Ankle sprains

In celebration of the start of Soccer season (and in anticipation of the coming hockey season) it is time to turn our attention to sports injuries.  Ankle sprains are pretty common with 1 per every 1000 days of sports played, and of course, it is the most common injury in basketball players (American Journal of Sports Medicine 2005 , Clinical Journal of Sports Medicine 1997  and Sports Medicine 2007 ).

What causes ankle sprains?  This is typically from an inversion injury.  This is usually due to a force from planting the foot as seen in cutting and jumping activities. 

Where would it hurt? The location of the pain is dependent on the severity of the sprain.  Typically the sprain involves the ligaments in the front of the foot then toward the heel, then toward the rear of the foot.  As the severity of the sprain increases, the number of involved ligaments increases.  Unfortunately, the location of the pain is pretty generalized.  It mostly hurts on the outside of the ankle and into the foot.  If the pain is strictly to the rear, it is concerning.  It is also concerning if there is pain at the bottom of the bones leading to the little toe, and over the Achilles tendon.  Finally, if there is pain in the ankle when the bones in the middle of the leg are squeezed toward each other, it may indicate a more significant sprain (Foot and Ankle International 1998)

How do you know if it needs an x-ray? The Ottawa Ankle rules are there to help doctors determine who needs to have an x-ray.  These rules have been validated into children as young as 5 years of age and in adults.  The rules require the following:

Injury is less than 10 days old

The patient can walk on the ankle (no matter however badly they walk)

There is no pain in the ‘malleolar zone’ along the rear edge of the ankle bones

There is no pain in the ‘midfoot’ or at the bottom of the bone leading to the little toe

If you do not meet these criteria, then a x-ray might help us find a fracture.  If you meet all the criteria, then an x-ray is not needed and is considered harmful (Academic Emergency Medicine 2009 and British Medical Journal 2003)

How long does it take to get better? Typically patient may continue to experience symptoms from the ankle sprain up to a year later.  In a study of 467 patients who had an ankle injury, 73% of them reported residual symptoms 6-18 months later.  As well, 40% of the patients reported severe symptoms (most commonly a sense of ankle weakness) and 43% were unable to jump or pivot on the ankle without symptoms.  The key elements that predicted residual symptoms included re-injury of the ankle, restricted activity for over a week, and trouble bearing weight over 28 days (Archives of Family Medicine 1999)

What are the best treatments? ICE!  Yes, ICE!  Use ice 20 minutes at a time frequently for the first 48 hours (American Journal of Sports Medicine 2004).  For the initial 48 hours, it is also recommended to keep the ankle elevated and rested (that is, do not walk on it), although to be honest, there are no specific studies that have looked at these interventions for effectiveness.  Once the initial pain is gone from the ankle at rest, then early mobilization seems to be helpful (Cochrane Library 2002  and  Journal of Family Practice 2004).  This early mobilization consists of using your big toe to spell out the alphabet in the air by rotating your foot (in both big and small letters).  It also includes flexing your ankle up and down.

Ankle braces are also helpful in keeping the ankle stable as it is healing especially in patients who have grade II sprains (American Journal of Sports Medicine 2006  and Lancet 2009).

Also, it is important to treat the pain, and the use of any pain medication (acetaminophen, diclofenac, indomethacin) seems to help patients equally well (Annals of Emergency Medicine 2005).  Additionally, over the counter versions of anti-inflammatory ointments seems to help reduce the pain and swelling nicely (American Journal of Sports Medicine 2005)

Handout on ankle exercises.

Next week, concussions!