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Athletes and Ankle Sprains: Don’t Just “Walk It Off”
Meet John Doe. John was a talented football player who aspired to become a professional athlete. In high school, he sustained a severe ankle sprain, and like many, he did not prioritize treatment and rehabilitation of this initial injury. Nonetheless, he received a scholarship to play sports at a Division I university. His ankle injury continued to linger. While his skill for the game was unparalleled, John’s performance did not improve as significantly as he had hoped. He continued to complain to his athletic trainer about sensations of his ankle “giving out,” and battled occasional ankle sprains throughout the season that were taped. Unfortunately, at the end of his collegiate athletics, his dream of playing in the National Football League was not realized, which he blamed on his ankle.
How Prevalent are Ankle Sprains?
Ankle sprains are some of the most common injuries that affect athletes of all ages.1 An estimated 28,000 ankle injuries occur daily in the United States and account for an estimated 15% of all athletic injuries.1,2 The National Collegiate Athletic Association (NCAA) injury surveillance system (ISS) estimates that 11,000 ankle sprains occur per year in collegiate athletics at a rate of 0.83 per 1000 exposures.2 Additionally, the National Electronic Injury Surveillance System (NEISS) determined an incident rate of 2.15 per 1000 person-years over a 5-year period.2 Approximately 30% of those who do sustain an ankle sprain will experience a recurrent sprain and residual symptoms, such as pain and instability.1,2 It has been noted up to 64% of people do not seek medical treatment after their initial ankle sprain, thus decreasing their subjective function and increasing their propensity of sustaining additional sprains or incidents of the ankle giving way.3
What You Should Know About Mechanism of Injury and Reinjury
The most common mechanism of injury for a lateral ankle sprain typically involves supination of the foot (plantarflexion and inversion) combined with external rotation of the lower leg.1 Stress is then transferred to the lateral ligament structures (anterior talofibular, calcaneofibular, and posterior talofibular ligaments), causing damage.1
The single greatest risk for injury is simply a history of prior ankle sprain.1 Studies have shown that an athlete sustaining an injury in their competitive seasons becomes 3 times as likely to sustain a sequential injury in the following season.4 Athletes are classified as high risk when having faults at the Lower Quarter Y-Balance Test and Functional Movement Screen, and experience pain during testing or have a prior injury. Those athletes are 3.4 times more likely to become injured.5 In addition, athletes with quick clearance to return to unrestricted activity after an injury may also present with many residual risk factors for future injury. Being prematurely cleared for unrestricted activity demonstrates high recurrence rates, prolonged symptoms, diminished quality of life, limited physical activity levels across the lifespan, a propensity to develop chronic ankle instability, and an increased risk for ankle osteoarthritis.1,6,7
Understanding Chronic Ankle Instability
During plantarflexion and inversion, tension from the ATFL can displace the fibula anteriorly, causing an anterior positional fault of the fibula.1,7,8 There is a strong correlation between the amount of anterior positioning of the fibula and the onset of edema during the initial injury.1 This acute swelling maintains the fibula in a displaced position.8 It is proposed that repetitive ankle sprains can cause constant anterior fibular position/fault, thus predisposing to a reinjury and contributing to chronic ankle instability (CAI) from the anterior positional fault.7,8
Chronic ankle instability (CAI) is a residual symptom of ankle instability and a feeling as if the ankle is “giving way.”1,2 Athletes with CAI tend to have a decrease in dorsiflexion range of motion originating from either arthrokinematic restriction, an osteokinematic restriction, or a combination of both.2 The posterior talar glide, posterior distal fibula glide, and anterior proximal fibular glide are all tests that can clinically be used to assist in determining arthrokinematic restrictions.2 Limited ankle dorsiflexion can be a deterrent to many functional movements and activities such as squatting, lunging, jumping, and changing directions.3 Improving dorsiflexion range of motion is an important intervention for altering high-risk movement patterns commonly associated with noncontact anterior cruciate ligament injury.9
Weight-bearing force over the ankle joint can reach up to as high as 4 times a person’s body weight.10 The tibiofibular joint plays a crucial role in appropriate load distribution from the foot into the lower leg.10 Lateral ankle sprains can be associated with disruption of the distal tibiofibular joint or syndesmotic injuries.10 Instability of this joint may lead to accelerated osteoarthritis of the ankle with poor subjective outcomes after injury.7,10
Lateral ankle sprains contribute to 13-22% of all osteoarthritis cases and 80% of posttraumatic osteoarthritis cases involving the ankle.12 Of the posttraumatic osteoarthritis cases that developed after injury, 50% occurred after a single acute sprain, whereas the other half was because of recurrent sprains or CAI.12 Individuals with posttraumatic osteoarthritis of the ankle may develop this condition at a younger age than those who have idiopathic osteoarthritis, with the mean age of onset in the fifth decade of life and an age range that includes patients in their 20s.12
Important Concepts Regarding Returning to Sport
Ankle sprains can be associated with perineural fibrosis of the superficial peroneal nerve, injury of the common peroneal nerve and posterior tibial nerve.13 There is decreased latency in hip muscle activation leads to decrease postural control.1,13 These changes were noted up to 2 years after the occurrence of injury. The changes are likely attributed to ankle joint laxity or from the deafferentation of the nerves that innervate the joint capsule and ligaments.13 It is suggested that reinjury rate is caused by impaired proprioception after sustaining an ankle sprain, therefore balance and sensorimotor training is an integral component of ankle rehabilitation and have been shown to effectively reduce ankle reinjury rates.1,14 While these are things to consider before returning the athlete to sport, there are currently no published evidence-based criteria to inform return to sport decisions for patients with a lateral ankle sprain injury.12
To return successfully back into performance all intrinsic and extrinsic risk factors must be addressed.12 Clinicians need to be attentive to intrinsic risk factors which include reduced ankle dorsiflexion range of motion, decreased proprioception, reduced static and dynamic postural balance, poor neuromuscular control and running technique, reduced ankle muscle strength, reduced cardiorespiratory endurance, and delayed peroneus brevis reaction time.12 These intrinsic modifiable risk factors are targeted by the appropriate selection of exercise prescription. clinicians should be able to recognize extrinsic risk factors, such as type of sport, position played, athlete exposure, frequency of jumping and landing, risk of stepping on an opponent’s foot, and playing surface when assigning rehabilitation protocol.
Additionally, to determine an athlete’s readiness to return to play a simple and quick in-office performance assessment can be performed by having the athlete execute a single-leg hop (SLH) for distance.15 Female athletes with >10% asymmetry of SLH for distance were at 4 times increased risk for injury of the foot and ankle.15 Male athletes with higher performance scores (SLH > 75% of their height) were associated with up to a three-fold increase in injury to the lower extremity, foot, or ankle.15
Concluding John Doe’s Story
In middle age, John became less active following college and settling into his life routine of work and family. He decided to begin a fitness routine, and his ankle issues began creeping back up on him. His physician recommended performing a round of physical therapy and while therapy helped some, it didn’t eliminate the problem. This cycle goes on for years and eventually requires John to seek a consultation from a podiatric surgeon who recommends total ankle replacement. John, although happy with the outcome of the surgery and the happiness he has in his life, still has a single burning regret. The regret of not taking his high school injury seriously and instead, “walking it off.” This thought in the back of his mind during every workout and while watching and cheering on his favorite player in Sunday night football was, “That could have been me.”
Dr. Miller is a Fellow of the American College of Foot and Ankle Surgeons. He is the Director of the Pennsylvania Intensive Lower Extremity Fellowship in Malvern, PA, and the Podiatric Residency Program at Phoenixville Hospital in Phoenixville, PA.
Dr. Kotzeva is a current Fellow of the Pennsylvania Intensive Lower Extremity Fellowship in Malvern, PA.
References
1. Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013;48(4):528-545.
2. Hubbard-Turner T. Lack of medical treatment from a medical professional after an ankle sprain. J Athl Train. 2019;54(6):671-675.
3. Hubbard-Turner T, Turner MJ. Physical activity levels in college students with chronic ankle instability. J Athl Train. 2015;50(7):742-747.
4. Brumitt J, Heiderscheit BC, Manske RC, Niemuth PE, Rauh MJ. Lower extremity functional tests and risk of injury in division III collegiate athletes. Int J Sports Phys Ther. 2013;8(3):216.
5. Beckman SM, Buchanan TS. Ankle inversion injury and hypermobility: effect on hip and ankle muscle electromyography onset latency. Arch Phys Med Rehabil. 1995;76(12):1138-1143.
6. Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. Br J Sports Med. 2006;40(9):767-772.
7. Lehr ME, Plisky PJ, Butler RJ, Fink ML, Kiesel KB, Underwood FB. Field‐expedient screening and injury risk algorithm categories as predictors of noncontact lower extremity injury. Scand J Med Sci Sport. 2013;23(4):e225-e232.
8. Rhon DI, Teyhen DS, Kiesel KB, et al. (2020, February). Does Recency of Musculoskeletal Injury Strengthen Association between Past Injury History and Future Injury Risk? In 2020 Combined Sections Meeting (CSM). APTA.
9. Hodges PW, Tucker K. Moving differently in pain: a new theory to explain the adaptation to pain. Pain. 2011;152(3):S90-S98.
10. Tassignon B, Verschueren J, Delahunt, E, et al. Criteria-based return to sport decision-making following lateral ankle sprain injury: a systematic review and narrative synthesis. Sports Med. 2019;49(4):601-619.
11. Dill KE, Begalle RL, Frank BS, Zinder SM, Padua DA. Altered knee and ankle kinematics during squatting in those with limited weight-bearing–lunge ankle-dorsiflexion range of motion. J Athl Train. 2014;49(6):723-732.
12. Donovan L, Hertel J. A new paradigm for rehabilitation of patients with chronic ankle instability. Physician Sportsmed. 2012;40(4):41-51.
13. Kobayashi T, Suzuki E, Yamazaki N, et al. Fibular malalignment in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2014;44(11):841-910.
14. Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Manual Ther. 2008;13(1):63-67.
15. Hubbard TJ, Hertel J, Sherbondy P. Fibular position in individuals with self-reported chronic ankle instability. J Orthop Sports Phys Ther. 2006;36(1):3-9.
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