Acute ankle sprains are among the most common musculoskeletal injuries. In the US, the estimate of ankle injuries is 2,000,000 per year and probably much higher as most get treated at home.
A study in the Netherlands found that the incidence of ankle sprains were 5.5 times higher than data reported from the emergency department.
Up to 70% of individuals who sustain an acute ankle sprain may develop a residual physical disability which may include chronic ankle instability.
Acute ankle sprains occur at high rates in all levels of sports participation however 50% of all ankle sprains treated in US Emergency Departments did not occur during sports activity.
The incidence of ankle sprains is higher in females than males and decreases with age.
Among college athletes in the Unites States, acute ankle sprains are the most commonly reported injury representing at least 15% of all injuries in this population. In high school, the prevalence is similar to college at 15-17% of all sports related injuries. At the highest level of competition, ankle injuries are even higher especially among elite basketball players.
In the NBA, ankle injuries were the most common followed by low back injuries. In the NFL, the athletes sustain a higher incidence of high ankle sprains as compared to other professional sports. High/syndesmotic sprains represented approximately 40% of ankle sprains in this population. In addition to sports, populations that participate in intense physical activity such as military personnel have a high rate of ankle sprains.
After initial injury the frequency of reinjury is significantly higher. In a systemic review of the literature, the authors noted a substantial proportion of all acute ankle sprains sustained during sports were recurrent; for example, 46% of acute ankle sprains that occurred in volleyball, 43% in American football, 28% in basketball and 19% in soccer were recurrent injuries. Other research has identified the proportion of recurrent ankle sprains to be 12-47% in the general population. In a study of 9811 military cadets, individuals with a history of ankle sprain had 3.5 times greater risk of sustaining another injury during the study period than those who had no history of ankle sprain.
Acute Ankle Sprains have a high recurrence rate which is associated with the development of ankle instability. Chronic ankle instability is characterized by laxity and mechanical instability that interfere with activity. Chronic ankle instability can develop after an initial ankle sprain, from multiple injuries to the same structure or from other mechanisms ultimately leading to insufficiency of the ankle complex.
In a recent review, 70% of individuals who sustain a lateral ankle sprain may develop CAI over a short period after the initial injury and further review 40% prevalence after one year after the injury. Chronic ankle instability was reported twice as often by female athletes 32% vs male 17%.
Potentially the most concerning long- term outcome of ankle sprain injuries is the development of posttraumatic osteoarthritis. Individuals who have post traumatic osteoarthritis of the ankle may develop this condition at a younger age than those who have idiopathic osteoarthritis with a mean age of onset in the fifth decade of life and an age range that includes patients in their twenties.
Acute Ankle Sprains are characterized by the stretching or tearing of the supporting ankle ligaments. 75% of all ankle sprains are lateral ankle sprains involving the anterior talofibular ligament. Approximately 15% are medial ankle ligament sprains involving the deltoid ligament. 10% are high ankle sprains (syndesmosis) anterior inferior tibiofibular ligament or posterior inferior tibiofibular ligament.
Three Types of Ankle Sprains
The most common type of ankle sprain is an inversion injury or lateral ankle sprain. The foot rolls inward and pressure is applied down on top of the inverted foot. This damages the ligaments on the outer ankle- the anterior talofibular ligament, the calcaneofibular ligament and the posterior talofibular ligament.
Less common are sprains affecting the ligaments of the inner side of the ankle. These are referred to as a medial ankle sprain when injured or the deltoid ligament. This is a group of 4 ligaments.
The third and most severe type are syndesmotic sprains which injure the tibiofibular ligaments These ligaments join the tibia and fibula just above the ankle. Syndesmotic sprains, which occur most often in contact sports, are especially problematic since they are likely to cause chronic ankle instability and recurrent sprains.
A syndesmosis is defined as a fibrous joint in which two adjacent bones are linked by a strong membrane or ligament.
A syndesmotic or high ankle sprain is one that involves the ligaments binding the distal tibia and fibula at the distal tibiofibular syndesmosis.
Injury to this syndesmotic area occurs when the foot twists outwards relative to the leg.
This external rotation injury occurs when the foot is externally rotated and fixated, the leg is forcefully rotated inward and the shearing force disrupts the ligament connecting the lower tibia and fibula.
Grades of Ankle Sprain Severity
Grade 1- minimal stretching of the ligaments with no tearing
- Mild pain and tenderness with no joint instability and no difficulty bearing weight
- Recovery time is usually 1-3 weeks
Grade 2- partial tear of the ligaments with moderate pain, swelling and bruising. Loss of range of motion and function
- Pain on weight bearing and walking
- Recovery time is usually 3-6 weeks
Grade 3- full tear or rupture
- Severe pain swelling bruising
- Instability with loss of function and range of motion
- Unable to walk or bear weight
- Recovery time several months
Sprained Ankle Diagnosis
- Physical exam by healthcare provider
- X-Rays if bony involvement is to be ruled out
- Ultrasound can be used to review the ligaments while in motion
- Ct or MRI to show torn ligaments, bone chips or other involvement
Treatment
- Rest
- Ice
- Compression
- Elevation
- NSAIDS such as motrin for pain and swelling
- Crutches as needed
Most ankle sprains heal with no problems in 1-2 weeks, however 33% of patients still can have some pain after one year. Physical Therapy consult is recommended since reinjury is common. Severe sprains with ligament and joint instability may need surgery.
High ankle sprains are increasingly seen in football players at all levels. These sprains result in significant more lost time from the sport due to the nature of the damage that occurs. High ankle sprains have been thought to occur because of the increased traction provided by artificial turf fields as well as the lighter more flexible cleats the players now use.
Another theory is most football players tape their ankles and therefore more force is displaced higher into the high ankle area.
If the injuring force is great enough, there may be a separation of the tibia/fibula which allows an abnormal shift of the ankle joint. This can lead to chronic stiffness, pain, and early onset osteoarthritis of the ankle. MRI should be done in these cases to show subtle signs of injury as well as to rule out other damaged soft tissue structures such as ligaments, tendons and cartilage.
Treatment of High Ankle Sprains
Treatment of high ankle sprains is much the same as the other ankle sprains although more prolonged. RICE is the initial treatment and splinting. NSAIDS are usually added for pain and swelling but there is limited scientific studies to prove the benefits of these drugs.
Once the inflammatory phase is over, physical therapy should be instituted with gradual return of the range of motion to weight bearing and walking.
Surgery is rarely necessary for high ankle sprains and is only indicated if there is a significant injury to the ligaments around the area resulting in a separation of the tibia fibula. Surgery entails placing a screw across the bones to restore their normal anatomy and ecuperation is usually 4-6 months following.
Platelet Rich Plasma is an autologous blood concentrate, rich with growth factors and cytokines that can aid in the repair of damaged tissue. PRP is being used in the treatment of high ankle sprains with great success.
Studies
Knee Surg Sports Traumatol Arthrosc 2015 Nov;23(11) : 3383-92 PMID 24938396
Purpose: Syndesmotic sprains are uncommon injuries that require prolonged recovery. The influence of ultrasound guided injections of platelet rich plasma into the injured antero-inferior tibio-fibular ligaments in athletes on return to play and dynamic stability was studied.
Conclusions: Athletes suffering from high ankle sprains benefit from ultrasound guided PRP injections with shorter return to play, re-stabilization of the syndesmosis joint and less long- term residual pain.
Foot Ankle Surg 2020 Oct;26(7): 750-754 PMID 31640921
Purpose: We aimed to clinically evaluate the effect of platelet rich plasma therapy in patients with acute lateral ankle sprain treated with rigid immobilization
Results: The treatment group (PRP) presented the highest reduction of pain and better functional scores than the control group at 8 weeks
Can Elite Dancers Return to Dance After Ultrasound Guided Platelet Rich Plasma Injections?
J Dance Med Scien 2018 Dec 1;22(4): 225-232 PMID 30477612
Purpose: Dancers exert tremendous stresses on the lower extremities rendering them prone to injuries that can curtain training and performance. The goal of this study was to evaluate clinical improvement in a population of elite dancers following treatment with ultrasound guided platelet rich plasma injections for various lower extremity sites by assessing when they were able to return to dance.
Conclusion: It is concluded that ultrasound guided platelet rich plasma injections may play a role in the treatment of various lower extremity injuries in elite dancers with the majority of dancers in this series returning to dance within 6 months.
Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our Platelet Rich Plasma Kits are FDA approved and designed for safety and effectiveness. They are cost effective and very easy to use. Our kits provide consistency of concentrated product when obtained from the same source.
Juventix Regenerative Medical offers a patent pending LED Photo- Activator to activate the platelets and begin the regenerative process. The activation, a critical step in the release of cytokines and growth factors, is accomplished with light and not with the addition of other chemicals such as Calcium Chloride or Thrombin.
Juventix Regenerative Medical supplies a Bio-Incubator that transforms the Platelet Rich Plasma into an Injectable Platelet Rich Fibrin. The PRF, commonly called the “second generation of platelet products, has a broader range of clinical applications while providing outstanding outcomes.
RESTORE, REVIVE, REGENERATE- JUVENTIX REGENERATIVE MEDICAL
Regenerative Regards,
Dr. Robert McGrath
