Sprained ankle •Diagnosis of sprained ankle•Management of Sprained Ankle

Subarna Debbarma (BPT, DNHE)

What Is Sprained ankle ?

An Sprained ankle  is when the ligaments that support the ankle get overly stretched or torn.

Anatomy of Ankle Ligaments


Ankle sprains are one of the most commonly encountered injuries by athletes and non-athletes alike , with an incidence of 6–8 per 1,000 person hours in sports such as rugby and football . While often considered a benign relation to the more significant ankle fracture, evidence has accumulated to suggest that even a simple ankle sprain may result in significant long-term morbidity, with up to 40% of injuries resulting in residual symptoms . Normally, this continuous symptomatology may result from unpretentious bone injury,osteochondral injury, delicate tissue thickening, progressing incendiary cycles, and ligament or tendon injury. While in an emergency department, these may not be considered “clinically significant” their existence changes the prognosis for individuals markedly and therefore should also impact upon the management. Furthermore, despite the abundant literature considering the diagnosis, management and morbidity of the ankle sprain, typical primary care management of the ankle sprain appears not to have changed in recent years.Typically, both in research papers and clinical practice,the diagnosis of ankle sprain involves a history of a painful inversion injury to the ankle, lateral swelling and bruising,and the absence of a fracture on simple x-ray imaging .Grading of the ankle sprain is subsequently determined by the degree of damage to the lateral ligament complex and the associated clinical findings. Unfortunately, while the grading may, to some degree, reflect the pathology of the lateral ligament, it remains a subjective tool , which may not reflect the complexity of the underlying pathology, or the likelihood of a satisfactory outcome .The degree of injury to the lateral ligament complex will have a significant impact upon the subsequent stability and function of the ankle, and therefore will require careful evaluation and appropriate management. The most common mechanism of injury in the ankle is inversion and supination of the foot, with external rotation on the tibia, resulting in lateral ligament injury . The typical sequence of ligament injury involves initially the anterior talofibular ligament(ATFL), the anterolateral capsule, distal tibiofibular ligament,calcaneofibular ligament (CFL), and finally the posterior talofibular ligament (PTFL). However, inversion injury of the ankle, while routinely characterized by its impact on the lateral ligament complex , will also have associated pathology, which may subsequently impact upon the functional outcome of the ankle. Associated pathology may include both intra- and extra-articular hemorrhage, intra-articular traumatic synovitis, subchondral bone bruising,chondral damage, and medial ligament . With progres-sively increasing force, significant fractures may occur around the ankle. It is well recognized that simple imaging may miss a range of fractures around the ankle joint, including such as fractures of the anterior process of the calcaneus, the poste-rior process of the talus, the talar dome, lateral process of the talus and the fifth metatarsal, a high quality of imaging must be sought, and a high index of suspicion maintained.

What causes a sprained ankle?

Falling or tripping on uneven surfaces.
Landing incorrectly after a jump.
Losing balance.
Participating in sports that involve rolling or twisting your foot (basketball, football, soccer, tennis).

What Are the Signs & Symptoms of an Ankle Sprain?

trouble bearing weight or walking on the ankle

What are the Prevention of Sprained Ankle?

Stretch regularly to keep your ankles flexible.

Ankle range of motion and strengthening exercises to keep your muscles strong.

Always warm up before playing sports, exercising, or doing any other kind of physical activity.

Use tape, lace-up ankle braces, or high-top shoes to support the ankle.

Wear shoes that fit well. Tie any laces and close any Velcro or other straps to make the shoes as supportive as possible.Don't wear shoes with high heels.

The first step toward optimal management of the inversion ankle injury is an accurate diagnosis. Delineation of both the so-called “clinically significant” and less significant pathology (that is pathology not requiring immediate surgical or manipulative intervention) and the provision of a specific diagnosis should be the diagnostic goal. Considering everything which is not a fracture of the ankle to be a simple sprain
is an oversimplification, and should be avoided.

Much has been written about the use of specific rules in imaging, for the diagnosis of significant ankle fractures, with a goal of both minimizing unnecessary radiation exposure and cost. Rules such as the Ottawa ankle rules and Leiden ankle rule are typical examples , but the importance of careful assessment prior to imaging cannot be emphasized enough.
One outcome of this process of minimizing imaging is the classification of fractures into clinically significant and “not significant” by emergency departments, primary practitio-
ners, and trauma centers . However, as can be seen above,this differentiation does not mean that the outcomes are optimal for those without significant fractures. Hence, it is critical that rules such as the Ottawa Ankle Rules be recognized for what they are – a means of reducing the number of images performed, while not missing fractures requiring operative or manipulative treatment. They are not designed for use by
a clinician working in sports medicine, wishing to optimize the clinical outcome for an ankle following an inversion injury. In order to optimize clinical outcomes, a careful
examination and consideration of the underlying pathology must be performed.

Management of the Sprained Ankle

There is little consensus  in the literature regarding the most appropriate management of the ankle sprain. However,it is clear that to maximize the likelihood of a positive outcome, even an uncomplicated ankle sprain should be man aged aggressively. Inadequate rehabilitation may result in prolonged ankle instability, dysfunction, inflammation, or pain. Initial management (elevation, compression,and ice) is recommended. Technique for icing is in a bucket of ice and water, continuous moving of the ankle, there by preventing loss of range of motion. While it remains unclear what an ideal duration for ice application  is 10 min on ice,10 min off ice, on an hourly basis for 24 h, 2 hourly for 24 h,and subsequently following any rehabilitation session for at
least 2 weeks . Compression should around the medial and lateral malleoli to minimize swelling and applied between bouts of ice for 3–5 days.Offloading with crutches may be utilized if indicated by pain and dysfunction, but rapid progression to pain free weight bearing should be encouraged as pain and mobility improve over 3–5 days. Numerous splints are available commercially and have been shown to have significantly enhanced out-comes compared with simple tubigrip . Indeed, the use of the tubigrip has been reported to have no effect on recovery and may actually increase the need for analgesia in grade I and II ankle sprains . However, in the early phases any thing which enhances comfort, provides some compression and is convenient to take on and off may be considered reasonable. For a syndesmotic lesion, offloading and compression of the tibiofibular joint with bracing is mandatory.Prolonged immobilization should be avoided to prevent both muscle atrophy and arthrofibrosis .Use of analgesic or anti-inflammatory medication remains controversial. Anti-inflammatory medication has been shown to reduce pain and allow a more rapid return to functional movements, but the long-term benefit of anti-inflammatories may be limited . Acutely inflamed ankle, there are reports of the early successful treatment of athletes with an isolated ankle sprain with intra-articular and periarticular corticosteroid injections.This has no evidence base and has numerous potential negative effects including a potential negative impact on the chondral surface. Recently, the successful use of periarticular hyaluronic acid in the acute ankle sprain has been reported,but this requires further evaluation before becoming commonplace . The use of hyperbaric oxygen has not been shown to be efficacious in the ankle sprain . Future interventions may include the use of autologous growth factor application and stem cell implantation to assist in anatomical healing, and this promises to be an exciting area of development over the next 10–20 years.

Physiotherapy should be instigated early, with a view to minimizing swelling and inflammation and rapid return to functional movements. The return of dorsiflexion range is a critical indicator for the return to functional activities, and the use of passive talocrural mobilization from early rehabilitation has been shown to enhance this process . Electrical therapy remains contentious in its absolute benefit, Ultrasound Therapy is very Effective ,although may reduce pain . Mobilization with normal gait is mandatory and requires management of both pain and functional movements. In the subacute phase of management, increased pain-free exercises and proprioceptive activities should be encouraged, with a graduated progression to increasing complexity, functional movement and, finally, sports-specific
activity . Cardiovascular fitness, core stability, and local muscle strength training need to be instigated early .

Surgical treatment of the lateral ankle sprain should be considered in the high grade injury, and if there is associated comorbidity (e.g., chondral or osteochondral lesions), the
injury is recurrent and the patient has failed an adequate rehabilitation program.

However, indications for surgery remain unclear and even the presence of a grade III injury in an athlete is not an absolute indication for surgery.Secondary prevention of the ankle sprain should involve ongoing proprioceptive training, appropriate warm-up,incorporating functional proprioceptive movements and conditioning programs.

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