The ankle is a “hinge or gliding” joint made of bones and several ligaments at the end of each leg. Due to the composition of ligaments, ankle injuries can take a long time to heal. Ligaments have low vascularity which means that there aren’t many arteries or veins to provide blood flow to these components. Blood is needed for the body to make new cells and repair injuries. When you run, jump, and spin, your ankles take on forces that can equal up to several times your body weight. When stability is compromised, the force that can be supported greatly decreases.
Brief Anatomy of the Ankle
The ankle is made up of two joints, three bones, and several ligaments that connect bone to bone.
- The tibia (aka the shin bone) runs down the front of the leg. This bone has two protrusions at the base, the bony bumps that you feel on your ankle. The medial malleolus is on the inside of the ankle and the posterior malleolus is at the back of the ankle. One very important ligament, the deltoid ligament is a triangular band that connects at several points of the medial malleolus.
- The fibula (aka calf bone) is the thin bone that runs parallel to the tibia on the posterior (back) and distal (outside) part of the leg. Many ligaments connect the fibula to other bones. The lateral ligament complex is composed of three different ligaments that connect the fibula to the front and back of the talus bone (aka the ankle bone) and the calcaneus (aka heel) bone. Both the ankle and heel bones are below the tibia and fibula.
- Several more ligaments connect and stabilize the tibia and fibula. The anterior inferior tibiofibular ligament is the main ligament that connects the tibia and fibula in the front of the leg. In the back of the leg, the posterior inferior tibiofibular ligament crosses with the transverse ligament. The interosseous ligament runs the length of the leg from knee to ankle between the tibia and fibula.
- These ligaments that are all around the bones that make up the ankle as well as stabilize it forms a part of the joint capsule which lubricates the articulating joints.
- Many muscles and tendons also contribute to ankle stability and are responsible for the movement of the ankle. The main basics include flexor digitorum longus, flexor hallucis longus, soleus, gastrocnemius, tibialis, anterior, extensor digitorum longus, tibialis anterior tendon, and the Achilles tendon.
How to Identify a Sprain vs. a Strain
The main difference between a strain and a sprain is that a strain affects muscles and tendons and a sprain affects the ligaments. Muscles are located deep inside the leg, often used to protect and stabilize bones, working symbiotically, and tendons connect muscles to bones. Ligaments provide added mobility and stability to bone structure and they connect bone directly to bone.
A sprain is usually due to a single event of acute trauma. It affects ligaments and injuries range from overstretching the ligaments to tearing them completely. A strain often occurs due to repeated overstretching or even tearing of muscles and tendons. Strains are common among athletes. While both strains and sprains present with ankle swelling, localized pain, weakness, and instability, the treatment for either is very different. Improper treatment can lead to further injury and future chronic conditions.
Identifying Different Types of Sprains
The ligaments of the ankle stabilize and provide movement for different parts of the ankle. Each type of sprain affects a different ligament. Understanding how the sprain affects the specific part of your ankle is important for knowing how to treat the injury. Generally speaking, the more ligaments that are involved and the more they are stretched or torn, the more ankle instability will occur. A sprain can happen with irregular motion or acute trauma.
- An inversion sprain affects most often affects the lateral (outside of the leg) ligaments of the ankle. This includes the anterior talofibular ligament and the calcaneofibular ligament. When the ankle turns at a degree farther than it should (commonly referred to as “rolling the ankle”), the anterior ligaments are overstretched and may tear. The posterior talofibular ligament is included in this type of sprain but is rarely affected since it is far stronger than the other ligaments.
- An eversion sprain occurs on the inside of the ankle and affects the deltoid ligament. It’s a similar movement to the inversion sprain but the abnormal angle happens in the opposite direction. This type of sprain commonly happens in conjunction with a fibular fracture and usually results in a tearing of the deltoid ligament and not just overstretching.
- Just above the ankle, the tibia and fibula are connected by a fibrous joint called “syndesmosis.” A high ankle sprain is therefore usually referred to as a syndesmotic ankle sprain, or SAS because it affects the tibiofibular ligament that forms the syndesmosis joint. The high ankle sprain differs most from other ankle sprains in that it can cause a severe loss of stability if not found and diagnosed early after the injury.
Loss of Stability After a Sprain
The overstretching or tearing of ligaments when a sprain occurs causes loss of stability in addition to pain, swelling, and weakness at the site of injury. Since ligaments have low vascularity and take a long time to heal, they will likely never be as strong as they were before the injury and improper care after the injury can lead to chronic conditions that cause further loss of stability. When a sprain happens, the stress affects bones, muscles, cartilage, and joints. After the injury, sometimes even years later, stiffness and inflammation in the joints are known as post-traumatic arthritis. Improper exercise and conditioning after an injury can lead to tendonitis which is an inflammation of the tendons at the connecting bones to muscles at the ankle.
All types of arthritis include cartilage wearing down between bones and subsequent inflammation. Post-traumatic arthritis is a precursor to osteoarthritis, a degenerative disease that occurs with age. If chronic conditions begin early on due to injury, the result may be joint replacement or other surgery. Physical therapy and proper treatment of an ankle sprain can prevent excess loss of stability or the need for surgery.
Treatment for an Ankle Sprain
If you suspect an ankle sprain of any kind, it is important to have it diagnosed and treated as soon as possible. Your doctor may recommend the R.I.C.E. protocol, which stands for “rest, ice, compression, elevation” in a cycle for the first couple of days following a sprain. After that, physical therapy exercises may be used to restore stability and recover the ligaments that were injured.
Physical Therapy Exercises for Ankle Stabilization
Your physical therapist will use a number of exercises to stabilize your ankle and help the ligaments heal after a sprain. The ankle works in conjunction with many different muscles, joints, tendons, ligaments, and bones in the leg and foot. A kinetic chain refers to the way these components affect each other while they move. Open chain exercises involve the foot being able to move freely, like how the lower leg swings up while using a leg curl machine. Closed chain exercises involve the foot in a stationary position. Lunges, squats, and push-ups are examples of closed chain exercises. Some common strengthening and stabilizing exercises include:
- Using the toes to trace the alphabet engages all the muscles of the ankle without bearing weight on injured ligaments. It is a common rehabilitation exercise that can be done early on after an injury.
- Heel raises can be done when the injury has had more time to heal. While standing at a bar or counter that you can hold onto, lift heels slowly and then lower slowly. Doing this exercise slowly is important because this allows control and stability to develop again.
- A resistance band can be utilized to allow strength and stability to use without bearing too much weight on an injured ankle. Starting with light resistance, loop the foot into the band and press the toes against it. Pull up with the hands and flex the foot forward and then back slowly and with control.
Braces and Bearing Weight
When you’re cleared to begin bearing weight on your injured ankle, a compression sock, ace bandage, or other stabilizing braces may be used during athletic activity to add some stability while rehabilitation is ongoing. These assistive devices allow you to move and exercise an injured ankle with less risk of further injury. Ask your doctor if physical therapy would be helpful so that a professional can help you make sure that you’re doing your exercises correctly and safely. With proper treatment, ankle stabilization and rehabilitation after a sprain are possible. If you are seeking physical therapy services, or have questions about your ankle, call and speak to one of our doctors at 570-208-2787 or e-mail us at cawleyptfrank@gmail.com. We’d love to help!
