It’s one of the most common injuries to occur in sporting fields and in athletes. The sprained ankle is an easily encountered injury as the ankle is subject to so much pressure in terms of stabilisation and effective balancing of the entire body as it launches from one foot to another and propels us forward, upward, sideways as well as ensuring even distribution of weight and softening shock upon landing from jumps and said propulsions. Thats a lot of work!
The ankle serves as the locomotor of the body. Leonardo Da Vinci and Aristotle discussed the importance of the ankle joint as a mover of the human body and the biomechanics involved in allowing a human to walk in it’s upright form is one of the most valuable motions of the human and allows us to survive at a most fundamental level.
The TALOCRURAL JOINT as it can often be referred to is most unique in the body as it is the only mortise and tenon joint in the body. This fundamental structure which involves one structure being encased completely by the other in a vice like stabilisation (so much basis of IKEA laden furniture that we should all understand just how fundamentally strong it is) and serves as a strong and stable joint for long structures that require immense stabilty. Yes IKEA do it right until we decide we want to loosen the fabled screws and lock mechanisms and undo all that stabilising flat packed glory when we move house. And oddly this is almost what we do with our ankle ligaments when we sprain them, we take away the fundamentals of swedish design..
Fun aside, the mortise and tenon joint is one of the strongest joints in woodworking and so it serves the same purpose of dorsiflexion (flexed foot) and plantarflexion (pointed toes) in the ankle. The two bones of the lower leg (tibia and fibula) travel down and form a vice like pincer over the top of the Talus bone. Like a peg connecting over a clothes line. The bone that is underneath the talus in the foot is the Calcaneus bone (heel bone) and this in turn forms part of the ankle joint . The ankle itself is made up of three joints:
TALOCRURAL - synovial hinge joint that connects the distal ends of the tibia and fibula with the talus bone. The Tibiotalar joint is the stronger of the two and bears more weight .
SUBTALAR - is made up of the talus bone and the calcaneus (heel bone) and is the articulation over which the Talocural joint sits.
INFERIOR TIBIOFIBULAR JOINT - meeting point of the the two bones of the lower leg where the tibia inserts on top of the bulbous fibula bone. This joint allows
The ankle by nature of it’s dimensions and dexterity also allows for this joint to glide and so enable sideways motion and stabilty. It’s a very clever thing.
An ankle sprain is when the ligaments that support this crazily dextrous joint are forced beyond their capacity and they tear… resulting in an ankle sprain. There are four main ligaments of the ankle joint:
DELTOID LIGAMENT which lies on the medial (inside) side of the ankle connecting the medial malleolus (end (distal) part of the tibia to the talus and calcaneous. It is the strongest ligament and usually doesn’t sprain.
ANTERIOR TALOFIBULAR LIGAMENT (ATFL) is one of two ligaments that joins the lateral malleolus (end (distal) part of the fibula to the talus bone. It runs forward along the talus bone. Most common ligament to break in a sprain
POSTERIOR TALOFIBULAR LIGAMENT (PTFL) also connects the lateral malleolus of the fibula to the talus and runs backwards (tposteriorly) from the malleolus to the talus bone
CALCANEOFIBULAR LIGAMENT attaches the lateral malleolus to the calcaneus bone
*There is also the Sindesmotic Ligament which doesn’t necessarily span the ankle but is important in stabilising the INFERIOR TIBOFIBULAR JOINT. Injury in this instance is termed a HIGH ANKLE SPRAIN.
The ankle is most stable in Dorsi-flexion (flexed foot) and less so in Plantar-flexion (toes pointed) so most ankle sprains will occur in the Plantar-flexed position or when you are attempting to land from a jump or stride on your toes. Inverting the foot underneath you when you land or rolling inward when your foot hits the floor is the most common occurrence of the ankle sprain. You can imagine the immense strain of landing your whole weight on the ankle as it inverts and how this pressure and weight is impacted upon the three main lateral ligaments of the ankle. The most common injury occurs in the ATFL as it is in the location of the most impact on an inverted and plantar-flexed ankle.
When you sprain an ankle you tear the ligaments and those torn fibres need to heal. Whenever you tear fibres you are going to have internal bleeding within the structure and there may also be torn fibres of muscles or blood vessels that lie inside and around the ligaments and bones. The tearing of these blood vessels will result in discolouration and bruising that will go from yellow to purple depending on the severity of the sprain. You will also have a high degree of swelling that will isolate the joint capsule to prevent further movement or injury.
Severity of sprains come in 3 different categories:
Grade 1 - more an overstretch of the ligaments and micro-tears of the fibres. Mild tenderness and swelling. 5 -14 days recovery
Grade 2 - Partial tearing of the ligament. Instability of the ankle in certain movements and ability to weight bear is compromised. Movement is painful even without weight bearing. 4-6 weeks recovery
Grade 3 - a full rupture of the ligament. Major instability of the ankle in many directions as more ligaments are torn. Weight bearing is almost impossible. 6-12 weeks recovery
Swelling and bruising can last anywhere from 5 -10 days. If the swelling does not reduce after this time you should consult a medical professional for a more complete assessment which may involve imaging to ascertain the particulars of the injury.
Managing a sprained ankle is vital. It is not always necessary to go to a doctor for an ankle sprain. A physio or medical practitioner should be able to give enough assessment of a sprain and what degree it is. Home managment should include rest (ie GET OFF IT. DO NOT STAND ON IT. DO NOT WALK ON IT), compression with a compression garment or bandage and elevation to assist with lymphatic flow. Immediate application of ice 2-4hrs post injury is prescribed to assist with containing swelling.
The importance of moving and getting mobility on an ankle sprain is vital. Once the swelling has reduced sufficiently to enable movement you should immediately start with doing simple exercises whilst the leg is elevated. Writing the alphabet with your foot is a great way to get movement going. being able to get through the entire alphabet in lower case will be difficult and you will tire and the ankle will get exhausted. Be patient, you may only be able to get to M or N. Once you can make it through in lower case, move onto capitals. Until you can do this, no other movement is necessary.
Weight bearing is the indicator. If you can put your foot down and stand on one leg, then you can start to walk on the ankle and move. Bathing in some Epsom Salts can also help with some of the inflammation and assisting with controlling the swelling. Keeping the leg up and off the floor is important as well. Basically once you can control the swelling then you can start moving forward onto more progressive rehabilitation.
Progressive rehabilitation from a sprained ankle is important and it is possible to come back from an ankle sprain at 100% - if you do the work! And there is a lot of work to do. There are a myriad of exercises and ideas to include for a sprained ankle and to make it even stronger than it was before. But that is for another article…