© NARRABEEN SPORTS MEDICINE PHYSIOTHERAPY CENTRE PTY LIMITED | PRIVACY POLICY | 2021

March 2019

Ankle sprains are the most common injury related to sport & exercise - and even when a sprain seems mild & insignificant - it leads to long term problems in 44% of sprained ankles.  These ankles go on to develop chronic instability.

Ankle injuries have the highest re-injury rate of any lower body injury.     

So what do we need to do to get this right?

# 1   "I'll wait til the swelling goes down before I go to physio..." 

Don't wait to come to physio!  Assessing your ankle & reducing the swelling to help restore your range is all part of the service.  The longer the swelling sits around the ankle, the more difficult it can be to remove - and the stiffer your ankle stays for longer.  Swelling will change the sensory input to the nervous system which negatively affects functional joint stability.  Reducing swelling & restoring range are our first priorities.  Swelling together with mechanism, history, ability to weight bear & examination are all important factors in assessment.  Don’t wait - come in to see us ASAP.

#2   It’s just a rolled ankle - I’ll walk it off…

Sure, not every ankle sprain is going to be career ending and not every ankle needs crutches and immobilisation - but there are some significant injuries that can occur, that when missed, can cause long term pain & heartache.  Even the most basic lateral ankle sprain requires assessment & thorough rehabilitation to not lead to regular sprains.

Ligament tears that are not given the respect they deserve will lead to chronic instability in 44% of ankles - causing joint damage, often resulting in surgery and long term functional disability (see our commonly missed injury section below).  So, walk it - straight to physio.  

#3   I’ll just take some anti-inflammatories for the swelling & pain.  

The use of non steroidal anti-inflammatory drugs (NSAIDs) in the first few days after ligament or muscle injury is not recommended.  When the ligament is injured, swelling brings with it the natural chemicals that initiate healing.  This inflammatory response is blocked by the use of NSAIDs.  

There is evidence that depending on what type of NSAID you use, it can cause increased bleeding, impair bone repair and likely affect tissue healing.  

So for pain relief, try analgesia - but leave the anti-inflammatories for a few days.  Better still - be guided by your Sports & Exercise Physician.

#4   My ankle feels stiff but I have to get back to training.

Almost half of people who  sprain their ankle go on to re injure and become recurrant sprainers - particularly if the initial injury was a Gr 2 sprain.  So heading back to training before you have all of the measurable parameters back to normal, some rehabilitation under your belt & have trained the skills required for your sport - is madness!  Although taping & bracing can help protect an unstable ankle, nothing beats thorough rehabilitation.  Physiotherapists will make sure that:

• Knee to wall measurement (dorsiflexion) has returned to normal (L = R)
• Strength & endurance of the calf and foot muscles are back normal
• Proprioception & balance is trained, progressed & practised to reduce recurrence of injury

#5  I've had a few sessions of physio - that should be enough. 

Research shows that supervised rehabilitation will reduce the risk of re injury.  

Rehabilitation - under supervision has many phases that need to be completed depending on the stage of tissue healing.

1. Initial inflammatory phase (hours - days):   Protect (tape/brace), compress, ice, elevate.
2. Repair phase (days - 6 weeks+) : restore normal range, strengthen & start to challenge proprioception (balance).  Players may return to modified training, starting straight line activities & fitness, progressing to selective change of direction drills & skills.
3. Remodelling (6 weeks + to 3 months) : if you stop now - the quality of the scar tissue & repair will be limited - there is still so much work to do.  Jumping, landing, pivoting, agility, change of direction.  Rehabilitation through this phase needs to be sports specific and include a reintroduction to full training.  

To finish your rehab early - sets you up for re-injury, long term instability & disability.

5 biggest mistakes people make when they sprain their ankle

Kang et al (2014).

What are the commonly missed injuries & fractures in the ankle?

1.  Syndesmosis - high ankle sprain  

3.  Anterior process of the calcaneus.

4.  Posterior process of the talus.

5.  Lateral process of the talus.

6.  Talar dome - osteochondral lesion.

DO YOU HAVE PERSISTENT ANKLE PAIN, SWELLING, INSTABILITY?

We should exclude these diagnoses above with a thorough history, examination and backed up with some quality imaging.  These are the injuries are often missed on early examination, with poor imaging and often require referral to an Orthopaedic Specialist. 

Symptoms > 6 weeks should always be re-examined.

2.  Base of the 5th metatarsal - avulsion fracture & common bone for missed stress fractures.

Anandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle injuries. Br J Sports Med 2005;39:e14

Drewes, L. K. et al. (2009) ‘Dorsiflexion deficit during jogging with chronic ankle instability’, Journal of Science and Medicine in Sport, 12(6), pp. 685–687.

Vicenzino, B. T. et al. (2018) ‘Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium’, British Journal of Sports Medicine, 52(20), pp. 1304–1310. doi: 10.1136/bjsports-2017-098885.

Council, A. M. (2005) ‘Practice Essentials — Sports Medicine Practice Essentials - Sports Medicine.  183(7), pp. 82–99.

Hopkins JT, Palmieri R. Effects of ankle joint effusion on lower leg function. Clin J Sport Med 2004;14:1–7

Milne, B. C. (1899) ‘Anti-inflammatory Drugs – Their Role In Sports Medicine : Which sports medicine conditions are NSAIDs and cortisone injections useful for ?’

Wienerroither, V. et al. (2018) ‘Effect of COX-2 inhibition on tendon-to-bone healing and PGE2 concentration after anterior cruciate ligament reconstruction’, European Journal of Medical Research. BioMed Central, 23(1), pp. 1–11. doi: 10.1186/s40001-017-0297-2.

Sauerschnig, M. et al. (2018) ‘Effect of COX-2 inhibition on tendon-to-bone healing and PGE2 concentration after anterior cruciate ligament reconstruction’, European Journal of Medical Research, 23(1), p. 1. doi: 10.1186/s40001-017-0297-2.

Vuurberg, G. et al. (2018) ‘Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline’, British Journal of Sports Medicine, 52(15), p. 956. doi: 10.1136/bjsports-2017-098106.

© NARRABEEN SPORTS MEDICINE PHYSIOTHERAPY CENTRE PTY LIMITED | PRIVACY POLICY | 2019