For any athlete, a sprain of the ankle lateral collateral ligament is one of the injuries that can ruin a sporting season, and is one that we want to avoid at all costs. Whether through bad luck or suboptimal physical preparation, ankle sprains are a common occurrence. Thousands of people in the UK and Ireland sprain their ankle every day.
So, in aiming to return to our best level as quickly as possible, we often seek the help of a physiotherapist. For good rehabilitation, it is essential that we understand the mechanics and kinematics (motion) of the ankle, and its strengths and weaknesses, to better prevent instability and come back even stronger.
Finally, simple rest and immobilisation is not enough to cure a sprain and restore complete function. The ankle is a complex joint and is the keystone to walking and running, so it deserves our full attention. A good ankle is a stable ankle; not merely a "painless" one.
The ankle consists of a multitude of small bones. From back to front, we find respectively the bones of the tarsus, then those of the metatarsus and finally the phalanges of the toes. The joints of Chopart and Lisfranc connect these bone categories and allow the smooth running of the foot. In addition, between each of these structures, small ligaments stiffen the system and give the foot great stability in the "front-to-back" axis.
The same is not true for the lateral axis, where this stability is greatly tested. In this plane, only the collateral ligaments (internal and external) stabilise the structure. They are less numerous, longer, and subject to a greater leverage. They also ensure the stability of the ankle joint (the talocrural joint between the leg and the foot). It is therefore logical that the most important instability will concern the lateral axis of the foot.
Most ankle ligament injuries involve the lateral side of the foot. It is therefore the lateral collateral ligament that is most often injured. Though referred to as a ligament, it is really set of three ligaments (the anterior talofibular, the calcaneofibular and the posterior talofibular ligaments) that jointly resist inversion of the ankle joint.
DEFINITION OF AN ANKLE SPRAIN
An ankle sprain is a ligament injury that results from two inseparable factors.
- An involuntary reversal movement (eg. foot going into inversion).
- Be in a closed chain at the time of instability (ie. foot on the ground).
The lateral collateral ligament can then become distended or ruptured. Ankle sprains are graded depending on the severity:
- Grade 1: Mild sprain. Distending or slight tearing of the ligament with mild tenderness, swelling and stiffness.
- Grade 2: Medium sprain. An incomplete tear of the ligament with moderate pain, swelling and bruising.
- Grade 3: Severe sprain. A complete tear of the affected ligament(s) from the external malleolus and / or the 5th metatarsal, with severe swelling and bruising.
A significant haematoma occurs from Grade 2. This is a consequence of a lesion of the fibular artery which is very close to the lateral collateral ligament. This will resolve after a few weeks.
The functional deficits resulting from such trauma are numerous. They appear from the first sprain and will become chronic if structured rehabilitation is not put in place quickly.From the first minutes, a number of cascading steps will be necessary for a return to the natural qualities of the foot. This cascade results in a healing period of many weeks.
DEFICIT #1: THE EVERTOR MUSCLES
The first deficit will be that of the evertor muscles (these stop your foot collapsing so that sole of the foot faces away from your other foot).
Indeed, if an ankle is destabilized in inversion, we can assume that the muscles doing the opposite movement are suffering from a deficit. The eversors (or fibular muscles) will then have to be re-educated to provide stability against this movement in future.
Hartsell & Spaulding (1999) established that one of the main factors responsible for ankle instability and the recurrence of sprains is the weakness of the evertor ankle muscles.1The table below shows us that after a sprain of the lateral collateral ligament, the evertor muscles lose strength. This is regardless of the type of contraction; concentric (foreshortening) or eccentric. The pathological ankle is shown in grey and the healthy ankle never having suffered a sprain, in white.
DEFICIT #2: PROPRIOCEPTION
The second deficit is that of proprioception; the ability that we have to sense movement, action, and location in space.
This ability is essential to keep an ankle stable (in a neutral position). Indeed, to have effective motor control of the fibular muscles during a forced inversion movement, it is necessary to have the information that the ankle is no longer in its neutral position. Without proprioception, there can be no efficient motor control.
DEFICIT #3: NEUROMUSCULAR CONTROL
Fibular reaction time is the period between inversion destabilisation and the onset of electrical activation of the fibular tissues. The shorter this time, the sooner the stabilising ankle muscles will be activated and then the risk of a sprain will be low.
A study by Menacho et al. (2010) suggests that “patients with traumatic recurrence have a longer fibular reaction time than healthy subjects”.2 The risk of sprain recurrence will therefore be higher if this parameter is not accounted for in rehabilitation.
Another study by Santilli et al. (2005) demonstrated that the duration of contraction of the peroneal muscles when walking was reduced on the pathological side.3 This therefore reflects both the failure of the proprioceptive system and of fibular reaction time.
The solution to reducing fibular reaction time is to work on reprogramming neuromuscular control. By exercising the pathological subject in patterns linked to their sport or activity. For example, by making a basketball player jump, by causing a handball player to suddenly change direction, or by making a ballet dancer work en pointes.
To go further, multiply the scenarios where the subject will be in working conditions close to their activity. Ankle rehabilitation should be done à la carte if optimal results are to be desired.
All this creates unconscious behaviour patterns and pre-contractions of the fibular tissues which will protect the ankle from a possible involuntary inversion.
Studies have pointed in this direction, for example, Thonnard (1986) demonstrated that there was a protective muscular activity even before the impact on the ground.4 Anticipation must become automatic. Above all, do not stay locked in a pattern where “feedback” guides our course of action. This is the "feed-forward" that will be!
THE RESUMPTION OF PHYSICAL ACTIVITY
D-day is approaching. Rehabilitation is coming to an end. The functional capacities of the ankle are finally restored. Feet are not (or less) painful, and the balance is perfect. Thanks to the proprioception exercises carried out, the strength is regained, the jumps and accelerations are done without a hitch. We can finally get back to training.
Take care with the first outings which are often synonymous with recurrence. Therefore, it is advised that for a short period, reduced to the strict minimum, but a maximum of 15 days, an elastic restraint (such as the DonJoy MaloLax) or an elastic ankle brace with strapping (such as the DonJoy StrapiLax Ankle) be used during training and matches.
A light restraint will give the patient confidence. It will also give the support needed to stabilise a newly recovered ankle. Care should be taken not to immobilize the foot too long after recovery as this can alter proprioception.
IMPORTANT PATIENT NOTE
It is advisable to consult a doctor or a sports physiotherapist who will prescribe the right brace for you depending on the sports activity practiced Pain is a sign that should not be overlooked. If the latter is pronounced and / or persists too long, it is advisable to consult a doctor.
References and picture sources
1. Hartsell HD, Spaulding SJ. Eccentric/concentric ratios at selected velocities for the invertor and evertor muscles of the chronically unstable ankle. Br J Sports Med. 1999 Aug;33(4):255-8. doi: 10.1136/bjsm.33.4.255. PMID: 10450480; PMCID: PMC1756184.
2. Menacho Mde O, Pereira HM, Oliveira BI, Chagas LM, Toyohara MT, Cardoso JR. The peroneus reaction time during sudden inversion test: systematic review. J Electromyogr Kinesiol. 2010 Aug;20(4):559-65. doi: 10.1016/j.jelekin.2009.11.007. Epub 2010 Jan 18. PMID: 20083415.
3. Santilli V, Frascarelli MA, Paoloni M, Frascarelli F, Camerota F, De Natale L, De Santis F. Peroneus longus muscle activation pattern during gait cycle in athletes affected by functional ankle instability: a surface electromyographic study. Am J Sports Med. 2005 Aug;33(8):1183-7. doi: 10.1177/0363546504274147. Epub 2005 Jul 6. PMID: 16000658.
4. Thonnard JL, Plaghki L, Willems P, Benoit JC, De Nyer J. La pathogénie de l'entorse de la cheville: test d'une hypothèse [Pathogenesis of ankle sprain: testing of a hypothesis]. Acta Belg Med Phys. 1986 Apr-Jun;9(2):141-5. French. PMID: 2949465.