The clinical manifestations of Ankle Sprain include the inability to walk or even move the joint, a searing or tearing sensation, pain that increases with mobility, color change and rapid bruising. The intensity of these manifestations depends on the severity of the sprain. Ankle sprain is classified based on clinical signs and functional loss, as follows: grade 1 (mild stretching of a ligament), grade 2 (more severe injury involving incomplete tear of a ligament), and grade 3 (complete tear of a ligament).
An Ankle can sprain in different directions and this will affect different ligaments.
Inversion sprain will affect the ligaments on lateral side of ankle. Eversion will impact those in the internal side and twisting movements can impacts those ligaments that are keeping together tibia and fibula bones
Acute ankle sprain management
It is well-known that all Grade I and Grade II ligament injuries are safely treated non-sugically. The recommended treatment is functional with a short period of rest, cooling (ice), compression and elevation to reduce the edema (PRICE), during the first 1 to 3 days, depending upon the amount of swelling, bruising and pain.
The ruptured ligaments should be protected from distraction and new injuries during healing, using external support i.e. ankle tape or brace to control the range of motion and to reduce the instability. The results after functional treatment of Grade I and Grade II ligament injuries are almost always satisfactory, and most athletes are able to return to sporting, providing they protect their ankle from further injury using external support.
There is still some controversy in terms of the optimal treatment of Grade III ligament ruptures as to whether these injuries should be treated non-surgically, by physiotherapy and early mobilization, or by primary surgical repair followed by immobilization using a plaster cast (either full or hinged).
All these studies have showed that the long-term results are satisfactory in most patients, regardless of the primary choice of treatment i.e. surgical repair, cast immobilization alone for 3 to 6 weeks or physiotherapy. Taken together, approximately 80 to 90% of patients with Grade III injuries will regain satisfactory functional stability after nonsurgical treatment.
Physiotherapy includes short period of immobilization, using ankle tape or elastic bandages. Training of range of motion, peroneal muscles and coordination training is started as soon as pain and swelling have subsided. Weight-bearing is encouraged from the beginning.
It can thus be concluded that physiotherapy is the treatment of choice when dealing with acute ligament injuries of the ankle joint, irrespective of the grade of injury. The remaining problem is how to identify those approximately 10% of patients who will develop chronic functional instability in spite of adequate primary treatment and may need surgical reconstruction at a later stage.
Chronic ankle sprain management
Chronic lateral ankle joint instability will develop in approximately 10% of patients after acute ligament rupture. This ligament instability, irrespective of its aetiology does not always require surgical reconstruction.
The indication for surgical treatment is recurrent ‘giving way’ in spite of proprioceptive training. Non-surgical treatment is therefore always recommended before surgical treatment. Surgical reconstruction is more often needed in athletes with high demands of ankle stability.
Of all individuals who have sustained acute ligament injuries, it is probable that less than 10% will need stabilizing surgery at a later stage. Before deciding on surgical treatment in a patient with chronic ligament insufficiency, a supervised rehabilitation program based on peroneal muscle strengthening and co-ordination training should be carried through.
Approximately 50% of patients with chronic functional instability of the ankle will regain satisfactory functional stability after 12 weeks on such a program.
Patients with high-grade mechanical instability have less chance of regaining satisfactory function by physiotherapy. These patients should undergo surgical treatment.
Return to sport after an ankle sprain
Decision-making regarding return to the sport in athletes may be challenging and a sports physician should determine this based on the self-reported variables, manual tests for stability, and functional performance testing.
Grade I ankle sprain normally takes around 2-3 weeks for the return to play, Grade II can take up 4-6 weeks and for a grade III it can take 3 months or more. There are some common myths and mistakes in the management of ankle sprains, which all clinicians should be aware of and avoid. These include excessive imaging, unwarranted non-weight bearing, unjustified immobilization, delay in functional movements, and inadequate rehabilitation.
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