Sprain of the ankle joint

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How does an ankle sprain occur?

The most common mechanism of injury is foot inversion, or inversion of the foot in plantar flexion - where the foot is loaded primarily on the outer edge and the ankle "escapes" to the side. Then, the ligaments lying on the lateral side of the ankle are damaged:

- anterior talofibular ligament (ATFL),
- calcaneofibular ligament (CFL),
- posterior talofibular ligament (PTFL).
In most cases, there is an isolated ATFL ligament injury, less often ATFL and CFL damage or all ligaments of the lateral ankle complex are damaged simultaneously.

Much less frequent damage occurs to the complex four-bundle tricuspid ligament that stabilizes the ankle joint from the medial side. The injury mechanism consists of dorsiflexion, abduction and inversion of the foot, for example when landing on uneven ground, when the outer edge of the foot is supported higher and the ankle is "deformed".

Symptoms of ankle sprain

When an ankle is twisted, a prickling may be felt in the area of ​​the lateral ankle. Pain and swelling gradually increase over 6-12 hours. The severity of symptoms depends on the number of damaged ligaments and whether they have only been stretched or their continuity has been completely broken. In orthopedics, there are several classifications of ankle sprains depending on the selected evaluation criterion. The most commonly used in practice is the 3-point scale:

1st degree ankle sprain - straining of the ligament.
Isolated strains of the ATFL ligament are accompanied by slight swelling and palpation tenderness of the ligament, in a clinical examination the stability of the joint is maintained.
2nd degree ankle sprain - the ligament fibers are partially damaged.
A ligament tear results in clear swelling and a greater degree of pain, limiting the range of motion, but maintaining stability.
3rd degree ankle sprain - the ligament is completely broken.
Complete rupture of the ATFL ligament or ATFL and CFL ligament is associated with massive swelling, hematoma, pain that makes it difficult to load the foot, severe pain limitation of the range of motion and joint instability (symptoms assuming that this is the first joint sprain and the joint was initially stable).

Diagnostics of ankle sprains

The stability of the ankle joint is assessed by the orthopedist during the following tests:

Anterior drawer - with the distal part of the lower leg stabilized, the doctor pulls the heel forward to perform anterior translation of the talus in the upper ankle joint. The increased range relative to the other limb suggests a complete rupture of the ATFL ligament;
Attempts to tilt the talus - the doctor stabilizes the distal part of the tibia with one hand and performs a forced inversion with the other, holding the talus and heel bones together. The increased range of dilation, especially with a soft end feeling, may indicate a break in the continuity of the ATFL and CFL ligaments. The test should always be compared with the opposite ankle joint.

A very important element of the diagnosis of ankle sprain is to find out whether the tibiofibular ligament connecting the bones of the shin has been damaged.

It is advisable to evaluate the capacity of the ligaments during a dynamic ultrasound examination of the ankle joint. When performing ligament tests, the doctor is able to assess the structure of the ligament and determine the degree of its damage on the ultrasound images. Ultrasound examination also allows to exclude other soft tissue damage:

- damage to tendons, tendon sheaths and straps,
- the presence of damage to other joints of the tarsus, hindfoot, the presence of exudate in them,
- swelling of the subcutaneous tissue and many others available on ultrasound.

X-rays are performed when a fracture is initially suspected in a clinical examination. The X-ray examination takes into account the images in the anterior-posterior, lateral, aimed at the ankle forks, and sometimes also oblique projections. If a high fracture of the fibula is suspected (Maisonneuve fracture), a radiograph is performed covering the entire length of the lower leg bone.

Magnetic resonance imaging is most often performed when traumatic damage to the cartilage of the talus bone is suspected. When twisting the ankle joint, the ankle block hits the articular surface of the ankles, which may result in injury to the cartilage itself or the cartilage along with the underlying bone layer - these are the so-called osteochondral lesion of the talus (OLT or OCD osteochondral defect or OCL - Osteochondral lesion).

What to do after an ankle sprain? 

Each ankle sprain should be diagnosed by an orthopedist for accompanying damage and complications - especially if there are additional symptoms in the area of ​​the foot or lower leg. The doctor determines the treatment plan depending on the degree of any instability in the ankle joint, the age and the preferred level of activity of the patient.

The procedure in the acute torsion phase usually involves the implementation of the so-called POLICE principles (Protection, Optimal Loading, Ice, Compression, Elevation - the points of which refer to the general principles of treating fresh injuries. The following guidelines briefly describe the management of ankle sprains without complications such as fractures or damage to the articular cartilage:

1. Protection - protection of stretched or damaged ligaments
   In the case of a first degree sprain, a sufficient form of protection will be stabilization of the ankle joint with taping glued on the ankle by a physiotherapist. Second and third degree sprains may require an ankle stabilizer to limit supination and pronation movements and partially relieve the limb with elbow crutches. In the acute period, avoid foot movements that reflect the injury mechanism, e.g. plantar flexion and foot supination in the case of ankle joint lateral ligaments injury.
2. Optimal Loading - ensuring appropriate conditions for the healing of the ligament
   If there are no clear indications for immobilization of the ankle joint in a cast (e.g. due to a fracture), it should not be put on. Unjustified immobilization leads to muscle contractions, reduced mobility in the joint, inelastic scar formation at the site of ligament damage, loss of receptors responsible for "feeling" of the joint, and ultimately impaired gait pattern. Longer immobilization of the joint is also associated with a greater risk of further ankle sprains, so if it can be avoided, it must be done.
   If possible, you should perform ankle flexion and extension movements within a painless range of motion. When walking on crutches, it is advisable to partially load the leg - also within the pain tolerance. Such procedure will allow for safe modeling of the ligament scar and faster return to normal activity.
3. Compression - optimal compression of a sprained ankle will be aimed at reducing swelling and improving deep feeling (better "feeling" of the ankle joint position). Compression can be achieved by applying an elastic band or wrapping an elastic bandage around the sprained ankle, starting with the metatarsus and ending with the ankle joint.
4. Elevation - keeping the leg elevated, for example, placed on a soft high stool, to facilitate the free flow of venous blood from the lower limb and reduce swelling of the ankle joint.

Ankle sprain - rehabilitation

As part of rehabilitation, manual therapy should be carried out, aimed at:

restoration of the full painless range of motion in the ankle joint,
the ligaments heal with adequate tension,
making the scar more flexible at the site of damage so that the ligament is resistant to subsequent loads.
A frequently used technique is deep transverse massage of the damaged ligament TFM (transverse friction massage), which reduces ankle pain, improves blood circulation in the healing ligament and stimulates the correct remodeling of the scar. In addition, it is advisable to mobilize the ankle and shin bones to restore the correct biomechanical relationships within the lower limb.

Exercises after ankle sprains are designed to:

- restore the physiological gait pattern with the correct foot transfer,
- improve deep sensation (proprioception),
- improve the functional stability of the ankle joint in static and dynamic conditions,
- strengthen the muscles of the lower limb,
- prepare to play sports safely.

Improving proprioception is one of the most important goals in rehabilitation after an ankle sprain. Thanks to the deep feeling, we are able to feel the position of our ankle without eye control, and then tighten the muscles so that the ankle joint remains in a safe position. The whole mechanism should take place automatically and without the participation of our consciousness. Damage to the ligament in which the mechanoreceptors that receive information about the orientation of the ankle joint are located may cause proprioception disorders. The result is incorrect or delayed activation of the muscles that actively stabilize the ankle joint. Proprioception training allows you to restore normal neuromuscular control, and therefore is an element of the prevention of re-sprains of the ankle. The level of difficulty of exercises for a sprained ankle adjusts to the age and patient's expectations regarding the preferred sports activity.

Surgical treatment of a sprain

In the case of complete rupture of the ligament with ankle instability, surgical treatment is considered. Up to 6 weeks after spraining, selected types of ligament injuries can be repaired with the modern Internal Bracing method that preserves the ligament itself. This is not always possible later on. It is then necessary to perform a complete ligament reconstruction with the removal of the graft or the use of an artificial ligament prosthesis.

Chronic ankle instability is one of the complications of a poorly diagnosed or incorrectly treated ankle sprain, or simply the result of a large sprain with ligament damage that was not initially treated with surgery.

Frequently asked questions about ankle sprains: