ANKLE SPRAIN

 INTRODUCTION:

• An ankle sprain occurs when the strong ligaments that support the ankle stretch beyond their limits and tear.
• Ankle sprains are common injuries that occur among people of all ages. They range from mild to severe, depending upon how much damage there is to the ligaments.
• Lateral ankle sprains are referred to as inversion ankle sprains or as supination ankle sprains.
• It is usually a result of a forced plantar flexion/inversion movement, the complex of ligaments on the lateral side of the ankle is torn by varying degrees.

Anatomy: 

• The bones that make up the ankle joint include the distal tibia and fibula (the medial and lateral malleolus, respectively) and the talus the bones that make up the ankle joint include the distal tibia and fibula (the medial and lateral malleolus, respectively) and the talus.

Joints:

ANATOMY OF ANKLE JOINT

• The Ankle Complex consists of 3 articulations The talo-crural (ankle joint) ( Mortise joint) is a hinge joint between the inferior surface of the tibia and the superior surface of the talus.
• It allows the movements of plantar flexion and dorsi flexion (sagittal plane).
• The talo-crural joint receives ligamentous support from a joint capsule and several ligaments, including the anterior talo-fibular ligament (ATFL), posterior talo-fibular ligament (PTFL), calcaneo-fibular ligament (CFL), and deltoid ligament.
• The ATFL, PTFL, and CFL support the lateral aspect of the ankle. Plantar flexion is the least stable position of the ankle joint, which explains why the majority of ankle injuries occur in this position.
• The inferior tibio-fibular joint is the articulation between the distal parts of the tibia and fibula, where a small amount of rotation (transverse plane) is possible.
• Injury in these joints called (high ankle sprains). Ligaments are strong, fibrous tissues that connect bones to other bones. The ligaments in the ankle help to keep the bones in proper position and stabilize the joint.
• Most sprained ankles occur in the lateral ligaments on the outside of the ankle. Sprains can range from tiny tears in the fibers that make up the ligament to complete tears through the tissue.
• If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes.
• Over time, this instability can result in damage to the bones and cartilage of the ankle joint. The joint is stabilized by a thick interosseous membrane and the anterior and posterior inferior tibio-fibular ligaments.
• The subtalar joint is an articulation between the talus and calcaneus and allows the movements of eversion and inversion (frontal plane).
• It also has an important role as a shock absorber. The ligamentous support of the subtalar joint is extensive, it is divided into 3 groups:
• (1) deep ligaments, (2) peripheral ligaments, and (3) retinaculum.
• The lateral ligaments of the ankle, composed of the anterior talofibular ligament (ATFL), the calcaneo-fibular ligament (CFL), and the posterior talo-fibular ligament.
• The medial (deltoid) ligaments are much stronger than the lateral ligament and are therefore injured much less frequently.

Causes:

• foot can twist unexpectedly during many different activities, such as: Walking or exercising on an uneven surface
• Falling down
• Participating in sports that require cutting actions or rolling and twisting of the foot—such as trail running, basketball, tennis, football, and soccer
• During sports activities, someone else may step on your foot while you are running, causing your foot to twist or roll to the side.
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Symptoms:

A sprained ankle is painful. Other symptoms may include:

• Swelling
• Bruising
• Tenderness to touch
• Instability of the ankle—this may occur when there has been complete tearing of the ligament or complete dislocation of the ankle joint.
• If there is the severe tearing of the ligaments, you might also hear or feel a “pop” when the sprain occurs.
• Symptoms of a severe sprain are similar to those of a broken bone and require prompt medical evaluation.

GRADES OF ANKLE SPRAIN:

• After the examination, your doctor will determine the grade of your sprain to help develop a treatment plan. Sprains are graded based on how much damage has occurred to the ligaments.

• Grade 1 Sprain (Mild) :
• Slight stretching and microscopic tearing of the ligament fibers
• Mild tenderness and swelling around the ankle
• Grade 2 Sprain (Moderate) :
• Partial tearing of the ligament
• Moderate tenderness and swelling around the ankle
• If the doctor moves the ankle in certain ways, there is an abnormal looseness of the ankle joint
• Grade 3 Sprain (Severe) :
• A complete tear of the ligament
• Significant tenderness and swelling around the ankle
• If the doctor pulls or pushes on the ankle joint in certain movements, substantial instability occurs.

Diagnosis of Ankle sprain :

• diagnosis is based on
• HISTORY : Taking an accurate history is an important step in determining the nature of the injury.
• A plantar flexion/inversion injury would indicate damage to the lateral ligament, whereas a dorsi flexion/eversion injury would indicate damage to the medial ligament.
• The previous history of injury on the same side will give clues as to whether the ankle was unstable too, begin with, or that a previous injury wasn’t properly rehabilitated.
• History of injury on the other side as well may indicate a bio-mechanical predisposition towards ankle injuries.

OBSERVATION: The physical examination begins with the general observation of the foot and ankle. Any signs of injury, inflammation, color changes of the skin or atrophy/hypertrophy of the muscles are noted.

• After that, observation of the foot and ankle continues in two different positions non-weight bearing (n-WB) and weight-bearing (WB) positions.
• Make a note of the gait pattern, degree of limp (if any), the facial expression on weight-bearing, and any other signs that may provide more information about the injury.

PALPATION :

• An important aspect of the initial examination is to determine the exact site of the lateral ligament sprain, whether it’s the ATFL, CFL, or PTFL (usually damaged in that order).
• Palpating the lateral aspect of the ankle over the course of the various aspects of the ligament complex will provide detailed information on the exact location of the tear.
• Begin palpating gently as this can potentially be acutely painful for the patient.

EXAMINATION :

• Range of motion (ROM)
• ROM of the ankle needs to be assessed actively and passively. The movements to be assessed are:
• Plantar flexion and dorsi flexion;
• Inversion and eversion.

SPECIAL TEST :

• Anterior draw
• Talar tilt
• Proprioception
• An anterior draw is done to test the integrity of the ATFL and CFL. With the ankle in plantar flexion, the heel is grasped with the tibia stabilized and drawn anteriorly.
• Talar tilt is done to assess the integrity of the ATFL and CFL laterally and the deltoid ligament medially. Again the heel is grasped, the tibia stabilized and the talus and calcaneus are moved laterally and medially.
• Proprioception can be assessed in any number of increasingly difficult ways, beginning with a simple single-leg stance. The patient can do it on the normal side first, to allow the therapist to get an idea of what the normal is and then attempt on the injured side.
• This test can be progressed by asking the patient to reach outside their base of support (BOS), rotating their neck, or by closing their eyes. Moving onto a wobble board or any other unstable surface will allow the therapist to assess the patient’s ability to respond to a changing surface.

Physiotherapy management

• REDUCE PAIN AND SWELLING: Initial management (i.e. within the first 48-72 hours) of an acute lateral ligament injury is to reduce pain and swelling by following the RICE regimen; Rest, Ice, Compression, and Elevation.
• If weight-bearing (WB) is too painful, the patient can be given elbow crutches and be non-weight bearing (NWB) for 24 hours.
• However, it’s important that at least partial weight bearing (PWB) is initiated relatively soon, together with a normal heel-toe gait pattern, as this will help to reduce pain and swelling.
• Gentle soft tissue massage can be performed to assist with the removal of edema and gentle stretches, as long as this is pain-free.

RANGE OF MOTION EXERCISE :

• active assisted movements of ankle joint include
• dorsiflexion
• plantarflexion
• eversion is especially
• inversion

RESTORE PROPRIOCEPTION :

• Proprioception training should begin as soon as pain allows during the rehabilitation program.

WEIGHT BEARING :

• marching weight-bearing should be initiated as pain allowed
• one leg standing
• toe standing
• heel standing
• toe walking
• heel walking
• lunges

THOSE ABOVE ARE COLLECTED FROM SOME BOOKS AND WEBSITES..

THANK YOU,

SRIKUMARAN PHYSIOTHERAPY CLINIC & FITNESS CENTER