Ankle Sprains: the long term risks
… and why you need to have it checked ASAP!
By Doug James, Physiotherapist and Podiatrist, intraining Running Centre
Ankle sprains are one of the most common acute injuries in the world, accounting for up to 5% of cases at Emergency departments in hospitals [5]. The injuries can be seemingly harmless in that the pain from most minor sprains tends to settle quickly, however, all ankle sprains should be assessed.
Assessment can differentiate the sprain type and severity which can help to determine the necessary recovery period [3,4] as returning to sport and exercise too soon comes with the risk of long-term consequences [2].
What is an ankle sprain?
Ankle sprains occur when your foot rolls excessively and strains (or ruptures) the fibres in the ligaments that attach your ankle to the side of your foot. This can happen on either or both sides of your foot, however, the inner (medial) side of the ankle has much stronger ligaments. The ligaments on the outer (lateral) side of the ankle are generally more prone to injury when the ankle rolls over the outside of the foot [2] (which happens far more frequently). This tends to happen commonly in stop-start sports such as basketball or soccer [2], but runners – particularly trail runners are susceptible to this injury.
Damage that occurs to the ligaments is graded on a 3-point scale from mild to severe based on injury history and clinical tests, with diagnostic imaging used occasionally to provide further insight into the extent of the injury.
Mild sprains (Grade 1)
In mild cases (Grade 1) ankle ligaments may be stretched or slightly damaged, some pain is felt usually at the time of the injury and usually improves over the course of a few days. Some swelling is expected and bruising to the foot, ankle or lower leg may or may not occur during this time.
Moderate sprains (Grade 2)
Moderate, or Grade 2 injuries are generally painful for longer as there is a larger degree of damage to one or more ligaments. Walking can prove difficult due to pain, and the ankle will likely be swollen with bruising that may last for up to a couple of weeks.
Severe sprains (Grade 3)
Grade 3 (severe) injuries can sometimes actually be less painful than Grade 2 injuries as the completely ruptured ligament(s) tend to stop hurting after a couple of days. The ankle is significantly less stable though due to the lack of supporting ligament support, and can progress on to long term injury if not properly treated.
Complex sprains and Long-term complications
Unfortunately, some ankle sprains are complex and severe and require greater care and time to heal.
Here are FOUR examples of more complicated injuries that can occur with ankle sprains.
#1 Avulsion Fractures
In cases of ankle sprains where standing is unbearable, fractures may have occurred to bones in the foot, ankle or lower leg. When the ankle rolls during a sprain there is often a forceful muscle contraction that can pull the bone away from the muscle insertion (a process known as “avulsion”). This tends to occur on the lumpy part of the side of the foot (styloid process and/or fifth metatarsal shaft), the tip of the ankle bone (malleolus), or less commonly just below the knee (fibula head).
Detection of the fracture is usually done with X-ray around the time of the injury but maybe repeated 2 weeks later if the initial scan is inconclusive (evidence of bone healing is more easily detected at this time and is indicative of a recent fracture). Depending on the location and severity of these fractures, treatment may involve immobilisation with a fracture (moon) boot with crutches, or surgery to reattach the bone.
#2 High Ankle Sprains
High Ankle Sprains are a more serious type of sprain that tends to involve a twisting movement of the lower leg (which may happen if the foot is caught while the body twists away from it) [4]. With this injury, pain tends to be felt higher above the ankle joint as the fibres the hold the two shin bones together are damaged.
In addition to specific clinical tests, diagnosis of this injury usually includes a standing X-ray, and Diagnostic Ultrasound or MRI. Return to the sport can occur in as little as two weeks for mild cases [4], though severe cases (where the shin bones have separated considerably), surgery is required to stabilise the leg and ankle.
#3 Osteochondral Talar Dome Lesions
Osteochondral Talar Dome Lesions (TDL) involve damage to the cartilage and bone on the top of the talus bone (where the foot joins to the shin). There are several different grades of this injury depending on the severity of damage to the cartilage and bone. It is not well understood how these injuries develop, though chronically unstable ankles (i.e. those that do not regain sufficient ligament strength after a strain) are at a greater risk [1]. There is evidence that bone bruising is often present in the Talus after some ankle injuries which may lead to the develop of TDLs [7]. This bone bruising can be present for over 9 months [7].
Osteochondral TDLs may involve compression of the bone and cartilage, or have a chip of bone dislodge within the cartilage. Diagnosis is made via MRI or CT scans, and will usually involve a period of immobilisation (fracture boot), and to a year of recovery. In recurrent TDL injuries, or where the ankle is chronically unstable surgical reconstruction of the ankle joint may be necessary.
#4 Post Traumatic Osteo-Arthritis (PTOA)
A further complication that can develop from lateral ankle sprains is Post Traumatic Osteo-Arthritis (PTOA) [6]. Osteo-Arthritis is the world’s most common joint disorder in the western world [5] and having a traumatic injury can increase its likelihood [6]. When it occurs in the ankle, the cartilage lining of the joint becomes thin and can result in pain, stiffness and inflammation in the ankle joint making walking and running uncomfortable. Proper management of acute ankle injuries is an important step to help minimise the amount of inflammatory change which may contribute to PTOA later occurring.
Early treatment for Ankle Sprains
Initial treatment should begin as soon as possible.
This involves protecting the injury from further damage. If the ankle is significantly sore, it is best not to run with the injury as pain and the resultant reduction in reflexes will force changes in gait and may make the injury more severe and/or create additional injuries. While the use of ice packs in ankle sprain management has been challenged more recently (arguments suggest that this can slow the healing rate) they can be useful for reducing pain which might help reduce long term complications. Compression and elevation are accepted treatments to reduce swelling and should be administered ASAP. Early mobilisation (walking) is useful in most cases as it encourages faster healing and less strength loss, but should be done in moderation over the first couple of days.
X-rays are generally only required if you are unable to stand on that foot due to pain and there is tenderness on the bony parts of the side of the foot or ankle. Pain in these locations can be indicative of a fracture and should be treated with additional care with a fracture boot, plaster cast or in some cases – surgery.
Return to sport rehabilitation
It’s been shown that all grades of ankle sprains result in reduced strength and stability in the injured ankle [2]. Failure to address these deficits results in a greater chance of a more severe grade ankle sprain, a higher than average likelihood of re-injury, and possible complications such as a long-term ankle injury. A good rehabilitation plan will include a personalised program aimed at addressing your particular deficits and restrictions present at assessment. This should be reviewed through the course of the rehabilitation process to ensure the exercises are suitably challenging and are being performed correctly.
Returning to running (or sport) can sometimes safely happen as early as one-week post sprain for lower grade injuries, though this should be done at an easy intensity and for a short amount of time. In cases where the initially diagnosed Lateral Ankle Sprain is persistently painful, or not responding to a rehabilitation program, suspicion a more complex ankle sprain should be raised. These types of injuries are discussed below and may require further imaging [7].
Remember… EARLY assessment and treatment is key
Runners can be their own worst enemies when it comes to stoically (or stupidly) ignoring injuries. Ankle sprains are an injury that deserves respect. Early assessment and treatment are essential to help guide you through the recovery and rehabilitation process while helping reduce the risk of it developing into a potentially more serious, long-term injury. If you’ve recently sprained your ankle, or have a recurrent history of this injury contact the intraining running injury clinic to discuss how best to manage your injury.
Book an appointment
Ph: 3367 3088 or [email protected]
DOUG JAMES
PHYSIOTHERAPIST | PODIATRIST | L1 COACH
Doug James is a qualified physiotherapist and podiatrist with a special interest in running and sports injuries. He combines the two treatment approaches to achieve successful outcomes for clients of all abilities from non-athletes through to elite athletes.
Bachelor of Podiatry (Honours), Master of Physiotherapy Studies.
Doug has undertaken further training in dry needling, Pilates, and Rocktape and may incorporate these as necessary during treatment.
Doug is also a keen runner having completed the New York Marathon.
Book an appointment
Ph: 3367 3088 or [email protected]
References
(1) Gregush, R. V., & Ferkel, R. D. (2010). Treatment of the Unstable Ankle with an Osteochondral Lesion: Results and Long-term Follow-up. The American Journal of Sports Medicine, 38(4), 782–790. https://doi.org/10.1177/0363546509351556
(2) Kobayashi, T., & Gamada, K. (2014). Lateral Ankle Sprain and Chronic Ankle Instability: A Critical Review. Foot & Ankle Specialist, 7(4), 298–326. https://doi.org/10.1177/1938640014539813
(3) Mauntel, T. C., Wikstrom, E. A., Roos, K. G., Djoko, A., Dompier, T. P., & Kerr, Z. Y. (2017). The Epidemiology of High Ankle Sprains in National Collegiate Athletic Association Sports. The American Journal of Sports Medicine, 45(9), 2156–2163. https://doi.org/10.1177/0363546517701428
(4) Miller, B. S., Downie, B. K., Johnson, P. D., Schmidt, P. W., Nordwall, S. J., Kijek, T. G., … Carpenter, J. E. (2012). Time to Return to Play After High Ankle Sprains in Collegiate Football Players: A Prediction Model. Sports Health, 4(6), 504–509. https://doi.org/10.1177/1941738111434916
(5) O’Connor SR, Bleakley CM, Tully MA, McDonough SM (2013) Predicting Functional Recovery after Acute Ankle Sprain. PLoS ONE 8(8): e72124. https://doi.org/10.1371/journal.pone.0072124
(6) Palmer-Green, D.S, Batt, M.E, & Scammell, B.E. (2016). Simple advice for a simple ankle sprain? The not so benign ankle injury. Osteoarthritis and Cartilage, 24(6), 947–948. https://doi.org/10.1016/j.joca.2015.12.019
(7) Wang, X. (2017). The Significance of MRI in Process Change of Osteochondral Lesion of Talus. Foot & Ankle Orthopaedics. https://doi.org/10.1177/2473011417S000408
