No products in the cart.
Lateral ankle ligament sprains are the most common injury affecting both general and athletic populations.[1-7] Within the UK and the US approximately 5,000 and 27,000 injuries respectively occur per day, with research showing that the anterior talofibular ligament (ATFL) is injured most frequently.[1-2] The ATFL connects the lateral malleolus to the neck of the talus, forming part of the lateral ligamentous structure of the ankle joint; alongside the calcaneofibular and posterior talofibular ligaments (PTFL).[1,5,9] Due to the biomechanics of the ankle joint, as plantar flexion (PF) increases the soft tissues are more susceptible to strain/injury; with most sprains occurring in PF, adduction and inversion, leading the ATFL to be injured before any other ligament;[1,5] the classic ‘rolled ankle’ or ‘going over on your ankle’
In the acute setting, to assess the ankle, simply placing the ankle into: PF, abduction and inversion will be sufficient to elicit pain in the ATFL – this is if the patient will let you. This in conjunction with the anterior draw test and palpation can lead to the diagnosis of an injury to the ATFL. In addition to this assessment a clinician should also check the syndesmosis, via the syndesmosis squeeze test, and assess for creptius at the foot/ankle: for possible Lisfranc injury or a 5th metatarsal fracture, and for crepitus at proximal fibula: attempting to rule out a Maisonneuve fracture. In the acute setting the Owatta ankle rules [1,5,10,11] can be applied to help the clinician decided if an ankle x-ray is required. Research suggests, that due to the bodies healing mechanisms initial soft tissue injury management, P.O.L.I.C.E (Protection, Optimal Loading, Ice, Compression and Elevation), should be commenced and a more thorough assessment should be completed 4 days post injury.[1,4] There are several grading systems available,[1,13] for musculoskeletal injuries and are dependent on the clinician present as to which is used.
As research suggests,[1,3-5,14] the treatment of choice for this type of injury should start with P.O.L.I.CE, to reduce pain and swelling; continuing with exercises when able. These early mobilisation exercises should take the form of gentle active range of motion (ROM) exercises e.g. plantar flexion, dorsiflexion, inversion, and eversion.[1,3-5] Early mobilisation provides controlled stresses to the ankle joint and has been shown to speed up the recovery of acute ankle injuries. My personal favourite to say to patients for ROM exercises, is to get them to write the alphabet or spell their name with their foot. To maintain cardiovascular fitness and to help work the ankle functionally, although in a controlled manner, one can use the stationary bike or elliptical.
When the patient is able to progress with their exercises, the progressions should always be functional in nature, with an element of proprioception/neuromuscular control (NMC).[1,3-5] Due to the importance of restoring NMC,[3,5] NMC exercises should be afforded their own time slot; as insufficient NMC is a contributing factor to both initial and secondary injuries. Functional treatment is based on the healing process of a ligament: during the first 3 weeks as new collagen tissue forms it is necessary to prevent unwanted inversion as this will lead to a weaker collagen being laid down, after 3 weeks the collagen begins to mature and responds to controlled stresses by correcting fibre alignment. The collagen will continue maturing, with a return to activities expected at approximately 4-8 weeks. Manual mobilisations, ultrasound, laser and electrotherapy were shown to have limited/no added value to ankle ligament rehabilitation.
Rehabilitation exercises, no matter their guise; be it strength, flexibility, or NMC, are always commenced on a stable surface. During a NMC session, the goal is to provide greater kinesthesia through better communication between the neural and muscular systems. Therefore to progress NMC exercises from a stable base, the exercise could include external perturbations (catching/throwing an object), be conducted on an unstable surface (foam pad/mat/beam), having a flight phase included,[16-17] or by combining progressions. An example here would be a single leg stand; this can be progressed by: throwing and catching a ball (reaching out of the base of support), standing on an unstable surface, and standing on an unstable surface whilst throwing and catching a ball.
An example rehabilitative exercise for the ATFL is the Step-up; whilst this may primarily be used for strength, it can have a great NMC adage. The step-up should only be commenced once the patient is: 1) fully weight bearing, 2) able to take their full weight on a single leg, and 3) is confident in stepping up through their injured side. Initially the step-up can be conducted onto a shallow box (Figure 1), which can be made higher (Figure 2) as the patient progresses.
- To start, the patient will stand facing the box (Figure 3), before stepping onto it leading with the injured side (Figure 4). The patient will stand up achieving full extension (Figure 5), before stepping back down in a controlled manner.
2.Adding a foam pad/mat onto the top of the box to create an unstable surface (Figure 6), then continuing as in 1.
3. Stable box; upon stepping up onto the box, adding in a hip/knee drive of the contralateral leg (Figure 7)
4. Foam pad/mat on box; stepping up onto the box with a hip/knee drive of the contralateral leg (Figure 8)
5. Stable box, hip/knee drive of the contralateral leg: achieving flight phase (Figure 9)
6. Foam pad/mat on box, hip/knee drive of the contralateral leg: achieving flight phase (Figure 10)
In addition to the foam pad/mat to progress the exercise the therapist can add in perturbations, these could be visual or physical perturbations. Visual perturbations could be advantageous for athletes, as they have to take in a lot of external information whilst remaining focused for their task at hand. The step-up is a very versatile exercise; in that it can be altered to conduct a side step-up (Figure 11), a step-up with an eccentric step down (Figure 12), a weighted step-up (Figures 13 and 14) +/- an eccentric step down
In summary, from the available research lateral ankle ligament sprains are the most common injury to affect both the general and the athletic populations, with the ATFL is injured most frequently. An increase in pain when placing the ankle into: PF, abduction, and inversion, combined with an increase in pain during the anterior draw test, and pain on palpation over the ATFL is sufficient to point towards an ATFL injury. Although it is very important for the clinician to still think about concurrent injuries: Ottawa ankle rules, Syndesmosis injury, Maisonneuve fracture, Lisfranc injury, 5th metatarsal fracture etc. An acute injury to the ATFL responds well to the P.O.L.I.C.E principle and early mobilisation, and should then be fully assessed 4 days post injury. This early mobilisation will provide the basis for sport specific training i.e. strength and NMC. NMC is one method by which the ankle can be made more stable; and as such reduce the likelihood of recurrent sprains/ankle instability.
Opinions expressed by physiogramworld contributors are their own.
- Lynch, S.A. and Renström, P.A.F.H., 1999. Treatment of acute lateral ankle ligament rupture in the athlete: conservative versus surgical treatment. Sports Medicine, 27(1), pp. 61-71.
- Tohyama, H., Yasuda, K., Ohkoshi, Y., Beynnon, B.D. and Renström, P.A.F.H., 2003. Anterior drawer test for acute anterior talofibular ligament injuries of the ankle: how much load should be applied during the test? The American Journal of Sports medicine, 31(2), pp. 226-232.
- Gutierrez, G.M., Kaminski, T.W. and Douex, A.T., 2009. Neuromuscular control and ankle instability. PM & R: The Journal of Injury, Function, and Rehabilitation, 1(4), pp. 359-365.
- Kerkhoffs, G., Van Den Bekerom, M., Elders, L.A.M., Van Beek, P.A., Hullegie, W.A.M, Bloemers, G.M.F.M., De Heus, E.M., Loogman, M.C.M, Rosenbrand, K.C.J.G.M., Kuipers, T., Hoogstraten, J.W.A.P., Dekker, R., Ten Duis, H.J., Van Dijk, C.N., Van Tulder, M.W., Van der Wees, P.J. and De Bie, R.A., 2012. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), pp. 854-860.
- Brukner, P. and Khan, K. 2013. Clinical sports medicine. 4th Australia: McGraw-Hill Education.
- Gribble, P.A., Bleakley, C.M., Caulfield, B.M., Docherty, C.L., Fourchet, F., Fong, D.T.P., Hertel, J., Hiller, C.E., Kaminski, T.W., McKeon, P.O., Refshauge, K.M., Verhagen, E.A., Vicenzino, B.T., Wikstrom, E.A. and Delahunt, E., 2016a. A 2016 consensus statement of the International Ankle Consortium: Prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine, 50(24), pp.1493-1495
- Gribble, P.A., Bleakley, C.M., Caulfield, B.M., Docherty, C.L., Fourchet, F., Fong, D.T.P., Hertel, J., Hiller, C.E., Kaminski, T.W., McKeon, P.O., Refshauge, K.M., Verhagen, E.A., Vicenzino, B.T., Wikstrom, E.A. and Delahunt, E., 2016b. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine, 50(24), pp. 1496-1505
- Platzer, W. 2009. Color atlas of human anatomy: Locomotor system. 6th Stuttgart: Thieme.
- Sman, A.D., Hiller, C.E., Rae, K., Linklater, J.L., Black, D.A., Nicholson, L.L., Burns, J. Refshauge, K.M., 2013. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. British Journal of Sports Medicine, 47(10), pp. 620-628.
- Bachmann, L.M., Kolb, E., Koller, M.T., Steurer, J. and ter Riet, G., 2003. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. British Medical Journal, 326(7386), pp. 1-7.
- Beckenkamp, P.R., Lin, C.W.C., Macaskill, P., Michaleff, Z.A., Maher, C.G and Moseley, A.M., 2016. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis. British Journal of Sports Medicine, Online First, pp. 1-8
- Bleakley, C.M., Glasgow, P. and MacAuley, D.C., 2012. PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), pp. 220-221.
- Mueller-Wohlfahrt, H.W., Haensel, L., Mithoefer, K., Ekstrand, J., English, B., McNally, S., Orchard, J., Van Dijk, C.N., Kerkhoffs, G.M., Schmasch, P., Blottner, D., Swaerd, L., Goedhart, E. and Ueblacker, P., 2013. Terminology and classification of muscle injuries in sport: The Munich consensus statement. British Journal of Sports Medicine, 47(6), pp. 342-350.
- Hossain, M. and Thomas, R., 2015. Ankle instability: presentation and management. Orthopadeics and Trauma, 29(2), pp. 145-151.
- Herrington, L., Myer, G. and Horsley, I. 2013. Task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary. Physical Therapy in Sport, 14(4), 188-198.
- Paterno, M.V., Myer, G.D., Ford, K.R. and Hewett, T.E., 2004. Neuromuscular Training Improves Single-Limb Stability in Young Female Athletes. Journal of Orthopaedic and Sports Physical Therapy, 34(6), pp.305-316.
- Coughlan, G. and Caulfield, B., 2007. A 4-week neuromuscular training program and gait patterns at the ankle joint. Journal of Athletic Training, 42(1), pp. 51-59.