Ankle sprain
The ankle is the most commonly injured joint in sport. Ankle injuries are common in football (soccer), in both professional leagues and more so in amateur leagues. They are common in children and adolescents as well as adults. Sprains of the lateral ligament complex (on the outside of the ankle) are the most common ankle injury in football.
The lateral ligament complex is actually made up of 3 separate ligaments. The ATFL is the one at the front that is most commonly injured and there is also the CFL at the side and the PTFL around the back. The most significant injury is one that has disruption to all 3 ligaments.
Risk factors for injury can be related to the athlete (intrinsic) or the environment (extrinsic). Intrinsic risk factors include reduced range of ankle motion (specifically dorsiflexion), reduced proprioception and balance deficiencies. Extrinsic factors include the playing surface and footwear used.
Ligament injury
Injury to the lateral ligaments is 4 times more common than injury to the medial ligaments (on the inside of the ankle). Lateral ligament injuries occur when the ankle is rolled with the sole of the foot pointing in (inversion injury) and this can occur on uneven ground, when changing direction or when stepping on an opponent’s foot. The athlete will complain of immediate pain and swelling and will sometimes walk with a limp afterwards. The ability to walk 4 steps after an ankle injury is one of the clinical determinants of severity of injury used in the Ottawa criteria for decision-making on the need for x-ray after ankle injury. The athlete will have tenderness around the injury and the location of the tenderness is also a consideration for the need for imaging.
The diagnosis is made by clinical examination and this is most accurate 5 days after the injury when the swelling and pain have reduced. If the athlete can walk on the ankle and is not overly tender on the nearby bones, imaging is not needed initially. If they are unable to walk or have significant bony tenderness an x-ray is needed to rule out a fracture. MRI is not usually needed for diagnosis of lateral ankle sprain but should be considered in ankle sprains that are still painful after 4-6 weeks of standard therapy to rule out other complications of the injury such as osteochondral lesions.
Management
Initial management goals are to limit pain and swelling and maintain range of motion. Normal gait is encouraged as soon as possible but crutches might be needed for a few days initially to help partial weight bear if the pain is too severe to walk without a significant limp. Ankle splints or braces can be used to limit extreme range of motion andallow early weight bearing while protecting against repeat injury.
Early functional rehabilitation is important to help return to activity and prevent reinjury and chronic instability.
Strengthening and proprioception exercises are particularly important for prevention of repeat injury. Functional exercises can be started once the ankle has full pain free ROM and adequate strength and proprioception. Return to sport is considered when functional exercises can be performed without pain at full pace. It is suggested to tape or brace prophylactically for 6-12 months after returning to sport, which helps to enhance proprioception and prevent reinjury. Neuromuscular training is very important for reducing injury risk long term but it takes 8-10 weeks to have any effect.
Surgery is rarely needed immediately after lateral ligament injury. Even grade 3 injuries (complete tears) to all three ligaments warrant 6-12 weeks of non-operative management prior to considering ankle ligament reconstruction. This operation is usually used for recurrent instability or persistent pain in chronic ankle instability.
If you have sustained an ankle injury that has resulted in significant joint swelling, pain or a limp, a consultation at Shire Sports Medicine can be beneficial for you to get an accurate diagnosis, to help guide management of your condition and to ensure the prevention of further complications.