previous injury to the lateral ligaments

Chronic ankle instability is most commonly caused by inadequate management and rehabilitation of acute ankle instability injuries

Golden rule for lateral ankle sprains is to start with non-operative conservative rehabilitation

As you can see, it is vitally important to be vigilant when it comes to sprained ankle treatment. Especially the treatment of lateral ankle sprains. By properly treating a lateral ankle sprain – you prevent chronic instability in the ankle. In this article we discuss treatment, management and prevention of the most common ankle injury = LATERAL ANKLE LIGAMENT SPRAIN. We also share tips on how chronic ankle instability can be prevented as well as other related factors.

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The picture on the left shows swelling and bruising after an acute ankle injury to the outside part of the ankle. How does this happen? Usually a trip or stumble over an object or during quick movements, resulting in your ankle twisting. The picture on the right shows the ligaments on the outside of your ankle. This injury, these ligaments and the treatment for them is what this entire article is about.

Sprained ankle treatment & Management

The golden rule for lateral ankle sprains is to start with non-operative conservative rehabilitation. As biokineticists, we provide rehabilitation to the ankle in the form of exercise treatment which in itself is a conservative treatment method. The end goal of rehabilitating a lateral ankle sprain is not only to regain pre-injury function & performance but to prevent the development of chronic ankle instability. It is only when the non-operative treatment has failed to rehabilitate the injury that surgery is considered to correct the damages of the anatomical structures.

How does Non-operative conservative rehabilitation look like?

The stages of ligament healing are used as a guideline for rehabilitation stages, goals and time periods allocated to recovery.

1. Acute injury

The first stage is where the inflammation is managed. The goal of this stage is to decrease the swelling and pain while ligament mobility & strengthening begins within pain-free ranges. Patients are advised to wear an immobilisation brace for ±2 weeks depending on the severity of the ligament injury. Take note that prolonged immobilisation is not advised because it can cause significant muscle loss. Stage 1 can take up to ±10 days.

Clinical evaluation is advised in most cases after an ankle injury. However, delayed assessment is advised for acute lateral ankle sprains is advised as this allows for some of the swelling to reduce. Which provides a more accurate diagnosis. A detailed evaluation should take be completed which includes medical history taking, mechanism of injury & clinical signs and symptoms. The ankle joint mobility, muscle strength, neuromuscular control & proprioception should also be evaluated. Although not necessary, sometimes additional investigations are needed.

What further investigations can a patient be referred to?

•     X-ray: To exclude fractures of the ankle joint.
•     Ultrasound: To establish any tears in the ligaments and tendons.
•     MRI: To establish any ruptures in the ligaments.

As biokineticist and exercise specialists, we do not provide treatment for the acute lateral ankle sprain injury. First aid principles with rest, ice, elevate and compression are followed right after the injury occurred. From there a physiotherapist can treat the swelling, bruising, pain and start with regaining range of motion and function.

2. Sub-acute injury

The second stage is referred to as proliferation. This is where we can start assisting you in your rehabilitation journey and reach the goals you have. This stage is focussed on improving range of motion, strength, coordination, and proprioception of the ankle along with its involved structures and tissues. Gradual progressions are introduced from to load the ankle accoridnly and prevent reinjury.  Stage 2 can last for ± 8 weeks or longer depending on the patient’s progressions.

We provide sprained ankle treatment after most of the swelling, bruising and pain has subsided. Depending on the severity (Grade 1 -3) of the sprain, we can start anywhere from ±10 days after the initial injury. The question then is, WHY go to a biokineticist if your swelling, bruising and pain subsided? You can walk again and you have most of your function back?

The answer = acute ankle injuries are only fully rehabilitated once you have regained all of your function, stength and balance as before the injury. If rehabilitation has not been completed in full, your ankle is still weaker. And the chances of another ankle injury happening, is high. Once this happens, you are at risk for chronic ankle instability. Which basically means you do not have proper stability in your ankle, which can lead to poor ankle mechanics, reduced ability to balance and years of problems with the ankle. Not to mention the fear of another ankle injury lurking around the corner.

Many athletes, elite and recreational end their sport endeavors because their ankles are just not keeping up with the demands of the sport. Commit to a complete ankle rehabilitation plan and keep doing what you love for as long as you can. 

3. Non-acute injury

The third stage is referred to as the remodelling of ligament healing. In other words – return to sport and higher performance levels. During this stage the patient returns to sport participation in a controlled and gradual manner over the ±12 weeks post injury. Rehabilitation training will include endurance, balance, proprioception, and sport specific drills. Biokineticists ensure your rehabilitation treatment is specific to you and your goals in stage 3. We assist to improve ankle joint muscular strength & endurance up to the required level of high performance, recreational or daily / work activities.

Proprioceptive / balance training alongside muscle reaction time training is focussed on to ensure that the ankle joint will be able to sustain and react appropriately to applied loads and forces. Attention is paid specifically to the muscles on the outside of the lower leg & ankle. With regards to sport specific drills and skills, biokineticists manipulate exercises and equipment to mimic the required sporting / working environment to prepare the ankle joint for the movements and skills required by the type of sport.

The end goal is to ensure you have fully rehabilitated the ankle injury and that you are at less risk of re-injuring the ankle while enjoying the activities you do at the highest level of performance possible. Click here here to read more about how we can help improve your performance.

Surgical management

It is only when the non-operative sprained ankle treatment has failed to rehabilitate the injury that surgery is considered to correct the damages of the anatomical structures. Surgery is used to restore or replicate the anatomical structures that have mechanical damage beyond conservative correction. There are many different surgical techniques used to correct a lateral ankle sprain and depending on the injury severity and correction requirements. Take note that patients with neuroarthropathy, spasticity, or peripheral vascular disease are contraindicated for surgeries. There are two main components dividing the different surgical methods:

1. Lateral ligaments of the ankle can be restored with original tissues or replaced by a graft.
2. Surgery can be performed through arthroscopy or open methods.

Chronic ankle instability & prevention

A deeper look into the damages of an acute lateral ankle sprain can show us why chronic ankle instability is so common within patients who have suffered a previous lateral ankle sprain.

When a ligament is injured, the surrounding muscle tissues and involved nerves can also be affected. Mechanoreceptors are sensory neurons (located in the muscles, tendons and ligaments) that get damaged during ankle sprains. These damages lead to disruptions in the nerve function to the ankle, affecting the ankle motor control. Rehabilitation of ankle sprains (acute or chronic) should therefore include neuromuscular / nerve rehabilitation such as proprioceptive / balance training to regain proper neuromotor control and function of the ankle.

When a person has chronic ankle instability they can experience the following signs & symptoms:

•       Impaired proprioception / balance / spatial awareness
•       Diminished neuromuscular control
•       Compromised strength of the muscle responsible for pointing the toes & standing on your toes.
•       Decreased ankle postural control – which can lead to the bridge of your foot to be very low, almost looking like flat feet.
•       Tight and or weak tendons such as the Achilles tendon which is the thick tendon behind the ankle

The difference between a short and long sport / work career are the things we do to prevent injuries and not only rehabilitate from them. Be proactive, not reactive ~ Labarre Alho, Head Biokineticist.

Risk factors for lateral ankle injuries & instability

1. Pervious lateral ankle injuries: Compromises biomechanical stabilisers
2. Height and weight: Increased height and weight are related to greater forces placed on ankle joint
3. Inadequate muscle strength: Decreased stability and control over the joint
4. Joint laxity: Decrease joint stability
5. Muscle reaction time: Effected neuromuscular response
6. Shoes: Ill-fitting shoes can decrease the support offered by the shoe
7. Unstable surfaces: Unstable surfaces and terrains can increase the risk of twisting the ankle joint

Ligament sprains are divided into 3 grades in terms of intensity and sprained ankle treatment goals differ within each grade

Associated injuries with lateral ankle sprains

Keep in mind that other associated injuries to surrounding anatomical structures may occur when the lateral aspect of the ankle gets injured. Your healthcare professional should rule out any of the following injuries when dealing with a lateral ankle sprain:

•       Fractures of the talus, calcaneus and or 5th metatarsal
•       Synchondrosis injuries
•       High ankle sprains
•       Peroneal tears, tenosynovitis and or cellulitis
•       Anterolateral impingement lesions
•       Attenuated peroneal retinaculum
•       Intra-articular loose body
•       Medial ankle tenosynovitis