Ankle sprains are a very common sports injury, accounting for about 75% of all ankle injuries. In most cases, the injury is often caused by excessive inward rotation of the toe while landing on the lateral side of the foot. The relatively weak lateral collateral ligament of the ankle is susceptible to injury (Figure 1). Injuries to the thicker medial collateral ligament of the ankle are relatively uncommon, accounting for only 5-10% of ankle sprains.
Depending on the degree of damage, the ligament may be overstretched and cause a tear, resulting in chronic instability of the ankle joint. Symptoms vary from mild to severe. Most have a history of sudden trauma, including twisting or turning injuries. The main manifestation is pain in the lateral aspect of the ankle joint, which is also often accompanied by swelling and even petechiae on the medial and lateral edges of the foot. Severe injuries can result in lateral ankle capsule tears, ankle fractures, and separation of the lower tibiofibular joint.
The lateral collateral ligaments, including the anterior talofibular ligament, heel-fibular ligament and posterior talofibular ligament, are the most commonly injured in ankle sprains. If there is also damage to the heel and posterior talofibular ligaments or even a tear in the joint capsule, it is more serious and can easily cause joint laxity or even develop into chronic instability.
If there is also tendon, bone or even other soft tissue damage, further diagnosis is needed. It is recommended that serious ankle sprains require prompt medical attention and consultation with a sports injury specialist, who can use X-rays, MRI, ultrasound and other tests to clarify the extent of the injury and whether arthroscopic surgery is needed.
Mechanism of injury: Most ankle sprains are caused by inversion of the ankle joint, and the inversion stress causes the lateral collateral ligament to tear. Usually there are very few valgus injuries in sports, mostly caused by some larger external forces such as car accidents. Valgus injuries usually have more serious consequences, easily causing ankle dislocation, fractures, tears of the medial triangular ligament of the ankle joint, and even vascular nerve injuries, which will not be discussed here.
Depending on the degree of sprain, there are three degrees of sprain: I: mild pain, slight incomplete tear of the lateral collateral ligament, mild swelling of the lateral ankle, and rarely joint instability; II: moderate to severe pain, swelling, stiffness, difficulty walking, some foot petechiae, moderate incomplete tear of the lateral collateral ligament, and partial joint instability; and III: the most severe injury. The pain and swelling are often more pronounced, the sole of the foot often appears obvious petechiae, the lateral collateral ligament is completely torn, and the joint appears obvious instability affecting normal activities.
Of course, if the injury is more severe, it may be accompanied by anterior internal ankle impingement, external ankle fracture, or even ankle dislocation.
Some ankle sprains may develop into complex regional pain syndrome (CRPS), a sympathetic nerve disorder causing a pain syndrome with localized pain, redness, burning sensation, and pain sensitivity that does not correspond to the site of injury. Patients with a combination of such complications can be quite problematic to treat and take longer to recover. I have seen patients in my practice with sprains 1-2 years old who still have localized ankle pain, inability to move normally, skin color changes, and other problems. These types of problems usually require a combination of treatments.
Treatment.
1. Emergency treatment (First Aid)
The goal is to control the pain and swelling as much as possible, which can be done with reference to the PRICE treatment principles for acute sports injuries.
The following measures should be implemented as early as possible within 48 hours of the injury.
Protection: Protection. A cast or brace may be used to protect the injury from further injury.
Rest: Rest (braking). Stop activity and avoid weight bearing on the affected lower extremity.
Ice: Apply cold compresses (ice, ice packs, cold products, etc.) to the swollen and painful area for 10-15 minutes, several times a day (may be every 2 hours). Do not let the ice directly touch the skin, use a towel to isolate it to avoid frostbite.
Compression: Compression can be applied with an elastic bandage. It will stop further bleeding and prevent severe ankle swelling. Adhesive support bandages are not recommended to immobilize the ankle until the swelling subsides.
Elevation: Elevate the lower leg and ankle as high as possible above the level of the heart (for example, lying down and placing a few pillows under the leg). The correct way to elevate the lower extremities should be: ankle over knee, knee over hip, and hip over body level.
Timely and effective first aid measures are important to speed up healing. Patients with severe sprains need to be seen in hospital immediately. Exclude the presence of a fracture, the need for crutches or a cast, and the need for medication. The specialist will guide you on the relevant treatment.
2.Follow up treatment
In the acute stage, physical therapy such as ultrasound or laser can be used to control the swelling and inflammation, and anti-inflammatory and analgesic drugs can be taken under the guidance of the doctor. Acute ankle sprains generally require at least 2 weeks of rest with brakes. If the swelling and pain improve and there is no significant aggravation, some functional training can be performed to help improve joint mobility and further control the swelling.
Plaster is an effective and economical method of braking and protection, so don’t be afraid to put it on, and you can choose it if necessary. However, a cast is relatively hot and uncomfortable, not easy to wear and clean, and cannot be walked on the ground. The better method of fixation at present is to choose the appropriate support and protective gear. In the acute stage, it is recommended to choose a splint-like brace with a strong restrictive effect. Walking boots are usually more protective, breathable and easy to walk and clean, but they are more expensive and recommended if economic conditions allow.
After the acute phase, some stretching and plyometric training can help restore mobility and muscle strength to the affected limb, laying the foundation for a return to normal walking and movement. Elastic band training is a relatively simple and easy to use training method. After plyometric training, it is necessary to add exercises to restore proprioception. The so-called proprioception is the deep sensation of the joint, including the sense of position, kinesthesia, etc. It is the basis of joint stability, and sprains and other traumatic injuries usually damage the proprioceptors. Proprioceptive training is usually done by balance exercises, either on your own or with the assistance of a machine.
Patients with MRI or ultrasound suggesting a grade III or greater ligament injury need to prevent chronic ankle instability. It is usually recommended to follow up with active rehabilitation and conservative treatment for 3 months and then check the stability of the ligaments and joint laxity. Patients with chronic instability who have not recovered significantly and are interfering with normal activities, or who have recurrent episodes of instability, may be considered for surgical treatment. Usually surgery can be performed using a combination of minimally invasive arthroscopy + small incision repair. Multiple ligament ruptures can also be treated with tendon reconstruction surgery.
3.Needs attention.
In the process of rehabilitation, if some of the following conditions occur, you need to come to the hospital in time to avoid delaying the condition.
1.After acute sprain, the swelling and pain are very obvious and accompanied by a large amount of skin bruising, with obvious pressure pain and activity limitation;
2.After resting and braking, the swelling and pain will slowly subside, but there will be pain when walking and moving more, accompanied by joint swelling (more likely to occur on uneven ground or stairs);
3.The swelling and pain improve, but when walking or exercising normally, there is often a “weak leg”, and may be accompanied by unstable symptoms such as falling;
4.History of ankle sprain, re-torsion during sports, and history of repeated sprains or joint loosening and instability.
5. Secondary redness and heat with pain in the whole foot and ankle, which may develop into chronic pain or complex focal pain syndrome (CRPS).