With a recent increase in ankle injury cases, I've decided to write a post about some of the key things about the injury. The ankle is probably by far the most commonly injured structure in any dynamic sport that requires jumping, cutting, and running, like: basketball, soccer, and volleyball, and it is also one of the most ignored injury in sports. The reason for the neglect is because the injury usually resolves by itself with rest. However, like all other injuries, without proper treatment and rehab, the chances of injuring the structure again is quite high.
By far one of the most commonly injured structure in the ankle is the ATFL (Anterior talo-fibular ligament) See image on top. The mechanism in which the injury occurs quite often involves landing of the foot on an unstable surface, such as another player's foot.
This action causes the foot to be in pronation (rotated inwards) on a planterflexed foot upon an externally rotated tibia (shin bone), which is a very unstable position for the ankle (see above). While in this position the ATFL becomes the lateral collateral ligament of the lateral ankle, and hence has the highest rate of injury amongst the 2 other lateral ligaments (calcaneofibular ligament, and posterior talofibular ligament). The injury can be graded into Grade I, II, or III. The classification can be defined as follows:
Grade I: no microscopic tear, with minor swelling and tenderness along the lateral ankle and no loss in ligament elasticity.
Grade II: partial tearing of the ligament is expected with moderate swelling, tenderness along the lateral ankle and pain. There is moderate loss in functionality, meaning gait and daily activities will be affected.
Grade III: major or a full tear of the ligament is expected with severe swelling and pain, there is full loss of function and range leaving the ankle completely unstable.
Unlike other joints, we as bipedal beings rely a lot on these ankle joints to support our daily living. After an injury to the ankle joint, whether benign or severe, it alters the way we move our body and how we propel ourselves during gait. Our brain and consequently, our body, is designed to adapt to the imposed demands of life, and the stronger the will, the more chances for the body to start compensating with other structures. Getting the right treatment and education about ankle injuries is imminent when it happens. Too many people and athletes ignore the seemingly small injury, and pay for the consequences few years or sometimes few months down the road. I cannot stress enough how important it is to treat an ankle injury right and go through all the rehab protocols when it happens. The more diligent one is able to follow the ankle rehab protocol, the lower the chances of reinjurying the same ankle again, and the faster the client will be able to get back into activities without complications.
Other than a Grade I ankle sprain, Grade II, and Grade III sprains affects functional ranges of the ankle. Here are the steps to guide you to regaining proper ankle biomechanics and neuromuscular control.
1. Recover range of motion: any range of motion exercises are helpful at this stage, whether active (within pain-free ranges) or passive (within pain-free ranges). This allows an increase in blood circulation to support the healing process of the connective tissue being injured. Other exercises can include, cycling.
2. Balance exercises: purpose here is to regain the kinesthetic control. From just single leg standing exercises on stable surface, to performing the exercise on uneven surfaces such as a wobble board or Bosu ball. Variations in walking exercises can be done (on the toes, on heels, on the outer ankle, inner ankle, short step/long step etc), along with any simple closed-chain weight bearing exercises such as a deadlift, or a squat. These stage should be progressed slowly throughout the rehab process, making it more demanding on the body by adding load, or increasing duration of the exercises
3. Strength training: one of the muscles that gets neglected and lose neuromuscular control is the peroneals. It is crucial to regain control of the peroneals as it is one of the main stabilizing muscles being injured with an inversion sprain. Other actions such as dorsiflexing the ankle (pointing the toes towards your head), plantarflexing the ankle (pointing the toes away from your head), and inverting the ankle (bringing the soles of the foot towards each other), should be done according to the strength and weakness of the muscles (most of it depends on the mechanism of injury, for all inversion sprains, inverters are almost never in need to be strengthened). Start with isometric exercises as it has been scientifically proven to be the safest way to rehabilitate, at the same time recruit the highest amount of motor units to the muscle in contraction. This can be done with therabands. Eventually, isotonic exercises can replace isometric exercises, and the parameters will depend on when the client "gives out" (I usually call it the neurological thershold, it represents the fatigue level of the brain for that particular movement).
4. Coordination training: the purpose of this stage is to stimulate the central nervous system, specifically the cerebellum. These are the usual plyometric training that people talk about. One thing about plyometrics is that people get into it without truly understanding the concept behind plyometric exercises. Plyometric exercises utilizes the SSC (stretch-shortening-cycle) within our reflex system. This reflex is also called the muscle spindle reflex, which is a natural phenomenon that occurs in a neurologically healthy human being when a muscle contracts in response to the same muscle group being stretched. When the client starts to rehabilitate or train during this stage, the movement is alot faster than previous stages. When speed is involved in a training/rehab program, it also means a higher chance of errors. The master error correction system in our brain is the cerebellum. Coordination training not only strengthens and rehabilitates the cerebellum, but it also trains the relfex response of the muscle in training, which all together allows for higher injury prevention capacity. Simple exercises such as skipping a rope, hopping on one foot back and forth, cone training, start/stop/sprint exercises are all considered as coordination training.
5. Back to sports: after successfully completing all the above stages, the client is most likely now ready to get back into sports. The reason why I say MOST LIKELY, is because there actually are no research that shows a particular program giving a 100% guaranteed athlete to be injury free when getting back into sports. The stats, however, is low enough allow the client to return to activities.
Keep in mind that this post is strictly on SPRAINED ankles, if the client cannot even bear weight on the injured ankle, there is a high suspicion for fracture. Depending on the type and severity of the fracture, surgical procedure may be needed other than immobilization.