Lateral Ankle Injuries: The Complete Guide
“I landed on someone else’s foot”.
Lateral ankle injuries are amongst the most common injuries sustained by athletes, especially those involved in contact sports or running on uneven surfaces. The mechanism of injury involves suddenly rolling the ankle inwards (inversion +/- plantarflexion) in a weight bearing position, stressing the structures on the outside of the ankle.
Typically, an athlete will have swelling and bruising on the outside of their ankle, walking with a limp and ankle movements will be painful, particularly turning the foot inwards and pointing the toe.
POTENTIAL STRUCTURES INJURED CAN INCLUDE
Lateral Ligaments (ATFL + CFL)
Peroneal tendons
Birfurcate ligament
Avulsion fractures of the anterior process of calcaneus, or the base of the 5th metatarsal
Fractures of the lateral malleolus or the base of the 5th metatarsal
Management
Treat (0-3 days)
Post injury, ensure you treat your injury with PEACE. Three days after injury start to LOVE your ankle. The PEACE & LOVE acronym is the most up to date acute management of soft tissue injuries.
Target (Day 3+)
Target Strength
Pre Return-To-Play, athletes should be able to perform 30 single leg calf raises!
This can be achieved through a tailored progressive calf strengthening program consisting of multiple variations of calf raises, combined with peroneal and tib post banded work.
Maintenance of other lower limb musculature is essential to prevent de-conditioning. Try non-weight bearing resistance training exercises such as; seated hamstring curls, knee extensions and glute bridges.
Target Balance & Proprioception
Pre Return-To-Play, athletes should be able to perform single leg balance on their toes for 30 seconds with their eyes closed!
A range of progressive and individualised balance exercises construct this phase of rehabilitation. Uneven surfaces, eyes open vs closed and external perturbations are incorporated to progress your balance.
Target Range of Motion
Pre Return-To-Play, athletes should have (close to) equal Knee to Wall Range of Motion
Progressive stretches targeting the gastrocs and soleus muscles combined with ankle joint mobilisations assist in regaining dorsiflexion range of motion.
Train
Return-To-Play
The decision for the athlete to return to competition should be made in correspondence with the athlete, medical team and coaches +/- friends/family. It is often recommended in the literature to view this phase as a continuum comprising of the following stages:
Return to participation - the athlete may be participating in rehab running or non-contact training drills at a level lower than the requirements of the competition, and is not yet "ready" medically, physically and/or psychologically.
Return to sport - the athlete has returned to sport, but not at their target level of performance.
Return to performance - the athlete has returned to their sport and is performing at or better than pre-injury level.
Careful consideration utilising evidence based questionnaires, clinical reasoning, appropriate outcome measures and stage of competition will provide the treating practitioner with the appropriate information to guide the athlete in a successful Return-To-Play phase of rehabilitation.
Need help rehabbing an ankle injury?
Current evidence shows lateral ankle sprains have an 80% chance of recurrence in the first year if not treated.
Multiple ankle sprains lead to Chronic Ankle Instability (CAI) and chronic pain. Up to 40% of of people who sustain their first lateral ankle sprain develop CAI within 1 year!
Alongside targeting strength, balance, range of motion and proprioception, ankle taping or bracing has been shown to be an effective way to reduce recurring lateral ankle sprains. These modalities reduce the risk of an ankle sprain by 69% (odds ratio = 0.31) with an ankle brace and by 71% (odds ratio = 0.29) with ankle taping amongst previously injured athletes.
References:
Ardern CL, Glasgow P, Schneiders A, et al2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, BernBritish Journal of Sports Medicine 2016;50:853-864.
Briet JP , Houwert RM , Hageman M , et al . Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury 2016;47:2565–9.doi:10.1016/j.injury.2016.09.016
Dizon JM, Reyes JJ. A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players. J Sci Med Sport. 2010;13(3):309–317.
Dubois B, Esculier J-F. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54:72-73.
Hansrani V , Khanbhai M , Bhandari S , et al . The role of compression in the management of soft tissue ankle injuries: a systematic review. Eur J Orthop Surg Traumatol 2015;25:987–95.doi:10.1007/s00590-015-1607-4
Khan KM , Scott A . Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair. Br J Sports Med 2009;43:247–52.doi:10.1136/bjsm.2008.054239
Singh DP , Barani Lonbani Z , Woodruff MA , et al . Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Front Physiol 2017;8:93.doi:10.3389/fphys.2017.00093
Vuurberg G , Hoorntje A , Wink LM , et al . Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med 2018;52:956.doi:10.1136/bjsports-2017-098106
