ANKLE INJURIES - a patient's guide
Dr Ruth Highet - Sports Physician

What is it?

The most common injury to present in a sports medicine practice is the "ankle sprain". Whether the result of rolling the ankle running on uneven ground, twisting the ankle coming down from a leap at netball, or having the ankle wrenched in a tackle - the athlete might be out for a few days or weeks as a result.

Most simple ankle sprains should recover with the athlete able to return to full pain free activity within two to four weeks. About 30% of patients however will still have pain at this stage and these may require further investigation. They have likely had more than "just a sprain to their ankle".

What can be done?

So you're out on your early morning jog enjoying the sanctity of the bush and you're tripped up by a gnarly root - what should you do?

Early treatment for an acute ankle injury should always ideally start with what's termed the "RICE" management - REST, ICE, COMPRESSION and ELEVATION.

The REST phase with most ankle injuries should usually only last 24 hours then is better replaced by early range of motion exercises often in conjunction with a physiotherapist. ICE should be applied every 2-3 hours to the acute ankle injury during the first 48-72 hours. This combined with keeping the ankle STRAPPED and ELEVATED will significantly reduce the amount of swelling occurring, in turn reducing the amount of downtime as a result of this injury. A Tubigrip or neoprene stocking type compressive bandage worn during the day (should be taken off for sleeping), will provide support as well as reducing the swelling.

Once the range of motion has been restored (lots of ankle/foot exercises - up/down and in/out ankle movements) and pain reduced then specific strengthening exercises aimed at strengthening the outside ankle structures, front and back of the calf and small muscles of the feet begin. These activities are ideally monitored by your physio balance (proprioception) exercises are also added to the rehabilitation programme prior to the athlete returning to their usual activities.

Unfortunately many ankle sprains do not receive appropriate or complete rehabilitation and these athletes we often see weeks or months down the track complaining of a chronically "sore ankle" which may "give way" easily as well.

If they feel apprehensive about using it on an uneven surface because it feels "weak", it is likely that the athlete has "chronic ankle instability" due to repetitive stretching and tearing of the ligaments on the outside of the ankle. Careful examination and stress x-rays of the ankle can confirm this. Management will involve appropriate strengthening exercises and lots of balance retraining (wobble board work, exercises standing on one leg with eyes closed etc).

Very occasionally surgery is required to reconstruct the ligaments but that is dependent on the demands placed on the ankle by the particular individual and their sport, and their response to a thorough rehabilitation programme. "Ultrasound only" applied over the area of swelling and tenderness is certainly not adequate physio for the acute or chronically sprained ankle. It has a very limited role in the early treatment of the ankle sprain but the rehab further down the track should focus on the strengthening and balance exercises.

Serious injuries

Of those ankles still sore at three weeks, a considerable number will involve more significant ligament, joint and bony injuries. Many bony injuries in the ankle don't show up on an ordinary x-ray. Sometimes specific views are required, sometimes a repeat x-ray further down the track (about 3-4 weeks later) will show up the fracture better.

Frequently however, more sophisticated imaging will be required to ensure there is no fracture, or other cartilaginous or ligamentous damage to the interior of the ankle joint proper or other joints of the ankle. This may be in the form of an isotope bone scan, CT scan or MRI scan. A bone scan is very sensitive for picking up bony injury or inflammation It involves having an injection of radioisotope dye into your arm followed by having pictures taken about 2 hours later when the dye has been dispersed around the body via the bloodstream. It will fairly closely pinpoint which area of the bone is damaged.

A CAT scan is very good for giving more information on certain types of bony injury e.g. precise location of fractures that have broken off into the joint. An MRI scan is very sensitive for picking up bone bruising (where there has been no bony "break" but definite contusion inside the bone), injury to the cartilaginous surfaces of the bone and inflammation of the synovium (the joint lining). So the history and clinical signs on examining the ankle will determine which of these scans would give the most information.

Having more detailed information from these other types of imaging may then indicate that arthroscopic (telescopic keyhole) surgery may be required to try and fix loose fragments, remove detached fragments of bone, cartilage, drill the bone surfaces to encourage healing or clean out any thickened joint lining that maybe getting pinched in the joint (synovitis).

So if you still have ankle pain, or marked swelling that may be making you still need to limp, three weeks after your "ankle sprain", then it is highly likely that you have sustained a more complex injury such as an undetected fracture, damage to the joint cartilage or lining, or tendon injury around the ankle. Some of these injuries won't get better without surgery and some of them if they remain untreated may certainly involve an increased risk of "wear and tear" arthritis in that joint later on. So it's sensible to get it checked out properly early on in the course of the injury. Don't assume that because you have a "weak" ankle as a result of previous injuries that nothing can be done about it! .