Everything You Need to Know About Ankle Sprains

1. Everything You Need to Know About Ankle Sprains By Michael LaBella

2. Objectives of the presentation • Students will become aware and be able to distinguish the difference between the 3 different degrees of ankle sprains. • Students will learn about the specific ligaments, muscles, and injuries that surround the ankle. • Students will learn the signs and symptoms of a lateral ankle sprain if one was to ensue during an athletic event. • Students will recognize the acronym “PRICE” as means of remembering how to treat a new ankle sprains. • Students will be gain a better understanding of how to prevent ankle injuries through various aids. • Students will gain the knowledge of rehabilitation after the ankle injury through various exercises specifically designed.

3. Anatomy of the ankle • The ankle is a complex part of the human body and much more amazing then one might think. • The ankle is a joint that serves much like a hinge on a door or a cabinet. • In order to function correctly in terms of walking, it is imperative that the ankle is working properly.

4. Did you know? • Despite being quite narrow, the ankle is an extremely stable joint? • In fact, the ankle can withstand…. • 1.5 times your body weight while walking • 8 times your body weight while running!

5. Bones that comprise the joint

6. The ankle joint itself is connected by three separate bones. • The talusworks as the hinge that allows the ankle to move up and down (dorsi and plantar flexion). • The tibiaalso known as the “shinbone” forms the medial part of the ankle. • The fibulaforms the lateral part of the ankle. • Both the tibia and the fibula connect into the top of the talus. • The whole three-boned structure is connected to the top of our heel bone called the Calcaneus

7. Ligaments of the ankle

8. There are three ligaments that are part of the ankle. • The anterior inferior tibiofibular ligament is the one that connects with the tibia and the fibula and goes above the front of the ankle. • The posterior fibular ligaments goes to the back of the tibia and fibula. • The final ligament, the interosseous ligament is the one that goes between the tibia and the fibula.

9. What is your Achilles Heel?

10. I am not sure about that mythological dude, but mine is a tendon and not a weakness!

11. On the contrary…. • The Achilles Tendon is not a weakness to us mortals. • It is, in fact, the largest tendon in the human body • It can withstand over a 1,000 pounds of force!

12. The purpose of the Achilles Tendon is to help us walk, run, and jump • In addition, it helps us stand on our tippy-toes • The Achilles Tendon attaches or gastrocnemius and soleus (calf muscle) to the calcaneus (heel bone)

13. Any other tendons? • Yes! The other tendons in our ankle are called the posterior tibial tendon and the anterior tibial tendon • The posterior attaches to the underside of the foot for arch support and to turn the foot laterally and medially. • The anterior attaches and helps us raise the foot. • The two tendons together are called the peroneals.

14. Muscles of the ankle. • Peroneus Longus • Peroneus Brevis • Anterior Tibialis • Posterior Tibialis • Extensors Hallucis Longus • Flexor Hallucis Longus • Extensor Digitorum Longus • Flexor Hallucis • Gastrocnemius • Soleus

15. The main muscles in the ankle • Peroneals are located on the lateral edge of the ankle. Their purpose is to bend the ankle down and out. • Gastrocnemius and Soleus are the calf muscles and also bend the ankle down. • Tibialis aids the foot in turning inward and upward.

16. Mechanism of the ankle injury

17. What is the typical type of ankle injury? • According to Dr. Douglas Ivins at the Univeristy of Oklahoma College,

18. No discrimination... • Among high school boys and girls who participated in the years of 2004-2005, ankle injuries were the MOST prevalent type of injury for both sexes. (Pfeiffer & Mangus 2008) • According to professor Jason Bennett “Ankle injuries, especially those to the lateral ankle complex, are the most common acute sports-related injuries presenting to sports medicine clinics and emergency rooms around the world”. (Bennett, 2002)

19. Lateral Acute Ankle Sprain • This is the typical type of ankle sprain. • Have you ever “twisted your ankle”? • Yea, me too. When you twist it on the outside near your pinky toe, that is the lateral sprain.

20. What makes the lateral part of the ankle so weak? • anterior talofibular ligament is the ligament that has the greatest impact on the lateral part of the ankle. • Unfortunately, the anterior talofibular ligament is both the weakest and the smallest out of all three of the ligaments in the ankle.

21. Mechanism of the injury continued... • Almost all of the ankle sprains occur at the moment of termination from running or jumping and landing on the foot • When the foot strikes the ground, the ankle will be in plantar flexion and the foot will be supinated (sole facing upwards) • Stability is mitigated due to the medial malleoulus becoming more distal (far apart) then the lateral malleoulus.

22. What happens next? • The peroneal muscle become over-forced and fall upon the anterior talofibular ligament. • This creates a rolling ball effect… after the ATF is completely torn, the stress is overted to the Calcaneo fibular ligament and eventually to the Posterior Talofibular ligament.

23. How are we able to recognize a sprained ankle? • Initial recognition of a sprained ankle can be examined in many ways. • Some of the reactions that will come in the event of a sprained ankle are : high level of pain, rapid onset of swelling, coldness or numbness in the injured foot, inability to bear weight, or a complicating condition.

24. As a coach, what should you look for if an ankle is sprained? • The initial sign for a coach to look out for is difficulty bearing weight on the injured ankle with a fairly high level of pain. • After this, swelling will certainly come into play. • Checking for the swelling is paramount in telling if the ankle is sprained or not.

25. There are different grades of ankle sprains to determine the severity.

26. The grades of ankle sprain are on a scale of 1-3 • Grade I (first degree)- Most common type of sprain which the ligaments are over-stretched but not torn completely. The ankle should have most of it’s stability. • Grade II (second degree)- Injury is significantly worse then the first degree. Usually the ligament is partially torn. • Grade III (Third degree)- Implies that one or more ligaments is fully torn. Instability while occur indefinitely.

27. Degree of ankle sprain table

28. How can we evaluate the injured ankle?

29. Questions for evaluators to consider. • Etiology of the injury (how did it happen). • Has the ankle been previously injured? The more that the ankle has been injured, the more susceptible it is to getting sprained again.

30. There are many factors to check when evaluating a sprained ankle • The first signs for severity of the sprain are for ecchymosis (bruising), tenderness, and swelling. • Another way to test is the stress test. • Performed by pushing on the ankle to determine abnormal movement of the

31. Other tests... • Anterior Drawer Test- A test that uses loads of weight to determine the integrity and stability of the ankle. • Talar Tilt test- This tests is used by cupping the heel of the injured ankle and inversion stress is applied. • Thompson Test- tests the Achilles Tendon. It is performed with the person laying down and pressure is applied to the gastrocnemius and soleus.

32. How are ankle sprains treated?

33. Remember the acronym PRICE!

34. Protection- The injured ankle should be kept out of further harm or injuries, especially during the crucial first 24-48 hours. • Rest-For about 24-48 hours after the injury, as much activity involving the ankle should be ceased as possible. • Ice- especially within the first 48 hours, the sooner the better, ice should be applied “20 minutes at a time every 3-4 hours” (Dr. Cluett). Any longer then 20 minutes can be detrimental to the injury and damage it further. • Compression- An ace bandage can be used compress the injury ankle, do not wrap too tight however! • Elevation- Ankle should be elevated higher then your heart as often as possible.

35. Proper ice techniques • 1) Get the ice on quickly-icing effects diminish after 48 hours • 2)Ice massage- the ice should not be stagnant, it should be moved around frequently. • 3)Elevate!- paramount to reduce the swelling. • 4) Watch the clock- no longer then 20 minutes should ice be applied. • 5) Time to warm- allow adequate time for the ankle to warm again before another treatment. • 6) Repeat- as often as desired

36. Rehabilitation of the injury

37. The stages of rehabilitation • Acute Stage (1-3 days)- Use PRICE, ankle can not support any weight. • Sub-Acute Stage (3-14 days)- Some weight can be put on the ankle, compression and ice therapy is still suggested. • Early Rehab (week 3)- Specific light exercise are used to prevent stiffness and reduce swelling. • Late Rehab (week 4)- Progressive strengthening of the muscles, intensity of exercise is increased. Use of ankle braces and casts are highly suggested. • Functional Rehab (week 5+)- Increase intensity gently to return to game-ready conditions. Pain should be mitigated (if present at all).

38. When to start rehabilitation. • It is suggested to start rehab as soon as you can apply pressure to the ball of your foot. • The purpose is to return balance and strength to the ankle . • This is done through various exercises specifically designed for different stages of recovery.

39. Earliest stages of rehabilitation . 1. Ankle Pump: Point toe, then pull back toward you as hard as possible. 2. Towel Gather: Spread out towel on floor. Pull toward you with toes until towel is fully gathered around foot. Repeat 10-15 times. 3. Ball Pick-up: Grasp ball between 1st and 2nd toes; pick up and transfer to opposite pile. Repeat 15 times.

40. Continued... • 4. Towel Stretches: Sit on a hard surface with your injured leg stretched out in front of you. • (a). Loop towel around foot and pull back to get a good stretch for 20 seconds and relax for 20seconds • (b). Pull the towel so that foot turns to other side; hold for 20 seconds, then pull to the other side; hold for 20seconds. • (c). Bend leg at 90 degree angle and loop towel around forefoot. With leg bent pull foot back for 20 seconds and relax for 20 seconds.

41. Exercises for later stages of ankle rehabilitation. • 5. Slantboard Stretch: • (a). Stand with your heels on A board and lean forward • (b). Turn your toes in with heels on the board and lean forward • (c). Stand with knees bent and heels down • (d). Stand with your knees bent, point toes inward and keeping heels down on the board. • 6. Wall Stretch: Facing a wall, put your hands against the wall at about eye level. Keep the injured leg back, the uninjured leg forward, and the heel of your injured leg on the floor. Lean into wall and hold for 15-20 seconds. Repeat 3 times. • (a). Knee straight; toes straight ahead • (b). Knee straight; toes pointed in

42. Continued... • 7. Soleus Stretch: Stand facing a wall with your hands at about chest level. With both knees slightly bent and the injured foot back, gently lean into the wall until you feel a stretch in your lower calf. Once again, angle the toes of your injured foot slightly inward and keep your heel down on the floor. Lean into wall and hold for 15-20 seconds. Repeat 3 times. • (a). Knees bent; toes straight ahead • (b). Knees bent; toes pointed in • 8. Ankle range of motion: You can do this exercise sitting or lying down. Pretend you are writing each of the letters of the alphabet with your foot. This will move your ankle in all directions. Do this twice. Singing the song is optional!

43. 9. Theraband: • (a). Dorsiflexion - Sitting with your leg out straight and your foot near a door, wrap the tubing around the ball of your foot. Anchor the other end of the tubing to the door by tying a knot in the tubing, slipping it between the door and the frame, and closing the door. Pull your toes toward your face. Return slowly to the starting position. Repeat 10 times. Do 3 sets of 10. • (b). Plantarflexion - Sitting with your leg outstretched, loop the middle section of the tubing around the ball of your foot. Hold the ends of the tubing in both hands. Gently press the ball of your own foot down and point your toes, stretching the Thera-Band. Return to the starting position. Repeat 10 times. Do 3 sets of 10. • (c). Inversion - Sit with your legs out straight and cross your uninjured leg over your injured ankle. Wrap the tubing around the ball of your injured foot and then loop it around your uninjured foot so that the Thera-Band is anchored at one end. Hold the other end of the Thera-Band in your hand. Turn you injured foot inward and upward. This will stretch the tubing. Return to the starting position. Repeat 10 times. Do 3 set of 10. • (d). Eversion - Sitting with both legs outstretched and the tubing looped around both feet, slowly turn your injured foot upward and outward. Hold this position for 5 seconds. Repeat 10 times. Do 3 sets of 10.

44. After these specific exercises, weight-bearing exercises can be used. • Such as…. • Walking on your tippy toes • Heel raises • Toe raises • Single leg balancing.

45. Guidelines for returning to play.

46. Precautions: what to watch out for • Athletes should take extreme precaution and be aware of the risks of re-injury of the sprained ankle. • Athletes should also be aware that overcompensation of the healthy ankle can cause injury as well.

47. First things first, get a professional opinion!

48. What tests will the doctor use? • Lateral hop test. Patients stand on the “uninjured” leg and hop as far as possible in a lateral direction with three continuous hops. They then stand on the “injured” leg and hop back to where they started, using three continuous hops. Patients must make it back to where they started, showing that their injured leg is of equal strength and stability as the uninjured leg. • Single leg stance (Modified Rhomberg Test). The patient stands and balances on the good leg with his or her arms crossed over the chest. Compare the duration that the patient stands on the single leg, without touching the other foot to the ground, to the duration that he or she stands on the injured leg. • Heel rocker test. The patient leans backward against a wall and pulls the toes and forefoot areas of both feet off the ground while rocking backward on his or her heels. The patient raises the toes repeatedly off the ground until full exhaustion. Check for any asymmetry in fatigue between the two ankles.

49. What now? • After carefully examining the results of the aforementioned tests, the doctor will suggest what type of activities you will be able to resume.

50. Helpful Chart • Chances are if you ask for a chart to help you know when you can come back to play, the doctor will give you something similar to this.