MANAGEMENT OF ANKLE INJURIES

By Kathy I. Dieringer, ATC, LAT, OPA-C

(Published in 1999 Spring Volleyball USA)

Statistically the most common athletic injury, ankle sprains continue to haunt players, coaches, and sports medicine personnel. Appropriate recognition and management of the ankle sprain are paramount to the safe, rapid return to participation. Inappropriate management, however, can lead to complications that will not only put the athlete at risk for subsequent injury, but also could be devastating to the athlete's health and career.

By definition, an ankle sprain involves injury to the ligaments providing support and stability to the ankle joint. Ankle sprains are generally classified in three ways: inversion, eversion, and syndesmotic sprains. Severity is measured according to the extent of ligament damage and joint instability. Each of these sprains is similar in the symptoms they cause and the course of action they require. (1,3)

The inversion sprain, by far the most common makes up 85% of all ankle sprains. (2,3,4) This injury involves the ligaments on the lateral, or outside, of the ankle. The mechanism of injury for this sprain is forceful inversion (turning the sole of the foot inward) or "twisting", such as when a player lands on an opponent's foot under the net. Conversely, the eversion sprain occurs when the outside of the foot is forced upward, causing injury to the medial, or inside, ankle ligaments. Finally, the syndesmotic sprain, or "high sprain", occurs the least often, but generally takes twice as long to heal as the inversion or eversion sprain. Syndesmotic sprains occur in a variety of ways: forceful dorsiflexion or plantarflexion, or more commonly forceful external rotation of the ankle. This "high sprain" is suitably named, because the ligaments involved are above what we commonly refer to as the true ankle joint. This injury presents more of a challenge for the athlete because of its slower healing, and both the athlete and coach must be patient enough to allow proper healing to occur. (1,3)

Ankle sprains are graded, according to their severity, as first, second, or third degree sprains. Severity is measured according to the extent of ligament damage and joint instability. First-degree sprains involve stretching of ligament(s), and are generally mild injuries. The athlete experiences mild pain, disability, point tenderness, and swelling. By contrast, second-degree sprains involve the tearing of ligaments, and are thus more serious. The athlete experiences moderate pain and disability, and is often unable to bear weight. The most serious ligament injury, the third degree sprain involves the rupture of ligaments. The result is severe pain, disability, loss of function, and joint instability. (1,4) Any athlete who sustains a second or third degree sprain should be x-rayed and evaluated by a physician to rule out a more serious injury, especially young athletes who have not stopped growing. (4) Coaches and players should realize the implications of not seeking proper medical intervention for any of these injuries.

With any ankle sprain, the athlete should expect a tender ankle that will "bruise" and swell within 24-48 hours. Because of this, acute care is extremely important in minimizing recovery time, and should, therefore, begin immediately. The common treatment of rest, ice, compression, and elevation (RICE) should be carefully followed, and is an excellent protocol for most ankle injuries. (3,5) Rest includes restricting the athlete from some or all activity for a period of time. The athlete may have to be completely restricted from volleyball, or may only be allowed to pass and serve, but each injury should be treated uniquely based on severity and the level of function of the athlete. As is well known, ice should be applied to the ankle during the first 48-72 hours after the injury in 20-minute increments. While icing, and as often as possible otherwise, the ankle should be elevated above the athlete's heart. In addition, wearing either a compression wrap or compressive brace will also minimize the amount of swelling in the ankle. Complete immobilization of the ankle is generally reserved for only the most severe ankle sprains or those with instability. (1,4)

In addition to treatment of an ankle sprain, rehabilitation is vital to the rapid recovery and protection from re-injury to the athlete. (5) Early, gentle motion in a pain free range is encouraged and beneficial to reestablishing function. Exercises such as ankle pumps, alphabets, gastroc-soleus complex (calf) stretching, and towel exercises are helpful with this. As swelling and pain subsides, more advanced exercises can be introduced such as: heel and toe walks, heel raises, elastic band/tubing exercises, and balance/proprioception activities. To retard the loss of conditioning, the athlete should swim or ride a stationary bike daily, and continue to strength train as is possible. Once the athlete has regained full, pain free motion and function, advanced rehabilitation can begin. Progressive resistive exercises (PRE's) are initiated, such as ankle weight machines, exercises involving cuff weights, jumping rope, walk-jog activities, and progressing to sprinting that involves changing directions. As a general rule, the athlete should be able to complete the exercise without pain, swelling, or limping, which could take anywhere from 3 days to 6 weeks.

Once the athlete is ready to return to exercise, the decision must be made on how to protect her/him from further injury. Taping an ankle has long been a popular method of providing support to the ankle, but current research, however, suggests that tape loses at least 40% of its strength within the first ten minutes of application, causing it to decrease in effectiveness. An ankle brace is a better option, since it can be tightened if it loosens. (6) Though there is no conclusive evidence that any one brace is superior, the key to providing the most protection is finding a brace that the athlete will wear comfortably and correctly. (4) Contrary to the belief of many, there is no documented evidence suggesting that wearing an ankle brace causes the ankle muscles to weaken. Studies have been published, however, that support the use of ankle bracing to prevent ankle injuries. (6) Clearly, preventing the ankle sprain is preferable to managing one that has already occurred.

Ankle injuries are inevitable in any athletic arena. The key to successful management is early identification of the type and severity of the injury. Once the injury has occurred, appropriate treatment and rehabilitation should begin immediately, and continue even after the athlete has returned to full activity. By following these steps, the athlete will return to activity as quickly and safely as possible, while preventing the occurrence of re-injury.

1. Arnheim DD, Prentice WE. Principles of Athletic Training. 9th ed. St Louis, Mo. McGraw-Hill Companies, Inc,; 1997: 434-445.

2. Birrer Richard B., Cartwright Thomas J., Denton John R. Immediate Diagnosis of Ankle Trauma. The Physician and Sportsmedicine. 1994; 22 (10): 95-102

3. Fu Freddie H., Stone David A. Sports Injuries. Baltimore, MD. Williams & Wilkins; 1994: 977-988.

4. Garrick James, Schelkun Patrice. Managing Ankle Sprains. The Physician and Sportsmedicine. 1997; 25(3): 57-68.

5. Karlsson Jon, Lansinger Olle. Chronic Lateral Instability of the Ankle in Athletes. Sports Medicine. 1993; 16 (5): 354-364.

7. Sharpe Sharon, Knapik Joseph, Jones Bruce. Ankle Braces Effectively Reduce Recurrence of Ankle Sprains in Female Soccer Players. Journal of Athletic Training. 1997; 32 (1): 21-23.