Background & Etiology (Cause)
The ankle is made of two joints. These joints need to be strong because they support the weight of the entire body. The ankle is one of the most versatile joint complexes in the body. It is built for weight bearing, mobility, adaptability and stability. The foot and ankle allow us to walk, stand, run and jump, and serves as our connection to the ground. The ankle must be able to withstand the stress of our body weight, and also be able to adapt to, and react quickly to changes in environment and walking surface.
Bone & Joints
The tibia and fibula (lower leg bones) end in prominences called the malleoli. The malleoli create the bony prominence seen on either side of the ankle, called the lateral malleus and medial malleolus. These bones meet the foot at the talus, forming the ankle joint. The second joint in the foot is the subtalar joint, which is formed where the talus meets the calcaneus (heel bone.) The ankle is made up of two joints, the inferior talocrural joint and the subtalar joint.
The inferior tibiofibular joint is located between the large bone of the lower leg (tibia) and the smaller fibula, which then attach to the talus bone of the foot to form the talocrural joint. The talocrural joint is sometimes called the true ankle joint and is responsible for dorsiflexion and plantar flexion (up and down) movement of the foot. The joint between the tibia and talus bears the most of our body weight.
Beneath the talocrural joint is the subtalar joint. The subtalar joint is located between the talus bone and calcaneus or heel bone. This joint is responsible for ankle inversion (turning in) and eversion (turning out).
The ankle joint and subtalar joint are held together by strong fibrous connective tissues called ligaments. Ligaments connect bone to bone. There are three major ligaments on the lateral (outside) aspect of the ankle, they are the anterior talofibular ligament, the posterior talofibular ligament, and the calcaneofibular ligament.
The inside (medial) aspect of the ankle has a complex of several ligaments, which tend to be much stronger than the lateral ligaments. These ligaments are the anterior and posterior tibiotalar ligaments, the tibionavicular ligament and the tibiocalcaneal ligament.
A sprained ankle is a common condition, which can happen to anyone in a variety of different situations. A sprain is a condition where the ligaments become stretched, and can either be slightly torn or completely torn.
Ankle Sprains occur when the foot twists, rolls or turns beyond its normal range of motion. The ankle joint is typically responsible for dorsiflexion, (pointing the toes toward the head) and plantarflexion pointing the foot toes down. Common causes of ankle sprains include:
- Landing hard on the ankle on an uneven surface
- Stepping onto an uneven surface
- Stepping down at an angle
- Participation in athletic activities
- Weakness of the supporting ankle muscles
- Balance and proprioceptive problems related to ankle injury or neuropathy
When the ligaments of the ankle become stretched too far, they can become partially or completely torn. A ligament tear is a serious injury, which may require surgery to repair.
- A traumatic injury, particularly when the ankle is turned either toes in or toes out.
- A fall or step where the foot is planted on an uneven surface
- Athletic injury contact or noncontact
Ankle Ligament Damage
There are three grades of ankle ligament damage, which range from mild to more severe conditions.
- Grade I: Slight stretching of the ligaments, with mild damage to the actual fibers of the tissue through micro-tearing. These injuries are typically treated with rest and guided exercises, in addition to stretching and strengthening activities.
- Grade II: The partial tearing of the ligament, accompanied by abnormal laxity of the ligaments in the ankle. This condition is typically treated by immobilization, followed by stretching and strengthening exercises. Retraining of sensory proprioceptors
- Grade III: A complete tear of the ligament, that results in severe instability of the ankle joint. Typically this condition is treated by immobilization, possible surgical reconstruction of the ligaments, and subsequent physical therapy.
In response to ankle ligament injuries, one should initiate the RICE protocol of Rest, Ice, Compression, and Elevation in addition to the following:
- Rest to avoid aggravating the injured ankle and ligament with excessive activity.
- Immobilization to keep the ligament from being stressed any further and promote healing in the correct position. Depending on the severity of the injury the ankle may be immobilized for a period of time.
- Ice to reduce inflammation and pain for the first 48-72 hours. Do not apply directly over skin and use ice intermittently during the day. Apply the ice for 20 minutes at a time. Do not apply any form of heat during this period.
- Contact your physician medical provider for complete diagnostic evaluation of the injury and follow up care.
- Physical Therapy may be indicated to treat and rehabilitate this injury for Grade I-III injuries.
- Grade III injuries may require repair of the injured ligament
Physical Therapists are professionals, educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis, and the goals of the patient or client.
Initial treatment will be focused on protecting the ligament, reducing pain and swelling, as well as restoring motion. As the physical therapy program progresses, strengthening, flexibility, and aerobic exercises, in addition to technique and proprioceptive training to protect the ankle and ligament will be added in an effort to restore normal activity level.
Grade I-II injuries may start off with immobilization to protect the ligament and joint. Physical therapy will be progressed based on the individual’s symptoms, with the removal of the immobilizing device and initiation of a stretching, strength and functional rehabilitation program.
Grade III injuries may require surgery, especially if other structures (like other ankle ligaments or tendons) are involved. Repair or tightening of the ligament may be necessary. Physical therapy will focus on restoring motion, strength and function based on the physician’s post-operative protocol. Full return to activity will depend on:
- Restoration of pain free full range of motion
- Patient ambulating independently without a limp
- Objective muscle strength in the 90% range
- Restoration of functional activities with emphasis on proprioceptive training
Common physical therapy interventions for this condition include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, deep friction massage and joint mobilization by a physical therapist to regain mobility and range of motion of the ankle.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strength to protect and stabilize the ankle and affected ligament.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the lower extremity chain and improve movement technique and mechanics (running, jumping and cutting) in use of the involved ankle in daily activities.
- Modalities that can include use of ultrasound, electrical stimulation, ultrasound, ice, cold laser and others to decrease pain and inflammation at the ankle and ligament.
- Home program includes strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Following an injury to the ligaments of the ankle one should seek a full evaluation from a physician or health care provider. Treatment may consist of the following:
- Clinical evaluation including a physical exam, X-rays and MRI in more severe Grade III injuries
- Use of ice and immobilization to stabilize and rest the joint
- Anti-inflammatory medication and pain medication as needed
- Progression to a brace if indicated
- Referral to physical therapy to progress rehabilitation following a period of immobilization.
- Surgery may be indicated in Grade III injuries or cases involving damage to other ankle structures secondary to instability.
The prognosis for these injuries when cared for correctly is good. Time frames vary with the severity of the injury. As a general rule, ligament density and incidence of instability play a role in how quickly these injuries heal. Grade I and II may take 4-8 weeks while Grade III injuries will require 3-4 months.