Ankle Sprains are one of the most common injuries in sports. Normally thought of a minor injury that requires rest, ice and elevation. It actually sets the body up for failure if ankle sprain treatment and healing is not taken seriously. An unstable base, afterall, causes an unstable structure - so the athlete needs to have strong and agile feet and ankles.
As the communicating bridge between our powerful leg muscles and our springy platform feet, the ankles play an important role in keeping us successfully upright, bipedal animals. These crucial components can become compromised when relied upon to navigate unstable surfaces, and one can be left with a painful and debilitating nuisance. The good news is that, unlike the brain, we have a good understanding of ankle anatomy and function. The body has an incredible ability to heal itself, and often professionals like physical therapists can help to expedite that healing process of an ankle injury.
Click the headings to learn about ankle anatomy and common causes of ankle injuries:
The ankle itself is comprised of several bones, notably the tibia and fibula of the lower leg and talus and calcaneus of the foot. The shape of these bones form a unique joint with multiple planes of possible movement. The tibia and fibula of the lower leg come together to form a cup shaped cavity that sits on top of the talar dome, the highest bone of the foot.
This "true ankle joint," or tibiotalar joint, allows for two primary movements, dorsiflexion and plantarflexion.
- Pull your toes up towards your shin bone - this is dorsiflexion.
- Point your toes down like a ballerina - this is plantarflexion.
The talus then rests atop the calcaneus, or heel bone of the foot. This is called the subtalar joint. Together with the tibiotalar joint, these junctions allow inversion and eversion.
- Pull the bottoms of your feet together - this is inversion.
- Push the bottoms of your feet away from each other - this is eversion.
Inversion and eversion are important to allow walking on unstable and uneven surfaces without falling. In addition to these multiple joints and joint surfaces, there is a network of connective tissues keeping these bones held together called ligaments.
The ligaments on the lateral (outer) aspect of the ankle are the:
- Anterior talofibular ligament (ATFL),
- Calcaneo-fibular ligament (CFL), and
- Posterior talofibular ligament (PTFL)
The ATFL and CFL are the most commonly injured ligaments and are affected in an inversion ankle sprain (described in detail below).
On the medial (inner) side of the ankle we have the:
- Anterior tibiotalar ligament,
- Tibiocalcaneal ligament,
- Posterior tibiotalar ligament and
- Tibionavicular ligament
These ligaments are known collectively as the deltoid ligaments, which are affected during an eversion ankle sprain.
Causes of Ankle Sprains
Ankle sprains are one of the most common sports injuries, estimated to impact thousands to tens of thousands of people on a daily basis. An ankle sprain can occur during daily activities as simple as stepping down off of a curb, but people at highest risk may be those participating in sports involving quick cutting or lateral movements requiring rapid changes in direction and speed. The most reliable predictor of injuring your ankle is having done it previously.
The most common type of sprain happens when athletes move laterally (to the side) during their sport. This happens often when shuffle stepping in tennis, running diagonally and kicking the ball in soccer, and landing after a jump in basketball. The typical ligament to be strained are the CF ligaments and ATFL ligaments (see above.).
Classification of sprains range from Type I (meaning mild stretch or damage to ligaments) to Type III (complete rupture of the ligament and an unstable ankle). Regardless of severity of sprain, it is important, for athletes especially, to seek early physical therapy care. A recent research study actually outlines that "patients with grade I and II lateral ankle sprains who are treated with early mobilisation and referral to physical therapy have demonstrated earlier return to function compared with patients who are treated with prolonged immobilisation and delayed referral."
Of course, ankle sprains can also cause a slew of other injuries of tissues at in the same instance. The following is a list of them.
Types of Ankle Injuries
The type of ankle injury often has to do with what specific tissues or combination of tissues were affected. The most simple way to arrange these injuries would be into bone, ligament, or tendon as the main damage.
- Bone: The most common bone injury in the ankle region is a fracture. Fractures often occur as a result of a traumatic event such as stepping in a hole while running, falling from a height, or landing on a slanted surface.
- Ligament: When the foot or ankle is pushed beyond its normal range of motion and the bones stay intact, ligaments can be stretched beyond their tensile limit or torn.
- Tendon: Where the muscle attaches to the bone is called a tendon. With repetitive movements or high impact activities, tendons can become inflamed leading to injuries known as tendinitis (acute inflammation) or tendonosis (prolonged irritation or pathology of the tendon).
FRACTURE Diagnosis and Treatment
The first step in diagnosing an ankle injury is to determine whether or not radiographs (x-rays) need to be taken to look for a fracture. In order to save time and resources, a set of rules were developed with research to better indicate when a fracture is possible or likely. This set known as the Ottawa Ankle Rules are as follows.
Get imaging if:
- you are over the age of 55
- you are unable to bear any weight through the affected ankle and take 4 steps at the time of injury or in the emergency department
- you experience severe point tenderness on the inside or outside tip of your ankle
Ankle treatment of a simple ankle fracture typically will involve a period of immobilization in a cast.
Depending on the severity of the fracture, you may be required to unload the tissues by using crutches while the bone heals. After an ankle fracture, it is important to see a doctor of physical therapy in order to safely return to walking. Your ankle tissues will shorten when immobilized in a case over time, so this will often require exercise and manual ankle injury therapy to improve range of motion and strength.
LIGAMENT Diagnosis and Treatment
When the ankle is quickly moved beyond its normal range of motion, ligaments can get stretched beyond their limits, and the result can be a sprain. If swelling, pain, and even bruising result, but the rules above do not indicate a need for imaging, we are often dealing with a sprain. Low-grade sprains will often heal themselves with time and rest, but seeing a physical therapist for diagnosis, manual ankle therapy, and strengthening/balance training has been shown to significantly decrease the time before returning to your favorite activities.
TENDON Diagnosis and Treatment
Tendon injuries are diagnosed based on location of symptoms and mechanism of injury. When pain the ankle or foot is related or reproduced by pressing on the muscles further up the leg, we become suspicious of the tendinous attachments to the bones. A key predictor of tendon injuries comes from how/when the person first started experiencing the symptoms. Common mechanisms of injury include repetitive impact activities such as jumping or running.
Shin splints are another common complaint from long distance runners and walkers. Shin splint pain feels very much like a soreness along the shin, usually on the inside of the shaft but can present on the top side of the shaft. The name “shin splints” is a misnomer because it does not necessarily mean that the shin is splinting, but rather it describes the pain that the runner is feeling.
Shin splints usually occur because of inadequate tissue adaptation when starting an exercise regime. Muscles along the lower leg control for the foot and when walking or running distances increase, these muscles are strained more and more.
Physical Therapy is very effective in helping with shin splints. Manual therapy is given to the affected muscles to help with tissue strain and taping/orthotics may be prescribed to help offload the muscles during activity. Your physical therapist may also recommend activity modification so the strain is not repetitively damaging the tissues. Strengthening the tibial muscles later on in the leg injury treatment progression would also help the runner/walker acclimate to stresses of long-distance running and walking.
Although the fix for shin splints may be simple and effective, simple shin splints may be masking something more severe. Only a trained Doctor of Physical Therapy can discern posterior compartment syndrome, actual stress fractures in the lower leg and shin splints. When the therapist has doubts about the diagnosis of shin splints, further insights by a podiatrist or an orthopedist may be necessary. If the limb is swollen, red and has unrelenting pain, this may signal something more severe.
Seeing a skilled ankle physical therapist is crucial with nagging tendon injuries in order to determine the source of dysfunction, whether that be a weakness, muscle imbalance, joint hypomobility, joint hypermobility, or a footwear issue. Often the most beneficial ankle sprain treatment for tendon injuries will include a training modification and specific strengthening exercises called eccentrics. These are very individualized ankle injury treatments, so it's important to team up with a Doctor of Physical Therapy such as those at the Portland Area Stride Strong clinics who are willing to put the time into learning about you and your goals.
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