Doherty, C. et al 2017). This is mainly felt on the outside of your ankle but can still occur on the inside. It is caused by repetitive rolls while you are growing up or as an adult. Approximately 20% of people who experience an ankle sprain develop chronic instability (Vuurberg, G. et al 2018). That is quite a few people, so let’s talk more about it.
Chronic instability of your ankle can cause you to experience increased levels of pain during activity, feel unsteady on your feet, impact your balance or control and even decrease muscle strength around your ankle and leg. The cause of an ankle sprain is not just confined to the sporting field, but can often occur accidentally during normal daily activities, like walking down stairs, or tripping over some grass on a walk. It impacts a wide age group, not only just children, and can result in considerable problems later on down the track.
The structures that could be involved:
“File:919 Ankle Feet Joints.jpg” by OpenStax College is licensed under CC BY 3.0.
It is more likely that people with chronic instability experience it due to “lateral ankle sprains”. This means injuries to the outside of the foot, and these equate to approximately 85% of all ankle sprains across the world (Fowler, R. 2013). This is because the structures on the inside of the foot are more stable compared to those on the outside.
On the outside area of the ankle, there are some structures that are really important for the overall stability of your ankle. These include the lateral ankle ligaments; the anterior talofibular, calcaneofibular and posterior talofibular ligaments. As seen in the image above, they form somewhat of a triangle around your outside ankle and help to keep it stable. When rolling the foot inwards, these ligaments can be put on stress, and if this pushes past the point at which the ligament can hold, it causes tissue damage. This injury will most likely present with swelling, bruising and pain when touching and putting weight on that leg, primarily over that outside ankle area (Boyce, S.H et al 2005).
What are some examples of how it can happen?
Think about it this way, remember when you were younger and you would always have little or big ankle rolls, whether it was because you loved to play netball and landing from a jump wasn’t the easiest thing to do, or you got a puppy one summer and found that when playing in the backyard you always seemed to twist your ankle the wrong way.
Sometimes the roll wouldn’t seem so bad, only a little bit of pain at the time or when walking lasting for a day or two. Other times you noticed more swelling or bruising, decreased range of motion in your ankle and that putting weight on that leg felt really painful. Both of these situations are considered to be an ankle sprain, but of varying degrees and if not rehabilitated correctly can cause further issues down the track (Boyce, S.H et al 2005). For example, the biggest risk factor to attain CAI is by having sprained your ankle again after the original injury (McCriskin, B.J. et al 2015).
What are the risk factors for CAI?
Recurring ankle sprains is the biggest risk factor for CAI. The literature has shown that after the first ankle roll, up to 73% of patients experience at least one ankle sprain afterwards (Herb et al 2014). Of these patients, up to 59% of those have long term problems (Herb et al 2014). Moreover, between 30-70% of initial ankle sprains result in development of CAI (Herb et al 2014). But a history of sprained ankles is not the only risk factor, so what are some of the other ones?
– Higher body weight or body mass index
– Female gender
– Young in age
– Reduced lower limb reaction time
– Poor muscle strength
(McCriskin, B.J. et al 2015)
How to tell if you have CAI?
There are some signs that can lead you to thinking that CAI is an area of concern for you. These could include, but are not limited to: (Doherty, C. et al 2017, McCriskin, B.J. et al 2015):
– A history of multiple sprains, big or small
– Perceived instability and feelings of giving way or loss of control during activities – Decreased postural control or balance on the injured side
– Feelings of weakness around the area
– Difficulty knowing how your foot is positioned in space during activity
It is always recommended to seek a professional opinion regarding this suspected diagnosis, as this would be the best source of information regarding your injury and how it can relate to your history.
So what to do about it?
Once you have spoken to a professional the most likely route of rehab will include conservative treatment (i.e. non-surgical treatment). This will initially involve trying to manage the most recent ankle sprain that has occurred, such as utilising the PEACE + LOVE* method (hyperlink to Chelsea’s article ice vs heat?), focusing on reducing swelling and introducing early mobilisation (Fowler, R. 2013).
After the initial levels of pain and swelling have reduced, the focus of physiotherapy will be aimed at restoring strength, improving motor control and trying to help the patient achieve their goals, for example returning to their pre-injury function (McKeon P.O et al 2008).
A study completed in 2002 by Kerkhoffs et al compared rigid immobilisation in the form of bracing and functional management of acute lateral ankle sprains. They found a higher rate of return to sport in those who were managed with functional protocols (McCriskin, B.J.et al 2015). In addition, studies have shown that balance and coordination training are effective interventions for the prevention of ankle sprains, specifically in patients who have a long history of recurrent ankle sprains (Boyce S.H. et al 2005).
Surgery is mostly reserved for patients who present with chronic ankle stability and who have not improved with a thorough course of conservative management, and is not normally recommended as the first route of treatment (McCriskin, B.J.et al 2015). An assessment by a physio is the most common starting point for a rehabilitation journey, to help you get a better understanding of what is going on for you, and what can be done to help.
References
Patrick O. McKeon et al. (2008) Interventions for the prevention of first time and recurrent ankle sprains, Clinics in Sports Medicine. Elsevier. Available at:
https://www.sciencedirect.com/science/article/abs/pii/S0278591908000215 (Accessed: March 27, 2023).
Boyce, S.H., Quigley, M.A. and Campbell, S. (2005) Management of ankle sprains: A randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace, British Journal of Sports Medicine. British Association of
Doherty, C. et al. (2017) Treatment and prevention of acute and recurrent ankle sprain: An overview of systematic reviews with meta-analysis, British Journal of Sports Medicine. BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine. Available at: https://bjsm.bmj.com/content/51/2/113.short (Accessed: March 25, 2023).
Fowler, R. (2013) The weekend athlete: Common foot and ankle injuries, Consultant360. Available at:
https://www.consultant360.com/articles/weekend-athlete-common-foot-and-ankle-injuries (Accessed: March 28, 2023).
Herb, C.C. and Hertel, J. (2014) Current concepts on the pathophysiology and management of recurrent ankle sprains and chronic ankle instability – current physical medicine and Rehabilitation reports, SpringerLink. Springer US. Available at:
https://link.springer.com/article/10.1007/s40141-013-0041-y (Accessed: March 28, 2023).
Hiller, C.E. et al. (2011) Characteristics of people with recurrent ankle sprains: A systematic review with meta-analysis, British Journal of Sports Medicine. BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine. Available at:
https://bjsm.bmj.com/content/45/8/660.short (Accessed: March 26, 2023).
McCriskin, B.J. et al. (2015) Management and prevention of acute and chronic lateral ankle instability in athletic patient populations, World journal of orthopedics. U.S. National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363799/ (Accessed: March 28, 2023).
Vuurberg, G. et al. (2018) Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline, British Journal of Sports Medicine. BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine. Available at: https://bjsm.bmj.com/content/52/15/956.abstract (Accessed: March 26, 2023).
