Lateral ankle sprains are one of the most common injuries I see in clinic and a condition which if poorly managed can often give rise to more persistent issues than you would first think. Ankle sprains occur in most sports and rugby is no exception. More often than not lateral ankle sprains in rugby are caused at the breakdown when someone's ankle gets caught in the pile of bodies and your ankle twists inwards, this movement is called inversion. The most common mechanism of injury for a lateral ankle sprain is inversion and plantarflexion which can be seen in the picture below:
There are three ligaments which restrict inversion, however the ligament which is most commonly (80% of the time) affected during an injury like this is the Anterior Talo-Fibular Ligament more commonly known as the ATFL. This is the most commonly torn ligament in the body. I get asked a lot in clinic about what the difference between a sprain, strain and tear is and the simple answer is, they are all words to describe the same thing. When you go over on your ankle you stretch this ligament beyond its limits and it causes a small tear within the ligament. Whenever you use the word tear people think of a complete tear but this only occurs in extreme cases (Grade 3). There are several grades of tear depending on how much of the ligament has torn:
Obviously the higher the grade of ligament tear the longer you should expect it to take to recover. As a rough guide grade 1 tears usually resolve within 6 days, grade 2's can take up to 6 weeks and grade 3 usually resolve within 2-3 months however can sometimes never fully resolve if you don’t manage it correctly. How quickly you recover coupled with the level of swelling, bruising, trauma and disability at onset is a way of determining the grade of tear that has been sustained. However, when I am presented with someone who has more persistent ankle instability issues (3 months+) I would consider referring for an ultrasound or MRI depending on their management to date.
I treat lateral ligament strains a bit differently to some. For the first 48 to 78 hours I actually ask people not to take any anti-inflammatories, which some of you may be surprised to hear. A common mis-conception is that inflammation is bad and it is if it persists however in those first 2-3 days it is vital to help the injured structures heal. So why would you advise people to take medication to reduce inflammation. Once these first few days have elapsed then inflammation is counter-productive so I ask people to take ibuprofen three times daily after food for 6 days. Ibuprofen will not mask the pain, it is a NSAID (Non-Steroidal Anti-Inflammatory) so it works on reducing inflammation within the body, it is not a pain relief like paracetamol. You can also ice the ankle for 10mins or so at a time however this has been shown to be effective for pain but not to reduce inflammation. After that first week of complete rest I would begin hands on therapy to help restore full range of movement and improve your ankle strength. Towards the latter stages of your recovery we would do a range of ankle stability tests to make sure you are fully recovered and you can get back to rugby with confidence.
For the higher grade ankle sprains, I manage them far more cautiously. I putt them in an aircast boot for 2 weeks initially as this gives the ligament time to knit back together.
With effective initial management ankle sprains can resolve quickly and you can return to play quickly but if during those first few weeks they are managed poorly or you get back out on the pitch too soon, the pain can become persistent. Just like any sports injury the biggest predictor of whether or not you are going to get injured is whether or not you have had that injury before. Therefore, once you have sprained your ankle you need to do the proper rehab required to make sure it doesn't happen again. For some practical tips on how you can improve your ankle stability take a look at these videos:
As always if you have concerns about your ankle then please don’t hesitate to get in touch, I would be happy to help.
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