Photo: Western Bulldogs
Western Bulldogs fans will have likely witnessed Marcus Bontempelli suffering an ankle sprain in round one of the AFL. Fortunately, this has been assessed as a low-level sprain, and with access to the best rehabilitation it looks like he will make a timely return to the field. However, for some people ankle sprains can be a source of chronic pain and disability.
Let’s explore.
Whether during a heroic play during sport or losing footing on the footpath, chances are you know someone who has sprained their ankle. Maybe due to this fact, it is widely considered a mild injury that will self-resolve, to the point where approximately 50% of individuals do not go through rehabilitation.
Maybe not surprisingly, up to 40% of people experience chronic ankle instability after an ankle sprain, which can result in persistent pain, swelling, and instability. Not only can this be very disruptive to regular life, repeated trauma and poor ankle condition may even result in joint degeneration and cartilage issues.
The good news is that we do not have to sit idly by and just hope things resolve.
I’ve sprained my ankle. Now what?
The key components of a rehabilitation program should include:
The early stages
It is highly likely the ankle will need a period of protection. The preferred way to do this is to use a functional support brace or tape which allows for early loading of the ankle to help stimulate good strong healing of the ligaments. Crutches can be a helpful tool to provide some protection to the joint without having to completely rest. In cases of very significant injury, a short period of immobilisation in a moon boot may be utilised to assist in managing pain and swelling and to ensure optimal healing of the ligament.
Addressing the ankle defecits
A thorough assessment should identify which of the above key areas need addressing. It is very likely that a person after an ankle sprain will exhibit reduced strength, range of motion and control of their ankle.
Proprioception and control – During movement and balance, the ankle and nervous system work closely together to maintain control: the structures around the ankle provide detailed information to the brain, and as a result the brain provides instructions to the muscles around the ankle to adjust and optimise the ankle throughout movement.
After an ankle injury, the ability of the ankle to send information to the brain is compromised and as a result there is a lack of coordination and reduced reaction timing of the muscles which makes it harder to make micro adjustments to keep us steady. This unfortunately also means the ankle is more susceptible to injury in this time. Rehabilitation should include exercises that challenge balance to attempt to improve this coordination and improve accuracy of information sent to the brain.
Strength – Some of the key muscles around the ankle including the gastrocnemius, soleus and peroneals will likely be weak due to pain inhibition, reduced ankle stability and lack of use during the initial stages. Depending on the injury severity, strengthening may be done in a restricted range of motion initially and gradually built up as healing progresses.
Range of motion – The ankle may be restricted in movement globally, particularly with knee over toes movements (i.e dorsiflexion) such as lunging and going up/down steps. As symptoms reduce, exercises will likely be completed in larger ranges of motion covering a variety of angles and positions. It is important that this is done in a way that matches the condition of the ankle, as forcing some movements too soon can potentially prolong soreness.
Biomechanical retraining
After the initial injury, the body attempts to offload the sensitive ankle by changing the way we move by loading up the hip and the knee to compensate. This can be a great temporary strategy to give the ankle space to heal in the short term.
However, if the ankle deficits are not addressed properly, this can become “normal” even after the ankle has healed – the nervous system is still in “protect” mode after it is no longer beneficial. This can lead to a chronically underloaded ankle which can lead to weakness and instability. For some people, they may cope well with daily activities but on attempting a more demanding task such as going up steps, fast walking, running or even some gym work, they may experience pain, stiffness or instability. Interestingly, because the changes in movement patterns are arising from the way the brain interacts with the muscles and joints, some people even experience these changes in movement patterns on the unaffected side!
The first important step is to address the ankle deficits so that the ankle has capacity to re-take on its normal role in movement. When the ankle is ready, we can begin retraining the way the brain and nervous system uses and trusts our ankle. Initially, it is common to find that the ankle is hesitant to bend forward and accept load. This should be initially retrained with low load but high repetitions to ingrain the desired pattern. As this improves, rehab should be progressed to higher loads to restrengthen these previously compromised positions. The end result is to ensure good ankle, knee and hip coordination to reduce future injury risk, ensure optimal loading and enhance sporting performance.
Ankle sprains are very common, however they should not be underestimated. A good assessment and early intervention after an ankle sprain, particularly a first one, may save many headaches down the line.
Don’t hesitate to get in touch with one of our CSSM physios if you’re unsure if your ankle sprain needs further investigation.
About the author
CSSM physiotherapist Hugh Feary particularly enjoys the challenge of integrating people back into sport as fast as possible. Hugh has previously worked in GP clinics and private practice as well as a variety of local sporting teams, including the Fremantle Dockers in the AFLW. Hugh’s focus is on empowering his clients with the information and tools they need to manage their own health and get back to the things they love.
References
Doherty, C., Bleakley, C., Hertel, J., Caulfield, B., Ryan, J., & Delahunt, E. (2016). Recovery from a first-time lateral ankle sprain and the predictors of chronic ankle instability: a prospective cohort analysis. The American journal of sports medicine, 44(4), 995-1003.
Donovan L, Hetzel S, Laufenberg CR, McGuine TA. Prevalence and Impact of Chronic Ankle Instability in Adolescent Athletes. Orthop J Sports Med. 2020 Feb 18;8(2):2325967119900962. doi: 10.1177/2325967119900962. PMID: 32118082; PMCID: PMC7029541.
Herzog MM, Kerr ZY, Marshall SW, Wikstrom EA. Epidemiology of Ankle Sprains and Chronic Ankle Instability. J Athl Train. 2019 Jun;54(6):603-610. doi: 10.4085/1062-6050-447-17. Epub 2019 May 28. PMID: 31135209; PMCID: PMC6602402.
Vuurberg G, Hoorntje A, Wink LM, et al
Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline
British Journal of Sports Medicine 2018;52:956.
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