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Acute Ankle Sprain

Ankle sprains represent 15-20% of all sport injuries. They are in fact the most common injury sustained by athletes. Ankle sprains are more common in the younger age group in sports that require rapid changes of direction.

Sprains of the lateral ligament complex at the outside area of the ankle joint, represent 85% of all ankle sprains. The ligament complex on the outside of the ankle consists of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL)and the posterior talofibular ligament (PTFL). As the foot twists inwards in relation to the lower leg the ATFL is the first ligament damaged followed by CFL and finally the PTFL.

Traditionally these injuries are divided into three grades: Grade 1 or mild injuries result in tearing of some fibres with minimal bleeding. In Grade 2 or moderate injuries there is an incomplete rupture of the ligament and moderate bleeding. Grade 3 or severe injuries are characterised by complete disruption of the ligament.

Clinical  Presentation

Grade 1                             Pain but carry on with activity
         Able to bear weight
         Mild or minimal swelling
         Pain reproduced by stressing the ligament without laxity
         No functional and strength loss.

Grade 2                             Pain severe enough to stop carrying on with activity
       Able to bear weight
       Moderate swelling
       Pain on stressing the ligament with some laxity
       Some reduction in function and strength.

Grade 3                             Pain and inability to bear weight
       Severe swelling
       Gross laxity
       Possible complete loss of function and strength.

X-rays are important, in Grades 2 and 3 in particular, to rule out any associated bony ankle or foot injuries such as 5th metatarsal fractures (such as Wayne Rooney had). MRI scan may be useful in Grade 3 sprains to assess the damaged ligament and other associated soft tissue and bone injuries.

Treatment

This can be divided into three phases irrespective of how severe the injury is, however, the rate of progression from one phase to the next one is dependent on the grade of the injury.

Phase 1- Control of pain and inflammation
This phase starts immediately after injury and is achieved by protection, rest, ice, compression and elevation.

Phase 2- Restoration of full range of movement and muscle strength

Phase 3- Restoration of Ankle joint function and balance, restoration of general       
                Fitness and return to sport, prevention of future injuries.

Surgery

Persistent pain which fails to settle within 6-8 weeks is an indication for further investigation and possible surgery if the surface of the joint has been damaged (which may not be apparent immediately after injury).

Surgery is mainly indicated in those patients with severe/Grade 3 injuries who, despite conservative management, still suffer with instability symptoms with recurrent going over of the ankle. In these patients surgical reconstruction of the lateral ligament is recommended.

Return to sport

As with other sport injuries, return to play is permitted once the athlete is pain free, able to achieve a full range of Ankle and Foot movement and has regained enough strength to perform the sport specific activities. If the non-operative regime of treatment is successful, athletes are able to return to play within 3 months. With surgical intervention, return to play may take 3 to 6 months following surgery.

 
 
PERSISTENT PROBLEMS FOLLOWING ANKLE SPRAINS

Persistent problems following Ankle sprains may be due to:

1)Inadequate rehabilitation

This is thought to be the most common cause of persistent ankle pain following a sprain. A full, adequate rehabilitation programme, under a Physiotherapist's supervision, must be restarted.

2)Persistent lateral ankle instability

Chronic ankle instability may be functional or mechanical. Functional instability refers to an athlete's subjective feeling of "giving way" in the ankle, usually due to inadequate rehabilitation.
Mechanical instability is the increased laxity of the ankle joint, beyond the normal physiological range, caused by structural ligament damage. A specialist's opinion should be considered.
In the case of functional instability, a complete rehabilitation programme including functional ankle bracing and sometimes orthotic footwear may be considered.
Surgery is indicated for athletes with mechanical instability who are symptomatic despite having been through a complete and comprehensive rehabilitation programme. Surgery has a high success rate and the success rate is independent of the length of time since injury.

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