Sprained ankle | |
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Other names | Twisted ankle, rolled ankle, turned ankle |
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Lateral view of the human ankle | |
Specialty | Orthopedics, sports medicine, Physical medicine and rehabilitation, Family medicine |
Symptoms | Swelling, bruising, pain |
Diagnostic method | Physical examination |
Differential diagnosis | Maisonneuve fracture, high ankle sprain |
Treatment | Physical medicine and rehabilitation |
A sprained ankle (twisted ankle, rolled ankle, turned ankle, etc.) is an injury where sprain occurs on one or more ligaments of the ankle. It is the most commonly occurring injury in sports, mainly in ball sports such as basketball, volleyball, football, and tennis. [1]
Knowing the symptoms that can be experienced with a sprain is important in determining that the injury is not really a break in the bone. When a sprain occurs, hematoma occurs within the tissue that surrounds the joint, causing a bruise. White blood cells responsible for inflammation migrate to the area, and blood flow increases as well. [2] Along with this inflammation, swelling and pain is experienced. [1] The nerves in the area become more sensitive when the injury is suffered, so pain is felt as throbbing and will worsen if there is pressure placed on the area. Warmth and redness are also seen as blood flow is increased. [1] There is also decreased ability to move the joint. [1]
Movements – especially turning, and rolling of the foot – are the primary cause of an ankle sprain. [3]
The risk of a sprain is greatest during activities that involve explosive side-to-side motion, such as tennis, skateboarding or basketball. Sprained ankles can also occur during normal daily activities such as stepping off a curb or slipping on ice. Returning to activity before the ligaments have fully healed may cause them to heal in a stretched position, resulting in less stability at the ankle joint. This can lead to a condition known as chronic ankle instability (CAI), and an increased risk of ankle sprains. [4]
The following factors can contribute to an increased risk of ankle sprains:
Ankle sprains occur usually through excessive stress on the ligaments of the ankle. This can be caused by excessive external rotation, inversion or eversion of the foot caused by an external force. When the foot is moved past its range of motion, the excess stress puts a strain on the ligaments. If the strain is great enough to the ligaments past the yield point, then the ligament becomes damaged, or sprained. [5] [6]
The diagnosis of a sprain relies on the medical history, including symptoms, as well as making a differential diagnosis, mainly in distinguishing it from strains or bone fractures. The Ottawa ankle rule is a simple, widely used rule to help differentiate fractures of the ankle or mid-foot from other ankle injuries that do not require x-ray radiography. It has a sensitivity of nearly 100%, meaning that a patient who tests negative, according to the rule almost certainly does not have an ankle fracture. [7] If ankle pain is persistent 6–8 weeks after initial sprain, MRI imaging of the joint can be considered to rule out peroneal tendon, osteochondral, or syndesmotic injury. [ citation needed ]
Ankle sprains are classified as grade 1, 2, or 3, [8] and, depending on the amount of damage or the number of ligaments that are damaged, each sprain is classified from mild to severe. A grade 1 sprain is defined as mild damage to a ligament or ligaments without instability of the affected joint. A grade 2 sprain is considered a partial tear to the ligament, in which it is stretched to the point that it becomes loose. A grade 3 sprain is a complete tear of a ligament, causing instability in the affected joint. [3] Bruising may occur around the ankle. [9]
The most common type of ankle sprain occurs when the foot has a force, typically body weight, causing it to internally rotate to a higher degree than it is supposed to, affecting the lateral side of the foot. When this type of ankle sprain happens, the outer, or lateral, ligaments are stretched too much. The anterior talofibular ligament is one of the most commonly involved ligaments in this type of sprain, followed by the calcaneofibular ligament [10] and posterior talofibular ligament [10] respectively, the later found in more severe ankle sprains. Approximately 70–85% of ankle sprains are inversion injuries.
When the ankle becomes inverted, the anterior talofibular and calcaneofibular ligaments are damaged. This is the most common ankle sprain.[ citation needed ]
A less common type of ankle sprain is called an eversion injury, affecting the medial side of the foot. This happens when, instead of the ankle rotating medially resulting in an inversion injury (the foot rolling too much to the inside), the ankle rotates laterally resulting in an eversion injury (when the foot rolls too much to the outside). When this occurs, the medial, or deltoid, ligament is strained.
A high ankle sprain is an injury to the large ligaments above the ankle that join the two long bones of the lower leg, called the tibia and fibula. High ankle sprains commonly occur from a sudden and forceful outward twisting of the foot. This commonly occurs in contact and cutting sports such as football, rugby, ice hockey, roller derby, basketball, volleyball, lacrosse, softball, baseball, track, ultimate frisbee, soccer, tennis and badminton and horse riding.
Initial treatment commonly consists of rest, icing, compression and elevation (which is often referred to by the mnemonic RICE or sometimes PRICE with P being "protection"). These elements have been recommended by physicians for decades for the treatment of soft tissue damage, and sprained ankles, one of the most common soft tissue injuries. RICE helps limit the amount of swelling to the area, and "facilitates venous and lymphatic drainage". [11] While nearly universally accepted as a treatment, there is insufficient evidence to determine its relative effectiveness as therapy for acute ankle sprains in adults, [12] and the National Athletic Trainers Association notes that most of the rationale for using RICE or individual components is based largely on low-quality clinical trials and laboratory studies with uninjured participants or animal models [13]
Ice is often used to reduce swelling in cycles of 15–20 minutes on and 20–30 minutes off. Icing an ankle too long can cause cold injuries, which is indicated by the area turning white. [14] Also, it is often recommended that ice not be applied directly to the skin, but should have a thin buffer between the ice and the affected area, and some professionals think ice need not be applied at all. Recently, Gabe Mirkin, MD, who coined and popularized the acronym RICE in his The Sportsmedicine Book in 1978, no longer recommends "complete" rest or ice for healing a sprain. After reviewing modern studies, he notes that because ice closes off the blood vessels, "ice doesn't increase healing—it delays it," and "complete Rest may delay healing." He now advises skipping ice altogether unless needed to reduce pain from swelling. [15] A small but growing number of doctors no longer recommend RICE for sprains. [16] [17] [18]
In uncomplicated lateral ankle sprains, swelling of the soft tissue can be prevented with compression around both malleoli, elevation of the injured ankle higher than the heart, and pain-free exercises. [19]
An orthopedic walking boot is often used for the treatment of a sprained ankle injury. Braces and crutches are also used to help alleviate the pain so the injured ankle can heal as quickly and painlessly as possible.
Although found to be less effective than casts, compression bandages are used to provide support and compression for sprained ankles. Wrapping is started at the ball of the foot and slowly continued up to the base of the calf muscle; this allows the swelling to travel up toward the center of the body so that it does not gather in the foot. In addition, other external supports such as Kinesio taping does not "improve ankle functioning or performance in people with or without ankle injuries." [20] The "current evidence does not support or encourage the use of Kinesio taping applied to the ankle for improvements in functional performance, regardless the population." [20]
Many different types of rehabilitation exercises can be done to aid an ankle sprain regardless of the severity of the injury. The purpose of rehabilitation gives the ability for the ankle to regain strength and flexibility. A sprained ankle becomes swollen due to the increased amount of edema within the tissue. Physiologically, edema contributes to the sensation of pain in the ankle and so priority is given to allowing the fluid to leave the ankle. [21] This can be done instantly by implementing the RICE mechanism which is resting the ankle, applying ice, compressing, and elevating it. [11] The emphasis of the first week of rehabilitation should be on protecting the ankle to avoid further damage. As the healing progresses, stress can be applied by different mechanisms until the ankle is fully recovered. [22] The key to a fast recovery is to implement all the different types of ankle sprain exercises so that the range of motion will increase while the pain is decreasing. [23]
In cases where the ankle does not heal in an appropriate amount of time, other exercises need to be implemented so that strength and flexibility can be regained. Physical therapists assign different types of ankle sprain exercises that deal with ankle flexibility, strengthening, balance, and agility. If an ankle sprain does not heal properly, the joint may become unstable and may lead to chronic pain. [24] Receiving proper treatment and performing exercises that promote ankle function is important to strengthen the ankle and prevent further injury.
A short period of immobilization in a below-knee cast or in an Aircast leads to a faster recovery at 3 months compared to a tubular compression bandage. [25] In contrast, a randomized controlled trial has concluded that appropriate exercise immediately after a sprain improves function and recovery. [26] These exercises were focused on increasing ankle range of movement, activation and strengthening of ankle musculature, and restoring normal sensorimotor control, and were carried out for 20 minutes, three times a day. [26] After the injury, it is advisable not to walk for a couple of days. Bed rest will help to accelerate the healing process and eliminate the chance of mishandling the affected limb. Driving vehicles or operating machinery should not be attempted. Acute lateral ankle sprain (LAS) is a common injury in athletes and is often associated with decreased athletic performance and, if treated poorly, can result in chronic ankle issues, such as instability. Physical performance demands, such as cutting, hopping, and landing, involved with certain sport participation suggests that the rehabilitation needs of an athlete after LAS may differ from those of the general population. Depending on the patient's goals, early dynamic training after an acute lateral ankle sprain in athletes can result in a shorter recovery time and reduced likelihood of reinjury [27]
The amount of therapy that a person can handle will depend on their level of pain and the grade of sprain they experienced. It is not recommended to return to sports or extreme physical activities until hopping on the ankle is possible without pain. Wearing high-top tennis shoes may also help prevent ankle sprains if the shoes used are laced snugly and if the ankle is taped with a wide, nonelastic adhesive tape. [28]
For acute ankle sprains, manual joint mobilization/manipulation of the ankle has been found to diminish pain and increase range of motion. For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of-motion, decreased pain and improved function. [29]
To prevent sprains or re-injury from occurring, strengthening and stretching exercises should be done through a full range of ankle motion. To improve ankle mobility, ankle circles can be performed by extending the legs in front of the body and then moving the foot up and down, side to side, or rotating the foot in a circle. Another common exercise to improve mobility, as well as proprioception, is to use the toes to draw the letters of the alphabet in the air. Most importantly, the lateral aspect of the ankle joint should be strengthened with eversion exercises (i.e., underside of the foot is turned outward against resistance) to improve lateral ankle stability. [30] Stretching is also an important component of a strengthening program, to help maintain joint flexibility.
Balance and stability training are especially important to retrain the ankle muscles to work together to support the joint. [31] This includes exercises that are performed by standing on one foot and using the injured ankle to lift the body onto its toes. To further enhance balance and stability, exercise devices such as the wobble board can be used, progressing from double-leg to single-leg stance, first with eyes open and then with eyes closed, for enhanced effectiveness.
Flexibility exercises include a towel stretch [32] and writing the alphabet with the toes, which will increase the range of motion.
Ankle strengthening exercises are step ups and walking on toes which will strengthen the muscles around the swollen area. Rehabilitation exercises to strengthen the ankle has been shown to reduce the risk of re-injuring. Exercise prescription isn't clearly understood and deserves further research. [33]
Balance exercises include the use of a balance board, which helps the whole body function to maintain balance. The use of balance boards has been shown to produce significantly positive results in gaining proper balance. [34] While performing balance exercises, the activity can be altered by using a single legged stance instead of a double legged stance, by opening or closing one's eyes, or changing the surface of balance to stable or unstable. This exercise can also be used for primary prevention of ankle sprains, as a meta-analysis exploring it's efficacy in prevention showed that there is a significant decrease in ankle sprain incidence among those who perform these exercises compared to people who don't. [35]
Plyometrics exercises such as squat jumps and power skipping should not be implemented until the ankle has regained full agility.
Other strategies that can be used to prevent ankle injury include:
Most people improve significantly in the first two weeks. However, some still have problems with pain and instability after one year (5–30%). Re-injury is also very common. [36] The risk of recurrence can reach one-third of cases. [37] There are currently no published evidence-based criteria to inform RTS (return to sport) decisions for patients with a lateral ankle sprain injury. Return to sport decisions following acute lateral ankle sprain injury are generally time-based. [38]
Mild sprains (Grades 1-2) relating to over stretching or partial tears typically begin to feel better in a few days to a week and heal by six weeks. More severe ankle sprains (Grades 2-3) involving a full tear or rupture could take more than a few weeks or months to fully recover. [39] The mean time patients return to sports is 12.9 weeks. Average time to return to work after injury range from less than one week to two months. [40]
Ankle sprains can occur through either sports or activities of daily living, and individuals can be at higher or lower risk depending on a variety of circumstances including their homeland, race, age, sex, or profession. [41] In addition, there are different types of ankle sprains such as eversion ankle sprains and inversion ankle sprains. Overall, the most common type of ankle sprain to occur is an inversion ankle sprain, where excessive plantar flexion and supination cause the anterior talofibular ligament to be affected. A study showed that for a population of Scandinavians, inversion ankle sprains accounted for 85% of all ankle sprains. [34] Most ankle sprains occur in more active people, such as athletes and regular exercisers.
When an ankle sprain occurs, subsequent ankle sprains are much more likely to follow. [42] The rate of recurrence is particularly high for athletes in high-risk sports. [43] The most widely recommended preventative measures for recurring sprains are wearing ankle-protective gear [44] (tape, or ankle brace) and implementing exercises designed to strengthen the ankle and improve one's balance (e.g., balance ball exercises). In a review article of ankle sprain prevention research, the authors reference a season-long study on a group of soccer players. 60 players wore ankle-protective (tape or ankle-braces) throughout the soccer season, and another 171 players were enrolled in the control group, as they wore no ankle protective gear. At the end of the season, 17% of the players who did not wear ankle braces/tape sprained their ankles, while only 3% of the players who wore protection incurred the same injury. Amongst the players who sprained their ankles and did not wear ankle-protective gear, 25% had a history of previous ankle sprains. [45] Another peer-reviewed article references a study which concluded that ankle exercising could decrease the risk of recurring sprains by 11%. [46]
In a study comparing the prevalence of ankle sprains between age, race, and sex, individuals who were aged 10–19 years old had highest instances of ankle sprains. [47] It can be suggested that adolescents are more physically active, which leads to higher chances of ankle sprains. Since sports deal with high utilization of the ankle, over 50% of ankle sprains are due to sport-related injuries. [48]
Moreover, average ankle sprains for the general U.S. population are estimated at 5–7 ankle sprains for every 1000 person-years; however, a study showed that for military cadets, instances for ankle sprains were about 10 times those of the general population [49]
Another study comparing sex influences on ankle sprains found that male and female counterparts had similar incidence rates of ankle sprains. However, at a specific age range of 19–25 years old, males were found to have a substantially greater rate of ankle sprains than females. Furthermore, at ages 30 and over, females showed a higher incidence of ankle sprains than males. [41] From this, it can be said that age and activity levels are better indicators of ankle sprain risks than gender.[ citation needed ]
Sports injuries are injuries that occur during sport, athletic activities, or exercising. In the United States, there are approximately 30 million teenagers and children who participate in some form of organized sport. Of those, about three million athletes age 14 years and under experience a sports injury annually. According to a study performed at Stanford University, 21 percent of the injuries observed in elite college athletes caused the athlete to miss at least one day of sport, and approximately 77 percent of these injuries involved the knee, lower leg, ankle, or foot. In addition to those sport injuries, the leading cause of death related to sports injuries is traumatic head or neck occurrences.
The ankle, the talocrural region or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantarflexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.
A sprain is a soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers made of collagen that connect two or more bones to form a joint and are important for joint stability and proprioception, which is the body's sense of limb position and movement. Sprains may be mild, moderate, or severe, with the latter two classes involving some degree of tearing of the ligament. Sprains can occur at any joint but most commonly occur in the ankle, knee, or wrist. An equivalent injury to a muscle or tendon is known as a strain.
The anterior cruciate ligament (ACL) is one of a pair of cruciate ligaments in the human knee. The two ligaments are also called "cruciform" ligaments, as they are arranged in a crossed formation. In the quadruped stifle joint, based on its anatomical position, it is also referred to as the cranial cruciate ligament. The term cruciate translates to cross. This name is fitting because the ACL crosses the posterior cruciate ligament to form an "X". It is composed of strong, fibrous material and assists in controlling excessive motion. This is done by limiting mobility of the joint. The anterior cruciate ligament is one of the four main ligaments of the knee, providing 85% of the restraining force to anterior tibial displacement at 30 and 90° of knee flexion. The ACL is the most injured ligament of the four located in the knee.
Achilles tendinitis, also known as achilles tendinopathy, occurs when the Achilles tendon, found at the back of the ankle, becomes sore. Achilles tendinopathy is accompanied by alterations in the tendon's structure and mechanical properties. The most common symptoms are pain and swelling around the affected tendon. The pain is typically worse at the start of exercise and decreases thereafter. Stiffness of the ankle may also be present. Onset is generally gradual.
A joint dislocation, also called luxation, occurs when there is an abnormal separation in the joint, where two or more bones meet. A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma on the joint like an impact or fall. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves. Dislocations can occur in any major joint or minor joint. The most common joint dislocation is a shoulder dislocation.
A soft tissue injury is the damage of muscles, ligaments and tendons throughout the body. Common soft tissue injuries usually occur from a sprain, strain, a one-off blow resulting in a contusion or overuse of a particular part of the body. Soft tissue injuries can result in pain, swelling, bruising and loss of function.
A strain is an acute or chronic soft tissue injury that occurs to a muscle, tendon, or both. The equivalent injury to a ligament is a sprain. Generally, the muscle or tendon overstretches and partially tears, under more physical stress than it can withstand, often from a sudden increase in duration, intensity, or frequency of an activity. Strains most commonly occur in the foot, leg, or back. Immediate treatment typically includes four steps abbreviated as R.I.C.E.: rest, ice, compression, elevation.
An ankle fracture is a break of one or more of the bones that make up the ankle joint. Symptoms may include pain, swelling, bruising, and an inability to walk on the injured leg. Complications may include an associated high ankle sprain, compartment syndrome, stiffness, malunion, and post-traumatic arthritis.
An anterior cruciate ligament injury occurs when the anterior cruciate ligament (ACL) is either stretched, partially torn, or completely torn. The most common injury is a complete tear. Symptoms include pain, an audible cracking sound during injury, instability of the knee, and joint swelling. Swelling generally appears within a couple of hours. In approximately 50% of cases, other structures of the knee such as surrounding ligaments, cartilage, or meniscus are damaged.
RICE is a mnemonic acronym for the four elements of a treatment regimen that was once recommended for soft tissue injuries: rest, ice, compression, and elevation. It was considered a first-aid treatment rather than a cure and aimed to control inflammation. It was thought that the reduction in pain and swelling that occurred as a result of decreased inflammation helped with healing. The protocol was often used to treat sprains, strains, cuts, bruises, and other similar injuries. Ice has been used for injuries since at least the 1960s, in a case where a 12-year-old boy needed to have a limb reattached. The limb was preserved before surgery by using ice. As news of the successful operation spread, the use of ice to treat acute injuries became common.
The unhappy triad, also known as a blown knee among other names, is an injury to the anterior cruciate ligament, medial collateral ligament, and meniscus. Analysis during the 1990s indicated that this 'classic' O'Donoghue triad is actually an unusual clinical entity among athletes with knee injuries. Some authors mistakenly believe that in this type of injury, "combined anterior cruciate and medial collateral ligament disruptions that were incurred during athletic endeavors" always present with concomitant medial meniscus injury. However, the 1990 analysis showed that lateral meniscus tears are more common than medial meniscus tears in conjunction with sprains of the ACL.
Balance in biomechanics, is an ability to maintain the line of gravity of a body within the base of support with minimal postural sway. Sway is the horizontal movement of the centre of gravity even when a person is standing still. A certain amount of sway is essential and inevitable due to small perturbations within the body or from external triggers. An increase in sway is not necessarily an indicator of dysfunctional balance so much as it is an indicator of decreased sensorimotor control.
A tear of a meniscus is a rupturing of one or more of the fibrocartilage strips in the knee called menisci. When doctors and patients refer to "torn cartilage" in the knee, they actually may be referring to an injury to a meniscus at the top of one of the tibiae. Menisci can be torn during innocuous activities such as walking or squatting. They can also be torn by traumatic force encountered in sports or other forms of physical exertion. The traumatic action is most often a twisting movement at the knee while the leg is bent. In older adults, the meniscus can be damaged following prolonged 'wear and tear'. Especially acute injuries can lead to displaced tears which can cause mechanical symptoms such as clicking, catching, or locking during motion of the joint. The joint will be in pain when in use, but when there is no load, the pain goes away.
A high ankle sprain, also known as a syndesmotic ankle sprain (SAS), is a sprain of the syndesmotic ligaments that connect the tibia and fibula in the lower leg, thereby creating a mortise and tenon joint for the ankle. High ankle sprains are described as high because they are located above the ankle. They comprise approximately 15% of all ankle sprains. Unlike the common lateral ankle sprains, when ligaments around the ankle are injured through an inward twisting, high ankle sprains are caused when the lower leg and foot externally rotates.
A patellar dislocation is a knee injury in which the patella (kneecap) slips out of its normal position. Often the knee is partly bent, painful and swollen. The patella is also often felt and seen out of place. Complications may include a patella fracture or arthritis.
Knee pain is pain in or around the knee.
Posterolateral corner injuries of the knee are injuries to a complex area formed by the interaction of multiple structures. Injuries to the posterolateral corner can be debilitating to the person and require recognition and treatment to avoid long term consequences. Injuries to the PLC often occur in combination with other ligamentous injuries to the knee; most commonly the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). As with any injury, an understanding of the anatomy and functional interactions of the posterolateral corner is important to diagnosing and treating the injury.
Medial knee injuries are the most common type of knee injury. The medial ligament complex of the knee consists of:
Running injuries affect about half of runners annually. The frequencies of various RRI depend on the type of running, such as speed and mileage. Some injuries are acute, caused by sudden overstress, such as side stitch, strains, and sprains. Many of the common injuries that affect runners are chronic, developing over longer periods as the result of overuse. Common overuse injuries include shin splints, stress fractures, Achilles tendinitis, Iliotibial band syndrome, Patellofemoral pain, and plantar fasciitis.