Ankle inversion injuries

There was a great article last month in the British Journal of Sport and Exercise Medicine (Br J Sports Med 2012;46:12 854-860 Published Online First: 20 April 2012 doi:10.1136/bjsports-2011-090490 - http://bjsm.bmj.com/content/46/12/854.abstract?sid=6db81ad8-45a9-4dae-ac9c-7ad47b15bf45) regarding the Dutch Guidelines for the Management of Acute Inversion Ankle injury.  Inversion is the injury to the ankle that all athletes know and recognise where the foot folds inwards with the ankle injury occuring on the outside of the ankle joint.  There are probably few athletes who have not sprained their ankle at one time or another in their life especially if they are runners who like to get in a bit of terrain.

Ankle inversion injuries are common.  In my clinic the common story is:

I went over on my ankle.  It swelled up immediately.  I couldn't walk on it.  I went to A&E (Emergency Room) and they X-Rayed it.  They told me it wasn't broken and discharged me home.  The end.

So nothing broken??

Perhaps the massive swelling and bruising and the fact they couldn't walk on it passed them by...?

What is it about bones that make an injury complete?  Patients seem to relish the broken bone.  It is something they can understand.  Their friends understand it.  Their colleagues understand it.  Their boss understands it.  But 'soft tissue injury' is a bit.....girly!?

Am I having a rant?  Possibly.  But I guess that until basic anatomy and injuries are taught in school biology (instead of disecting the reproductive organs of a plant), patients will still come into the clinic with the same story.

ANYWAY!

So, critically, what should we be doing after the ankle inversion injury.  Well, we should be protecting it (crutches and then a brace or tape to maintain ankle stability and take the strain off the damaged ligaments), resting it (crutches again - don't load through it early on, when the ligaments are healing), icing it (to help reduce pain and swelling), compressing it (to help prevent daily swelling associated with gravity - because the damaged tissues become 'leaky' and ongoing swelling restricts movement and delays recovery) and elevating it (again to reduce swelling).

Initial rehab goals should be to reduce swelling and regain range of movement.  Early active non-weight bearing exercises should be encouraged as able.  And I'm going to stop here as far as detailed rehab is concerned because every ankle will have different needs depending on the exact injury and this should be managed under the care of a physiotherapist.  The only thing to add here is that rehabiliation should be progressive - at the correct pace for your ankle.  There will be loss of ankle 'mover' strength as well as strength through the whole kinetic chain i.e. the glutes/hamstrings/quads/calves etc. There will be a loss of stability and balance-sense (proprioception) which will need addressing.  Different types of strength need to be taken into account - strength work needs to include plyometric (bounce and recoil) strength as well as strength to transfer force and absorb load.  It is also important that the joints of the foot are mobilised to return ankle mobility - this needs to be done by a physiotherapist.  A stiff ankle can lead to other problems e.g. achilles tendinopathy, plantar fasciitis. 

Common problems after an ankle inversion injury include:
1) recurrent instability/ankle inversions
2) achilles tendinopathy (as above)
3) plantar fasciitis (as above)
4) lateral ankle pain secondary to peroneal tendon problems (perhaps due to overload from lack of stability of the ankle or through lack of movement in the joints of the ankle or perhaps (if associated with palpable clicking) subluxation of the peroneal tendons as they course round the lump on the outside of the ankle - lateral malleolus)
5) anterior impingement - pain at the front of the ankle joint when weightbearing through the ankle - an impingement of either soft tissue (scar tissue) or bone (you can get bony lumps on the ankle joint bones secondary to the 'trauma' at the time of the ankle injury and these can restrict the movement and 'impinge' the tissues there)
6) posterior impingement - pain in the back of the ankle (sometimes secondary to excess fluid in the ankle joint and impingement of the capsule at the back of the ankle or less commonly due to a bony injury at the posterior ankle joint).
7) sinus tarsi syndrome - inflammation of a 'tunnel' or sinus in the ankle secondary to altered movement in the ankle joint and ongoing inflammation. 

and this is not a comprehensive list.

So the unbroken ankle is not an uninjured ankle.  It was just not the bone that was fractured.  Of course the bone can still be injured even if not broken.  On MRI scan it is possible to pick up the ankle 'kissing injury' where the medial malleolus (bony lump of the distal end of the tibia on the inside of the ankle) smacks into the talus beneath it as the ankle is inverted.  This bone bruising (seen as fluid in the bone on MRI) can cause problems for a long time with medial ankle pain.  The deltoid ligament (broad medial ankle joint ligament) is usually also damaged in this process, explaining the medial ankle pain sustained despite inverting the ankle.

My final thoughts:
Avoid ankle injuries.  Incorporate balance and ankle strength and conditioning into your weekly timetable.  Avoid shoes that have a high heel raise or medial anti-pronation device, especially if running in difficult terrain.  The lower you are to the ground, the more stable you are.  And those that do run in difficult terrain - in my opinion - consider prophylactic taping - you can't stop injury if you put your foot down a large hole and the rest of you keeps going, but you might if it's taped and it's not quite so large...