Guest commentary: Ankle sprains 101
Ankle sprains, the diagnosis given when one or more ligaments about the ankle are stretched or torn as a result of rolling the ankle, are the most common athletic injury encountered in American emergency rooms. Physicians categorize the instability episodes as acute or chronic, based on their frequency.
When treating ankle sprains, in addition to restoring function, our primary goal is to prevent chronic instability. These frequent giving-way episodes of the ankle can be self-perpetuating and lead ultimately to chronic ankle pain, arthritis, deformity and loss of function. Studies have shown that people and animals with chronically unstable ankle ligaments over a long period of time walk and exercise less than otherwise equivalent counterparts with stable ankles. Despite this knowledge, many people receive little to no formal treatment for ankle sprain, significantly increasing the risk of further problems.
Anatomic studies of ligaments throughout the body show that ligaments contain a large number of nerve endings of various types, leading to theories that ligaments likely function not only as static restraints to excessive movement of joints but also as sensors that relay the position and movement of body parts to the brain, spinal cord and muscles. In this sensory capacity, ligaments play a critical role in proprioception (unconscious sense of relative position of body parts during movement) and kinesthesia (conscious control of muscles during movement). The recent successful utilization of neuromuscular training programs to prevent noncontact anterior cruciate knee ligament injuries, particularly in female athletes, provides strength to these theories. When ankle ligaments are stretched or torn, therefore, they allow excessive movement of the joint not only by virtue of being longer, but also because they no longer send good feedback information on position and movement to the brain, spinal cord and muscles. This leads to uncoordinated movement and a higher risk for repeat injury.
The most common ankle sprains involve a rolling of the ankle onto the outside of the foot (pinky-toe side) where the sole of the foot ends up turning excessively to face the opposite foot. We grade ankle sprains in severity based on the number of ligaments involved and how much each is stretched. As a result, the pain, swelling, bruising and disability can range from minimal symptoms to inability to bear weight and put on a shoe. In my opinion, the severity of the injury does not change the need for formal rehabilitation to restore the sensory functions of the ligament. Rather, I use the degree of injury to guide recommendations for length of immobilization in a brace, the need for crutches, and activities allowed in the early post-injury period. Regardless of severity, though, I recommend physical therapy, guided by a professional and/or home-directed, to limit the risk of future ankle sprains.
Prevention of a first sprain — for example, while playing basketball or hiking on a rough trail — is more challenging. Using experiences with knee ligaments, we can infer that training the ligaments before exposing them to risky activities might be helpful. For example, dribbling a basketball while one foot is on a wobble board or during agility drills can improve proprioceptive control. Use of supportive hiking boots that lace above the ankle or of an ankle brace under low-top hiking shoes also might prevent injury. The risk during sports and recreation can never be eliminated completely, however. Recognition of the potential for ongoing problems and the awareness that early immobilization, relative rest and formal physical therapy are all essential for preventing them are the keys to successful management of this very common problem.
Dr. Waqqar Khan-Farooqi is a foot and ankle specialist at Aspen Valley Hospital.
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