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Ankle Sprains – July Newsletter

Ankle Sprain Basics

Guest article by: Doug Reeves, SPT

Many of us have experienced a “twisted”, “turned”, or “rolled” ankle at some point while participating in the activities we enjoy. In fact, sprained ankles may account for up to 30% of all sports injuries1. But what is really happening to our ankles when we suffer one of these painful injuries? And how do we get back to participating in our favorite sports and recreational activities following one of these events?

There are several different categories of ankle sprains and the severity of injury can differ significantly within each category.

The lateral (or inversion) sprain, in which our foot is rolled inward (inversion/plantarflexion) while bearing weight, is by far the most common. The medial (or eversion) sprain, in which the foot is rolled outward (eversion/plantarflexion) does not occur nearly as frequently because of the relatively higher strength of the medial ligament as well as the bony structure of the ankle. Both lateral and medial sprain symptoms present similarly though.

Types of ankle sprains

There are three levels of severity to either the medial or lateral ligament complex when it comes to ankle sprains and they are graded accordingly. A Grade 1 injury is the least severe and usually resolves on its own. With a Grade 1 sprain, the ankle ligaments are stretched but not torn. As such, the patient will generally find:

  • function is not impaired
  • there is no inability to bear full weight
  • there is very little (if any) swelling
  • no ankle laxity is experienced

However, a Grade 2 sprain involves tearing, not just stretching, of the lateral or medial ankle ligaments. In this instance, the patient will experience:

  • point and diffuse tenderness
  • some dysfunction
  • slight to moderate laxity
  • mild to moderate swelling and discoloration
  • painful weight bearing resulting in a limp while walking and often requiring an assistive device such as a cane or crutches

To maximize outcomes, it is important that you do NOT immobilize the ankle with either a Grade 1 or Grade 2 sprain. The evidence suggests that early functional rehabilitation with guidance from a skilled physical therapist is much more effective than immobilization2.
Finally, a Grade 3 sprain entails a complete rupture of the medial or lateral ligament complex. Patients will present with:

  • point and diffuse tenderness
  • moderate to severe dysfunction and laxity
  • severe swelling and discoloration
  • limited or no ability to bear weight without an assistive device

As opposed to Grade 1 and 2 sprains, it IS recommended that a Grade 3 injury be immobilized via a cast, walking boot, or rigid stirrup immediately and for 10 days post injury2,4. Following the immobilization period, functional rehabilitation is indicated.

The last, and most severe, type of sprain is the high (Syndesmotic) ankle sprain. A syndesmosis is a fibrous joint between two bones and linked by ligaments and a strong membrane. Our lower leg bones, the tibia and fibula, are attached via an interosseous membrane that extends the length of the bones and at the ankle via a syndesmosis which includes the interosseous ligament (IOL), the anterior-inferior tibiofibular ligament (AITFL), the posterior-inferior tibiofibular ligament (PITFL) and the transverse tibiofibular ligament (TTFL)5,6.

lateral view of the ankle diagram of foot and ankle

Syndesmotic sprains account for up to 18% of all ankle sprains7 and often occur during sport when the foot is trapped and forced into external rotation, often with dorsiflexion and eversion as well. As with the other sprains, there are 3 grades. A high ankle sprain is considered to be Grade 1 when the syndesmosis is simply stretched. As such, the patient would experience:

  • delayed pain and swelling after the injury
  • continued ability to participate immediately following the injury.
  • Mild AITFL tenderness
  • Stable ankle

A Grade 2 sprain would represent a partial syndesmosis tear and the patient would present with:

  • Immediate pain and swelling
  • Inability to continue participation
  • Painful gait
  • Moderate AITFL tenderness

Finally, a Grade 3 sprain is a complete rupture of the syndesmosis. Symptoms would include:

  • A “pop” felt during the forceful external rotation
  • Severe pain and swelling
  • Inability to walk
  • Severe AITFL tenderness

Conservative treatment of a syndesmotic injury is similar to other ankle sprains, but with a much more graded return. In addition, a walking boot is initially required and weight bearing is limited to protect the damaged structures. As you would expect, these injuries are the slowest healing of the ankle sprains, often taking twice as long as a lateral Grade 3 sprain.

Your physical therapist is skilled and knowledgeable in both assessing the type of ankle sprain you’ve suffered and grading its severity. In addition, they’re able to perform other special tests that help to rule out or rule in other injuries that often accompany a sprain. Finally, they will set up a plan of care to:

  • protect your injured structures
  • treat your pain/inflammation/swelling
  • regain your prior:
    • range of motion
    • neuromuscular control and strength
    • proprioception and agility
    • functional and recreation/sport related skills
  • facilitate your return to sport

Finally, if you’ve suffered ankle sprains in the past it is possible to decrease the risk of future sprains. Neuromuscular control training regimens have been shown to decrease the risk of re-injury by up to 36%8. And both balance training programs9 and prophylactic bracing have also been shown to reduce the risk of recurrence. Your physical therapist can help implement a program to help you stay healthy and participating in the sports and activities that you enjoy.
foot in air brace
foot in lace up brace

Managing Lower Back Pain:
Why movement is so important

Holly Warner, DPT

Low back pain can be debilitating. It often hurts to bend, twist, rotate or stand upright. It is uncomfortable to cough or sleep and often hurts to get up and move around. The last thing anyone wants to do is move, but that is the one thing you must do.

Acute low back pain is defined as an episode of low back persisting less than 6 weeks. The prognosis for recovery is good and symptoms typically resolve within a few days. Though 30% of persons with acute low back pain will not recover within 1-year time and often symptoms become chronic.1a This may be due to lack of education or guidance on the diagnosis, prognosis and self-management of the condition. It may also be secondary to individuals fearing movement and therefore placing themselves on best rest avoiding movement secondary to pain and fear of pain.

A research study published in the Boston Medical Center Sports Science, Medicine and Rehabilitation Journal in 2015 looked into the effect of two programs for treatment of acute onset of low back pain. The study took 99 patients with acute severe low back pain <48 hours after onset of pain and randomized them into two groups 1) “Stay active in spite of pain” 2) Adjust activity to the pain”. Both groups had significant improvements in pain after 1 week, though the group advised to “stay active in spite of pain” increased their step rate from 4560 to 9865 steps/day in 1 week compared to 4317 to 6609 steps/day in the group advised to adjust based on symptoms. It is important to note that the pain improved in both groups, but the group advised to stay active met the recommended guidelines of walking nearly 10,000 steps/day. (1)

Joints need to move to stay healthy and to keep blood flowing for optimal healing. Lack of movement leads to stiffness and worsening of pain and disability. Early mobilizations is being executed in various therapy settings including the ICU. This is because it has been found that prolonged bed rest in ICU patients leads to reduction in muscle mass, bone mineral density loss and impaired body systems with notable changes occurring after only one week.2a Bed rest is not good for the overall health of the body, therefore remaining active will help one recover faster and stay healthy throughout the process.

Most of us will experience acute low back pain at some point in our life. Be confident in knowing your symptoms should improve within a week if you stay active and continue with your normal activities. It is also helpful to establish care with a physical therapist to receive a guided and supervised exercise program to help manage your symptoms and receive manual therapy if indicated as these treatments have been shown to help treat low back pain.3a Using heat and/or ice may also be helpful in managing symptoms, and try to avoid staying in any position for too long as this may cause increased stiffness and/or pain.

Here are some ideas of how to stay active:

  1. Go on shorter walks more often throughout the day (take a walk around the block morning, afternoon, and evening)
  2. Try walking in the pool
  3. Try gentle stretches like cat/camel, rockbacks, knee sways

Picture of how to do knee sways stretch
Knee Sways – gently rock knees side to side

picture of child's pose stretch
Quadruped Rockbacks/Child’s Pose Yoga Stretch – gently rock back onto heels holding stretch for a short time then returning to hands and knee position and repeat.

Picture of camel/cat stretch
Cat/Camel stretch – gently round spine and extend back through comfortable range of motion

1. Fong, D. T., Hong, Y., Chan, L., Yung, P. S., & Chan, K. (2007). A Systematic Review on Ankle Injury and Ankle Sprain in Sports. Sports Medicine, 37(1), 73-94. doi:10.2165/00007256-200737010-00006
2. Beynnon, B. D., Renström, P. A., Haugh, L., Uh, B. S., & Barker, H. (2006). A Prospective, Randomized Clinical Investigation of the Treatment of First-Time Ankle Sprains. The American Journal of Sports Medicine, 34(9), 1401-1412. doi:10.1177/0363546506288676
3. Kerkhoffs, G. M., Struijs, P. A., Marti, R. K., Assendelft, W. J., Blankevoort, L., & Dijk, C. N. (2002). Different functional treatment strategies for acute lateral ankle ligament injuries in adults. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd0029384. Hermans JJ, Beumer A, De Jong TA, Kleinrensink GJ. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. Journal of anatomy. 2010 Dec 1;217(6):633-45
4. Lamb, S., Marsh, J., Hutton, J., Nakash, R., & Cooke, M. (2009). Mechanical supports for acute, severe ankle sprain: A pragmatic, multicentre, randomised controlled trial. The Lancet, 373(9663), 575-581. doi:10.1016/s0140-6736(09)60206-3
5. Hermans JJ, Beumer A, De Jong TA, Kleinrensink GJ. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. Journal of anatomy. 2010 Dec 1;217(6):633-45.
6. Lin CF, Gross MT, Weinhold P. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. Journal of Orthopaedic&Sports Physical Therapy. 2006 Jun;36(6):372-84
7. Porter, D., Rund, A., Barnes, A. F., & Jaggers, R. R. (2014). Optimal management of ankle syndesmosis injuries. Open Access Journal of Sports Medicine, 173. doi:10.2147/oajsm.s41564
8. Hübscher, M., Zech, A., Pfeifer, K., Hänsel, F., Vogt, L., & Banzer, W. (2010). Neuromuscular Training for Sports Injury Prevention. Medicine & Science in Sports & Exercise, 42(3), 413-421. doi:10.1249/mss.0b013e3181b88d37
9. Mckeon, P. O., & Hertel, J. (2008). Spatiotemporal postural control deficits are present in those with chronic ankle instability. BMC Musculoskeletal Disorders, 9(1). doi:10.1186/1471-2474-9-76

1a Olaya-Contreras P, Styf J, Arvidsson D, Frennered K, Hansson T. The effect of the stay active advice on physical activity and on the course of acute sever low back pain. BMC Sports Science, Medicine and Rehabilitation. 2015;7(19). DOI 10.1186/s13102-015-0013-x
2a Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. Extreme Physiology and Medicine. 2015;4(16). DOI 10.1186/s13728-015-0036-7.
3a Stochkendahl MJ., Kjaer, P., Hartvigsen, J. et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. European Spine Journal. 2018;27:60-75. https://doi.org/10.1007/s00586-017-5099-2

Images retrieved from:
https://upload.wikimedia.org/wikipedia/commons/5/5d/Ankle.PNG https://upload.wikimedia.org/wikipedia/commons/e/e9/Slide2dede.JPG