Everything You Need to Know About Ankle Sprains

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Everything You Need to Know About Ankle Sprains

• By Michael LaBella

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Objectives of the presentation

• Students will become aware and be able to
  distinguish the difference between the 3
  different degrees of ankle sprains.
• Students will learn about the specific ligaments,
  muscles, and injuries that surround the ankle.
• Students will learn the signs and symptoms of a
  lateral ankle sprain if one was to ensue during
  an athletic event.
• Students will recognize the acronym PRICE as
  means of remembering how to treat a new ankle
  sprains.
• Students will be gain a better understanding of
  how to prevent ankle injuries through various
  aids.
• Students will gain the knowledge of
  rehabilitation after the ankle injury through
  various exercises specifically designed.

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Anatomy of the ankle

• The ankle is a complex part of the human body and
  much more amazing then one might think.
• The ankle is a joint that serves much like a
  hinge on a door or a cabinet.
• In order to function correctly in terms of
  walking, it is imperative that the ankle is
  working properly.

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Did you know?

• Despite being quite narrow, the ankle is an
  extremely stable joint?
• In fact, the ankle can withstand.
• 1.5 times your body weight while walking
• 8 times your body weight while running!

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Bones that comprise the joint
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• The ankle joint itself is connected by three
  separate bones.
• The talus works as the hinge that allows the
  ankle to move up and down (dorsi and plantar
  flexion).
• The tibia also known as the shinbone forms the
  medial part of the ankle.
• The fibula forms the lateral part of the ankle.
• Both the tibia and the fibula connect into the
  top of the talus.
• The whole three-boned structure is connected to
  the top of our heel bone called the Calcaneus

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Ligaments of the ankle
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There are three ligaments that are part of the
ankle.

• The anterior inferior tibiofibular ligament is
  the one that connects with the tibia and the
  fibula and goes above the front of the ankle.
• The posterior fibular ligaments goes to the back
  of the tibia and fibula.
• The final ligament, the interosseous ligament is
  the one that goes between the tibia and the
  fibula.

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What is your Achilles Heel?
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I am not sure about that mythological dude, but
mine is a tendon and not a weakness!
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On the contrary.

• The Achilles Tendon is not a weakness to us
  mortals.
• It is, in fact, the largest tendon in the human
  body
• It can withstand over a 1,000 pounds of force!

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• The purpose of the Achilles Tendon is to help us
  walk, run, and jump
• In addition, it helps us stand on our tippy-toes
• The Achilles Tendon attaches or gastrocnemius and
  soleus (calf muscle) to the calcaneus (heel bone)

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Any other tendons?

• Yes! The other tendons in our ankle are called
  the posterior tibial tendon and the anterior
  tibial tendon
• The posterior attaches to the underside of the
  foot for arch support and to turn the foot
  laterally and medially.
• The anterior attaches and helps us raise the
  foot.
• The two tendons together are called the peroneals.

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Muscles of the ankle.

• Peroneus Longus
• Peroneus Brevis
• Anterior Tibialis
• Posterior Tibialis
• Extensors Hallucis Longus
• Flexor Hallucis Longus
• Extensor Digitorum Longus
• Flexor Hallucis
• Gastrocnemius
• Soleus

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The main muscles in the ankle

• Peroneals are located on the lateral edge of the
  ankle. Their purpose is to bend the ankle down
  and out.
• Gastrocnemius and Soleus are the calf muscles and
  also bend the ankle down.
• Tibialis aids the foot in turning inward and
  upward.

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Mechanism of the ankle injury
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What is the typical type of ankle injury?

• According to Dr. Douglas Ivins at the Univeristy
  of Oklahoma College,

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No discrimination...

• Among high school boys and girls who participated
  in the years of 2004-2005, ankle injuries were
  the MOST prevalent type of injury for both sexes.
  (Pfeiffer Mangus 2008)
• According to professor Jason Bennett Ankle
  injuries, especially those to the lateral ankle
  complex, are the most common acute sports-related
  injuries presenting to sports medicine clinics
  and emergency rooms around the world. (Bennett,
  2002)

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Lateral Acute Ankle Sprain

• This is the typical type of ankle sprain.
• Have you ever twisted your ankle?
• Yea, me too. When you twist it on the outside
  near your pinky toe, that is the lateral sprain.

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What makes the lateral part of the ankle so weak?

• anterior talofibular ligament is the ligament
  that has the greatest impact on the lateral part
  of the ankle.
• Unfortunately, the anterior talofibular ligament
  is both the weakest and the smallest out of all
  three of the ligaments in the ankle.

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Mechanism of the injury continued...

• Almost all of the ankle sprains occur at the
  moment of termination from running or jumping and
  landing on the foot
• When the foot strikes the ground, the ankle will
  be in plantar flexion and the foot will be
  supinated (sole facing upwards)
• Stability is mitigated due to the medial
  malleoulus becoming more distal (far apart) then
  the lateral malleoulus.

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What happens next?

• The peroneal muscle become over-forced and fall
  upon the anterior talofibular ligament.
• This creates a rolling ball effect after the
  ATF is completely torn, the stress is overted to
  the Calcaneo fibular ligament and eventually to
  the Posterior Talofibular ligament.

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How are we able to recognize a sprained ankle?

• Initial recognition of a sprained ankle can be
  examined in many ways.
• Some of the reactions that will come in the event
  of a sprained ankle are high level of pain,
  rapid onset of swelling, coldness or numbness in
  the injured foot, inability to bear weight, or a
  complicating condition.

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As a coach, what should you look for if an ankle
is sprained?

• The initial sign for a coach to look out for is
  difficulty bearing weight on the injured ankle
  with a fairly high level of pain.
• After this, swelling will certainly come into
  play.
• Checking for the swelling is paramount in telling
  if the ankle is sprained or not.

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There are different grades of ankle sprains to
determine the severity.
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The grades of ankle sprain are on a scale of 1-3

• Grade I (first degree)- Most common type of
  sprain which the ligaments are over-stretched but
  not torn completely. The ankle should have most
  of its stability.
• Grade II (second degree)- Injury is significantly
  worse then the first degree. Usually the ligament
  is partially torn.
• Grade III (Third degree)- Implies that one or
  more ligaments is fully torn. Instability while
  occur indefinitely.

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Degree of ankle sprain table
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How can we evaluate the injured ankle?
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Questions for evaluators to consider.

• Etiology of the injury (how did it happen).
• Has the ankle been previously injured? The more
  that the ankle has been injured, the more
  susceptible it is to getting sprained again.

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There are many factors to check when evaluating a
sprained ankle

• The first signs for severity of the sprain are
  for ecchymosis (bruising), tenderness, and
  swelling.
• Another way to test is the stress test.
• Performed by pushing on the ankle to determine
  abnormal movement of the

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Other tests...

• Anterior Drawer Test- A test that uses loads of
  weight to determine the integrity and stability
  of the ankle.
• Talar Tilt test- This tests is used by cupping
  the heel of the injured ankle and inversion
  stress is applied.
• Thompson Test- tests the Achilles Tendon. It is
  performed with the person laying down and
  pressure is applied to the gastrocnemius and
  soleus.

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How are ankle sprains treated?
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Remember the acronym PRICE!
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• Protection- The injured ankle should be kept out
  of further harm or injuries, especially during
  the crucial first 24-48 hours.
• Rest-For about 24-48 hours after the injury, as
  much activity involving the ankle should be
  ceased as possible.
• Ice- especially within the first 48 hours, the
  sooner the better, ice should be applied 20
  minutes at a time every 3-4 hours (Dr. Cluett).
  Any longer then 20 minutes can be detrimental to
  the injury and damage it further.
• Compression- An ace bandage can be used compress
  the injury ankle, do not wrap too tight however!
• Elevation- Ankle should be elevated higher then
  your heart as often as possible.

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Proper ice techniques

• 1) Get the ice on quickly-icing effects diminish
  after 48 hours
• 2)Ice massage- the ice should not be stagnant, it
  should be moved around frequently.
• 3)Elevate!- paramount to reduce the swelling.
• 4) Watch the clock- no longer then 20 minutes
  should ice be applied.
• 5) Time to warm- allow adequate time for the
  ankle to warm again before another treatment.
• 6) Repeat- as often as desired

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Rehabilitation of the injury
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The stages of rehabilitation

• Acute Stage (1-3 days)- Use PRICE, ankle can not
  support any weight.
• Sub-Acute Stage (3-14 days)- Some weight can be
  put on the ankle, compression and ice therapy is
  still suggested.
• Early Rehab (week 3)- Specific light exercise are
  used to prevent stiffness and reduce swelling.
• Late Rehab (week 4)- Progressive strengthening of
  the muscles, intensity of exercise is increased.
  Use of ankle braces and casts are highly
  suggested.
• Functional Rehab (week 5)- Increase intensity
  gently to return to game-ready conditions. Pain
  should be mitigated (if present at all).

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When to start rehabilitation.

• It is suggested to start rehab as soon as you can
  apply pressure to the ball of your foot.
• The purpose is to return balance and strength to
  the ankle .
• This is done through various exercises
  specifically designed for different stages of
  recovery.

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Earliest stages of rehabilitation .

• 1. Ankle Pump Point toe, then pull back toward
  you as hard as possible.
• 2. Towel Gather Spread out towel on floor. Pull
  toward you with toes until towel is fully
  gathered around foot. Repeat 10-15 times.
• 3. Ball Pick-up Grasp ball between 1st and 2nd
  toes pick up and transfer to opposite pile.
  Repeat 15 times.

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Continued...

• 4. Towel Stretches Sit on a hard surface with
  your injured leg stretched out in front of you.
• (a). Loop towel around foot and pull back
  to get a good stretch for 20 seconds and relax
  for 20seconds
• (b). Pull the towel so that foot turns to
  other side hold for 20 seconds, then pull to the
  other side hold for 20seconds.
• (c). Bend leg at 90 degree angle and loop
  towel around forefoot. With leg bent pull foot
  back for 20 seconds and relax for 20 seconds.

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Exercises for later stages of ankle
rehabilitation.

• 5. Slantboard Stretch
• (a). Stand with your heels on A board
  and lean forward
• (b). Turn your toes in with heels on
  the board and lean forward
• (c). Stand with knees bent and heels
  down
• (d). Stand with your knees bent, point
  toes inward and keeping heels down on the board.
• 6. Wall Stretch Facing a wall, put your hands
  against the wall at about eye level. Keep the
  injured leg back, the uninjured leg forward, and
  the heel of your injured leg on the floor. Lean
  into wall and hold for 15-20 seconds. Repeat 3
  times.
• (a). Knee straight toes straight
  ahead
• (b). Knee straight toes pointed in

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Continued...

• 7. Soleus Stretch Stand facing a wall with your
  hands at about chest level. With both knees
  slightly bent and the injured foot back, gently
  lean into the wall until you feel a stretch in
  your lower calf. Once again, angle the toes of
  your injured foot slightly inward and keep your
  heel down on the floor. Lean into wall and hold
  for 15-20 seconds. Repeat 3 times.
• (a). Knees bent toes straight ahead
• (b). Knees bent toes pointed in
• 8. Ankle range of motion You can do this
  exercise sitting or lying down. Pretend you are
  writing each of the letters of the alphabet with
  your foot. This will move your ankle in all
  directions. Do this twice. Singing the song is
  optional!

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• 9. Theraband
• (a). Dorsiflexion - Sitting with your
  leg out straight and your foot near a door, wrap
  the tubing around the ball of your foot. Anchor
  the other end of the tubing to the door by tying
  a knot in the tubing, slipping it between the
  door and the frame, and closing the door. Pull
  your toes toward your face. Return slowly to the
  starting position. Repeat 10 times. Do 3 sets of
  10.
• (b). Plantarflexion - Sitting with
  your leg outstretched, loop the middle section of
  the tubing around the ball of your foot. Hold the
  ends of the tubing in both hands. Gently press
  the ball of your own foot down and point your
  toes, stretching the Thera-Band. Return to the
  starting position. Repeat 10 times. Do 3 sets of
  10.
• (c). Inversion - Sit with your legs
  out straight and cross your uninjured leg over
  your injured ankle. Wrap the tubing around the
  ball of your injured foot and then loop it around
  your uninjured foot so that the Thera-Band is
  anchored at one end. Hold the other end of the
  Thera-Band in your hand. Turn you injured foot
  inward and upward. This will stretch the tubing.
  Return to the starting position. Repeat 10 times.
  Do 3 set of 10.
• (d). Eversion - Sitting with both legs
  outstretched and the tubing looped around both
  feet, slowly turn your injured foot upward and
  outward. Hold this position for 5 seconds. Repeat
  10 times. Do 3 sets of 10.

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After these specific exercises, weight-bearing
exercises can be used.

• Such as.
• Walking on your tippy toes
• Heel raises
• Toe raises
• Single leg balancing.

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Guidelines for returning to play.
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Precautions what to watch out for

• Athletes should take extreme precaution and be
  aware of the risks of re-injury of the sprained
  ankle.
• Athletes should also be aware that
  overcompensation of the healthy ankle can cause
  injury as well.

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First things first, get a professional opinion!
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What tests will the doctor use?

• Lateral hop test. Patients stand on the
  uninjured leg and hop as far as possible in a
  lateral direction with three continuous hops.
  They then stand on the injured leg and hop back
  to where they started, using three continuous
  hops. Patients must make it back to where they
  started, showing that their injured leg is of
  equal strength and stability as the uninjured
  leg.
• Single leg stance (Modified Rhomberg Test). The
  patient stands and balances on the good leg with
  his or her arms crossed over the chest. Compare
  the duration that the patient stands on the
  single leg, without touching the other foot to
  the ground, to the duration that he or she stands
  on the injured leg.
• Heel rocker test. The patient leans backward
  against a wall and pulls the toes and forefoot
  areas of both feet off the ground while rocking
  backward on his or her heels. The patient raises
  the toes repeatedly off the ground until full
  exhaustion. Check for any asymmetry in fatigue
  between the two ankles.

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What now?

• After carefully examining the results of the
  aforementioned tests, the doctor will suggest
  what type of activities you will be able to
  resume.

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Helpful Chart

• Chances are if you ask for a chart to help you
  know when you can come back to play, the doctor
  will give you something similar to this.

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Or maybe a checklist like this

• Name ____________________________________________
  __ Date of Injury
• Phase 1 Ready to Start Rehabilitation
• A. I am wearing the protective tape, brace, or
  wrap that my doctor prescribed.
• B. I can stand on the injured leg without pain.
• C. Pain and swelling have gone down.
• Phase 1 complete. Date __________________________
  Days after injury ________________________
• Phase 2 Beginning Level
• A. My ankle does not feel too stiff to draw the
  letters of the alphabet with my toes.
• B. Strength in my calf and ankle muscles is back
  to normal.
• C. I know when I need to wear an ankle brace or
  taping and how to apply it.
• D. Neither low-impact aerobic exercise nor
  weight lifting causes pain or swelling.
• Phase 2 complete. Date __________________________
  Days after injury ________________________
• Phase 3 Intermediate Level
• A. Balance when standing on the injured leg is
  as good as the uninjured leg.
• B. Increasing my aerobic exercise or weight
  lifting does not cause pain or swelling.
• C. My general strength is back to preinjury
  level.
• Phase 3 complete. Date __________________________
  Days after injury ________________________
• Phase 4. Advanced Level
• A. My return-to-running program has been
  completed without pain or limitation.

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What about on the field?

• Unfortunately the doctor cannot be there, so
  evaluation would be the job of the coach or the
  athletic trainer.
• They should be working tandemly to look for
  weakness of the ankle, favoring of one side, or
  overall assymetry.
• It is suggested that drills are performed
  extensively before on-field play.

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What the coach and trainers should know.

• The coaches should always keep in mind that the
  health and successful healing of the athlete
  always comes first.

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How can I prevent ankle sprains?
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Initial protection of ankle sprains can be done
through proper exercises.

• Balancing exercises can help greatly increase the
  ankles strength therefore preventing injury.

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Balancing exercises

• Stand on one foot. Now reach with the opposite
  leg outward in all directions, forward, sideways,
  backwards, diagonally, etc. Reach out as far as
  possible and hold for three to five seconds.

• Each direction offers a different challenge to
  your balance and trains the receptors of the
  ankle, knee, and hip. The farther you reach the
  harder the balance leg is working. Start small
  and work your way up. You can also reach with
  your arms, as this challenges your balance
  differently.

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What if I still sprain my ankle?!?! Can help
prevent further injury in the future?

• Absolutely!
• Although the initial sprain makes the ankle
  weaker then before, many aids can be used to help
  prevent this injury again

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Proper sneakers for the sport being played.

• High-top sneakers for sports that require lateral
  moving and jumping are essential.
• The sneakers to the right are used for dancing
  and should ONLY be used for this purpose.

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If the shoe fits...

• Sneakers must also fit properly and must not be
  too narrow or large.
• many sports shoes are found to be too narrow for
  the wearers foot (Helal, King, and Grange 1986.
  )

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Sometimes well-fitting sneakers are not enough,
additional ankle support is needed.

• Ankles can be further supported by the used of
• Adhesive straps
• Braces
• Air stirrups

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The premise behind these aids is to...

• Help in the healing process of the sprained ankle
  
• Further prevent injury to already hurt ankle.
• Aid in stability and walking.

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I would like to thank everyone for taking the
time to read this presentation.

• If there are any questions, please feel free to
  contact me through next weeks discussion board!

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• References