Chronic Ankle Sprains - How a small structure creates big problems.
When it comes to ankles, we tend to think differently to most other body parts. You will frequently here someone remark that they are 'forever rolling an ankle'. This is common, and for some reason it is accepted. We don't think this way at the knee; for instance, 'my knee constantly buckles and gives way' is not something you hear as frequently. There's a reason for this. We believe the knee instability is more serious - we get it checked out, we potentially rehab it, we respect knee injuries. We don't respect ankle injuries. We think that repetitive instability is normal and is something that we 'just have.' Here's the thing, it doesn't have to happen, and it shouldn't happen. Treat your ankles with some time and respect and watch that ankle roll turn into an ankle rock of stability and strength.
When we roll an ankle the vast majority of the time we collapse inwards in an inversion sprain. We stretch our lateral ligaments and our anterior talofibular is usually the first to go. Does it stretch, tear, rupture? Who knows, we can generally agree on a grade of severity without imaging due to the nature of the symptoms. How swollen, how much pain, how much restricted movement. The ankle is weakest in a position of plantarflexion and strongest in dorsiflexion. In dorsiflexion our ankle is in what's called a 'close packed position', fitting snugly and congruently within it's ankle or talocrural joint. It likes being here and so do the ligaments, it feels strong and safe. Take the joint to plantarflexion and things start getting shaky. Here, we have less congruency and therefore stability, here we are prone to a sprain.
The Ottawa ankle rules have helped us immensely in treatment of ankle sprains. The Ottawa ankle rules state that an XRay is only required if one of the following criteria is met:
- Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus
- Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus
- Bony tenderness at the base of 5th metatarsal
- Bony tenderness at the navicular
- Inability to bear weight both immediately after injury and for 4 steps during intial evaluation
If these are all deemed negative, there is no likely fracture and we are just looking at ligament disruption. Then we get to more sever ankle injuries, where potentially complete disruption of the ligaments occurs. A 2002 systematic review concluded that there was insufficient information to reccomend surgery over conservative treatment of grade 3 ankle sprains. They found that functional recovery was quicker in those treated with rehabilitation.(Kerkhoffs, Handoll, Bie, 2002).
As mentioned earlier, in the majority of cases, chronic ankle instability comes from inadequate, poor or no rehabilitation. As with all injuries, we push rehabilitation in all injuries, and we want to make the rehab process as functional as possible and return the ankle and body back to a ready state for everyday life and sport.
What we notice with chronic ankle instability are three main findings; lack of ankle dorsiflexion, lack of stability on one leg, and weakness of the peroneals. It makes sense then to attack the problem from these three areas, aiming at including these exercises in sport specific movements.
We will follow up our next blog with how to improve these three key areas and develop rock solid ankle stability.