Ankle Sprains and Long Term Management

Understanding Ankle Sprains and Their Long Term Management
Posted on 01/14/2022
athlete holding ankle

Understanding Ankle Sprains and Their Long Term Management

Seth Beal MAT, LAT, ATC, CES

Head Athletic Trainer, Highlands Ranch High School

Among the general population, ankle sprains are a common yet not very well understood injury. From my personal experience evaluating and rehabilitating athletic injuries, many athletes and coaches tend to view ankle sprains as “simple” injuries. Unfortunately, this is not the case and this perspective can cause athletes to take the rehabilitation process following an ankle sprain less seriously. According to the research, there are an average of 2 million acute ankle sprains reported  among the general population each year, 600,000 of which involve trips to the emergency room.1 However, other reports have shown that 55% of people who suffer ankle sprains do not seek medical attention, so it is safe to assume that their prevalence is  significantly higher than reported.2 Among the documented cases, the healthcare cost for evaluation, treatment and rehabilitation of ankle sprains is $4.2 billion annually.1

Although the numbers above may seem surprisingly high, they actually only relate to the time it takes for an individual to return to full participation in their daily life. These numbers do not include costs for treatment or follow-ups if an individual develops any chronic symptoms later on (i.e. latent pain, instability, tightness, etc. developed 6-12 months after the initial injury healed). Unfortunately, 40% of all ankle sprains lead to the development of chronic symptoms roughly 12 months following the injury.3,4 Also, even if a patient does not develop chronic symptoms, the primary predictor for suffering a future ankle sprain is having had an ankle sprain in the past. So, in addition to potentially suffering a second injury and restarting the healing process, the new sprain can also lead to chronic symptoms. With all this in mind, it is imperative that individuals who have suffered an ankle sprain implement a home maintenance program to reduce chronic pain, instability, and their risk for future sprains. 

There are three main aspects of ankle function that are affected following a sprain: range of motion (ROM), strength, and proprioception (i.e. your perception of how, when and where your body moves).3 Not surprisingly, if these are the aspects most affected following a sprain, maintaining their function long term can assist in reducing chronic pain. In the rest of this article, I will describe some of the challenges that arise following the initial injury and provide some methods to address them and reduce chronic pain long term. 


Range of Motion (ROM)

When a ligament suffers a sprain, there is always damage to its structure, usually in some form of tearing or shearing. While healing, the body cannot recreate the same type of tissue that ligaments are composed of. Instead it uses scar tissue, a weaker substance, to fill in the damaged areas.5 The scar tissue is haphazardly dumped in the injured area and somewhat resembles the noodles on a plate of spaghetti. It has no particular alignment and can build up beyond the injured sight, significantly decreasing the ankle’s ROM.5 When ROM is limited, the ankle cannot be placed in its safest positions, which increases the likelihood of suffering another injury. Also, when the ankle cannot reach its full ROM, the muscles that stabilize the ankle may become weaker and tighten due to their restrictions.6 Muscle tightness or weakness can be a significant cause for chronic pain due to a lack of stabilization or imbalance.6 Below are the parameters for an effective foam rolling and stretching program that can benefit muscle length deficits and reduce chronic ankle pain:

Foam Rolling: 

  • Should always happen before stretching and between 3-5 days per week.

  • Begin on the floor in a seated position with both legs extended and the roller placed underneath the back of your knee.

  • Allow the roller to move 1 inch per second down to the heel and then back up to it’s starting point. Repeat this, but do not foam roll one area for longer than 90 seconds.  

  • Follow the same time frame for the inner and outer portions of the lower leg, but position yourself in a side plank to effectively reach the area.

Stretching: 

  • Position yourself in a staggered stance with the leg you wish to stretch placed in front, roughly 1 foot away from a wall.  

  • Roll up a hand towel and place it along the bottom of the balls of your feet. Then, lunge towards the wall until you feel a good stretch in your calf/achilles. 

  • Hold this for 30-60 seconds for both legs. Always make sure to do both sides. 


Strength

As indicated above, muscles can tighten and decrease their overall range of motion following an acute ankle sprain. In addition, muscles can quickly decrease in strength and physical mass due to swelling and lack of use.7 With muscular weakness and ligament damage the bony position of the ankle may shift slightly. This can affect our muscles’ angle of pull and exacerbate symptoms of pain and weakness from lack of stability if not actively addressed. Many people tend to depend on ankle braces and taping for support, which can be effective short term.8 However, our muscles are our first line of defense in ankle stabilization and are imperative for reducing injury and living pain free long term. Below are some at-home exercises that can help maintain stabilization and support of the ankle:


Towel Scrunches:

  • Lay a hand towel on the ground length wise and place an object that weighs between 2-5lbs on top of the towel at one end. 

  • In a staggered stance, place the balls of your foot on the opposite side from the weight. The majority of the foot should be off the towel, but the toes are on. 

  • Use your toes to grab the towel and curl them towards you so that the weight moves in your direction. 

  • Once the weight reaches you, that is considered 1 repetition. Complete 3 sets of 8 repetitions, 3 times per week on both feet. 

Heel Walks:

  • Stand with all weight on your heels, keeping the toes and arch of the foot off the ground. 

  • Walk back and forth on a flat surface (hallway, room, etc.) for 3 rounds of 30 seconds, 3 times per week. 

Eccentric Calf Raises:

  • Stand with the balls of both feet on the edge of a stair with the heels hanging off. Raise up with both so that you are standing tip-toe on the edge of the stair.

  • Lift one foot and remain on your one tip-toe, then slowly lower yourself down on the remaining leg. Try to count to five before reaching the bottom. 

  • Raise yourself back up with both feet and use the opposite leg for the second repetition and alternate legs for the rest of the set.  

  • 3 sets of 16-20 (8-10 per leg),  3 times per week.


Proprioception and Neuromuscular Control

Every ligament and tendon has a connection to the central nervous system (CNS), which allows them to send and receive signals.9 When a tissue is damaged, however, it’s connection to the CNS is damaged as well. When the CNS connection is damaged, key muscles that aid in landing and balance, such as peroneus brevis and longus, cannot receive signals to activate properly.10 Without proper activation, the ankle cannot stabilize itself and the risk for reinjury increases. Also, if our proprioception is damaged, our walking patterns can change, which can place excessive stress on other areas of the ankle and cause chronic symptoms.10 Below is an at home recommendation to improve and maintain proprioception and neuromuscular control:


Single Leg Balance:

  • Stand on one leg with your shoes off and hands on your hips. Try to keep pressure on the balls of your feet, but your entire foot must stay flat to the ground. Apply a slight bend to the knee of the leg you are standing on and keep your chest up. Maintain this position for the duration of the exercise.  

  • If you can do 3 x 30 seconds on both legs with little to no difficulty, make it more challenging by closing your eyes and/or stand on an uneven or carpeted surface. 


Although ankle sprains may be less visibly gruesome and life threatening than many other injuries, misunderstanding them and underestimating their recovery can have long term detrimental effects. During the pandemic, many of us have been exposed to the concept of working from home. Hopefully, with a better understanding of ankle sprains and some at home methods for self maintenance, more and more individuals will change their perception of ankle sprains and take better care of them long term. 


Resources:

  1. Waterman, Brian R. MD1; Owens, Brett D. MD2; Davey, Shaunette DO1; Zacchilli, Michael A. MD1; Belmont, Philip J. Jr. MD1 The Epidemiology of Ankle Sprains in the United States, The Journal of Bone & Joint Surgery: October 6, 2010 - Volume 92 - Issue 13 - p 2279-2284 doi: 10.2106/JBJS.I.01537

  2. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med. 2001;35(2):103-108. doi:10.1136/bjsm.35.2.103

  3. Mugno AT, Constant D. Recurrent Ankle Sprain. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560619/

  4. Al-Mohrej OA, Al-Kenani NS. Chronic ankle instability: Current perspectives. Avicenna J Med. 2016;6(4):103-108. doi:10.4103/2231-0770.191446

  5. Draper D, Knight K. Therapeutic Modalities: The Art and Science. Baltimore, MD: Lippincott Williams & Wilkins; 2008.

  6. Herzog MM, Kerr ZY, Marshall SW, Wikstrom EA. Epidemiology of Ankle Sprains and Chronic Ankle Instability. J Athl Train. 2019;54(6):603-610. doi:10.4085/1062-6050-447-17

  7. Londhe P, Guttridge DC. Inflammation induced loss of skeletal muscle. Bone. 2015;80:131-142. doi:10.1016/j.bone.2015.03.015

  8. Dizon JM, Reyes JJ. A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players. J Sci Med Sport. 2010 May;13(3):309-17. doi: 10.1016/j.jsams.2009.05.002. Epub 2009 Jul 7. PMID: 19586798.

  9. Moore K, Dalley A. Clinically Oriented Anatomy. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999.

  10. Heejaeng, Kim. Ankle Sprain Affects Lower Leg Muscle Activation on Vertical Landing, Half Point, and Gait in Female Ballet Students. The Journal of Korean Physical Therapy. 2019;31(2):129-133. https://doi.org/10.18857/jkpt.2019.31.2.129

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