Ankle Sprain

Subjective

An England under 21 Basketball player sprained his left ankle, after landing on an opponent’s foot after a jump shot. His ankle went over and it was very painful. The ankle swelled very quickly and he could not fully weight bear. Later that day the patient went to A&E and a check x-ray confirmed that there had been no fracture sustained. The patient was not immobilised following the sprain or given elbow crutches. I first met him at the four week post injury mark. At that stage the ankle was still very swollen and painful even on jogging and he had an important tournament for England in six weeks’ time. This is the patient’s first ankle injury. So far he had not undertaken any real form of physiotherapy.

Daily Pattern – the ankle is stiff first thing in the morning for 30 minutes and then sore after walking for more than 15 minutes. He does not feel he can run yet.

Past medical history – Nothing significant

Medication – Inhalers for mild asthma

Social History – lives with partner and trains most days Basketball or gym based

Observation

The ankle was still significantly swollen both the capsule and over the lateral ligaments. He has moderately flat feet both sides.

Movement

He had regained the majority of active movement at the ankle. Knee over foot (dorsiflexion) was painful and restricted to about half in standing/weight-bearing.

Muscles

Weakness of the ankle inverters (turning ankle/foot in) and everters (turning ankle/foot out) was noted and the ability to stand and balance on one leg diminished.

Nerve movement

There was some restriction of nerve movement in the leg.

Joints

The ankle joint was not stiff on testing, but sore when trying to stress the anterior/lateral ankle ligament. The most commonly injured ligament being the ATFL (anterior talo-fibular ligament) in the ankle. This was certainly the case for this chap and he had significant ligament laxity and a likely grade two tear of this ligament (around half the fibres).

Impression

Grade two lateral ligament sprain (ATFL) from an inversion injury. Unfortunately, this patient did not receive the best advice from the start and to optimise recovery and allow the ligament to heal in the correct position I would have suggested a ski-boot brace to be worn for four weeks, taking it out regularly to do range of movement exercise. This would have allowed the pain and swelling to settle much earlier. This will mean a delayed healing time for this player and his ligament has not been given the best chance of healing in the shortest position possible.

Treatment

I discussed the presentation with the patient to ensure he had a good understanding of the problem and the likely outcome of treatment. I advised him to buy a very structurally supportive ankle brace that he would be able to return to Basketball in. He started wearing this at all times during the day to help reduce pain and swelling, which worked very well and after 10 days he noticed his pain and swelling had improved by 80%. During this period he had already started to strengthen his ankle muscles, along with some stability training/balance practice. After two weeks in the brace we started adding in some tip toe drills and further strengthening work. In our sessions we continued to work on the ankle sensitivity/stiffness into dorsiflexion (knee over toes). After four weeks of treatment he started running drills and was taking part in light training. We then progressed to end stage hopping drills and final high level strengthening of the ankle. By week six he could fully participate in training and his running was back up to full speed without pain.

Home instructions

I advised him after four weeks to only use the brace for sport and any active training from thereafter. He worked hard between physiotherapy sessions on his exercises and gym programme.

Outcome

With the use of an ankle brace this patient was able to compete for England with no pain and no risk of re-injury. He was advised to use the brace/tape for three months until his ankle is strong enough to compensate for the weakened lateral ligament. He was reviewed regularly to ensure he reached the final stages of rehabilitation over that three month period, and he was advised to keep up with his ankle rehab for the remainder of his sporting career due to the increased laxity of the injured ligament that tends to remain.

Thoughts

As this case demonstrates, getting the most appropriate and early treatment for an injury is vital to ensure the damaged structure heals in the best possible position. If this is not in place then the recovery/return to sport can be delayed and can leave long term weakness/instability in an area.

 

Phil Pask