Ankle Sprains

What is it?

This is an overstretching or tearing of the ligaments on the outside of the ankle joint and foot.  The ligaments most commonly involved are the anterior talofibular ligament  toward the front of the ankle, the calcaneofibular ligament directly to the outside of the ankle, and less commonly the posterior talofibular ligament toward the back of the ankle.  This is the most common type of ankle sprain, noted as high as 85% of all ankle sprains, and occurs when the foot rolls to the inside with weight bearing activities.  This can occur while hiking on uneven ground especially with a heavy pack or when falling from a boulder problem and landing on the edge of the crash pad.1,2,3  Climbing shoes that are excessively small can also contribute to this injury.4  There has been an increased risk of ankle sprains with bouldering and sport climbing.5

What does it feel like (Symptoms)?

Significant pain and swelling is typically noticed on the outside of the ankle and it may be difficult to walk or bear weight on the ankle.

Prevention

There is a high rate of recurrence after the initial sprain so preventing this injury from occurring is key.  There are four key factors involved with preventing this injury:

  1. Range of motion and flexibility:  Assess and address as needed any differences between the left and right ankles for dorsiflexion, plantarflexion, inversion, and eversion range of motion as well as gastrocnemius and soleus flexibility. (See below)  A lack of dorsiflexion specifically has been shown to increase the risk of spraining the ankle.1,3
ankle dorsiflexion – pull your toes towards your nose
Repeat 10 times, 3-4 times/day in a pain free range.
ankle eversion – move your foot up and out
Repeat 10 times, 3-4 times/day in a pain free range.
ankle inversion – move your foot towards the big toe side
Repeat 10 times, 3-4 times/day in a pain free range.
ankle plantaflexion – push your toes down like you are pushing down on the gas pedal
Repeat 10 times, 3-4 times/day in a pain free range.
gastrocnemius stretch – keep the back knee straight and shift your weight forward until you feel a stretch in the back calf
Hold for 30 seconds and repeat 2-3 times, 2-3 times/day in a pain free range.
soleus stretch – bend the back knee and shift your weight down into the back foot until you feel a stretch in the back calf
Hold for 30 seconds and repeat 2-3 times, 2-3 times/day in a pain free range.

2. Strength:   Assess and address as needed any differences in ankle eversion, inversion, and plantarflexion as well as hip abduction and extensor strength (see below).1,3

ankle eversion strengthening – move your foot up and out
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range.
ankle inversion strengthening – move your foot towards the big toe side
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range.
single leg heel raise – raise up onto the ball of your foot
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range
hip abduction strengthening – move your leg out to the side and return to midline
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range. Feel free to add resistance.
hip extension strengthening – move your leg back and return to neutral
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range. Feel free to add resistance or try a single leg bridge instead.

3. Balance and proprioception:   Proprioception is a joint’s ability to tell where it is in relation to the rest of the body.  Deficits with proprioception can cause the foot to land in a way that increases the chance of a sprain while walking, hiking, or landing from a boulder.6  The best exercises to address this issue are performed while standing on one leg.  The progression of these exercises from easiest to hardest is to stand on one leg on even ground with the eyes open for 60 seconds.  If this is easy, try either closing the eyes or standing on an uneven surface such as a wobble board, Bosu ball, or better yet: a slack line. As this becomes easier, stand on the uneven surface with the eyes closed.  Adding a single leg quarter squat to this can make it even more challenging.1-3,7-9

single leg stance – close eyes or stand on an uneven surface to make more challenging
Hold for 60 seconds, repeat 2-3 times, 3-5 times per week.
single leg quarter squat – stand on 1 foot and squat down in a pain free range making sure your knee is in line with your toes and your pelvis stays horizontal (doesn’t tip down when lowering)
Repeat 10-15 times, 2-3 sets, 3 times per week in a pain free range.

4. Crash pad positioning:   Spotters should always have a sense of where the climber will fall and to place the pad so the climber will fall in the middle of the pad as opposed to on the edge.  While in the gym or outside, make sure all the pads are connected and there are no spaces where the climber’s foot could land in between pads.

Treatment

This injury should be medically evaluated to determine the extent of the injury including any fractures or dislocations.  The Ottawa Ankle Rules were developed to determine if an X ray is necessary.20, 21   An X ray is indicated if any of the following are present:
1. bony tenderness along the back side of the bottom part of the fibula or lateral malleolus
2. bony tenderness along the back side of the bottom part of the tibia or medial malleous
3. bony tenderness at the base of the 5th metatarsal
4. bony tenderness at the navicular
5. Unable to walk at least 4 steps

bones of the foot and ankle

The use of crutches (or walker/cane) and functional support using a brace, wrap, or taping while gradually increasing weight bearing may be required if the pain is causing significant limping.  In an acute injury situation, pain is the body’s way of telling you what to do or not do in order to allow it to heal.  Inflammation is a crucial phase of the healing process, where dead or damaged tissue is removed and special cells are called on to lay down new tissue.  Research is showing that blocking the inflammatory phase of the healing process (with NSAIDS, for example) can actually slow the healing of bone and soft tissue.11-19  That being said, decreasing pain and inflammation should be considered for the first 3 days after the injury if 1. pain is preventing you from sleeping (check here for the importance of sleep) 2. pain is unbearable (stress hormones will be released which can slow the healing process) or 3. there is extreme swelling, theoretically damaging healthy tissue that wouldn’t have been damaged due to the injury.

There is a high rate of recurrence after an initial ankle sprain and many people develop chronic ankle instability, so it is important to address any of the key factors that may be limited due to an ankle sprain including:2

  1. Range of motion/flexibility:    Assess and address as needed any differences between the left and right ankles for dorsiflexion, plantarflexion, inversion, and eversion range of motion as well as gastrocnemius and soleus flexibility. (See figures in the prevention section above as well as a figure below for a  stretch for the tibialis anterior muscle.)  Also, practice tracing the alphabet in uppercase letters with your foot.1-3  When these motions have been regained with minimal pain, strengthening can be initiated.
tibialis anterior stretch – point your back toes down and straighten your knee
Hold for 30 seconds, repeat 2-3 times, 2-3 times per day, 3-5 times per week

2. Strength:   Assess and address as needed ankle eversion, inversion, and plantarflexion as well as hip abduction and extension strength (See the figures in the prevention section above).1-3  Progress to the single leg stance and single leg quarter squats as seen in the prevention section above and add the following lunge.

Forward lunge – step forward, drop straight down, return to start, repeat on the other side
Repeat 10-15 times, 2-3 sets, 3 times per week in a pain free range

After these exercises can be performed pain free, squat jumps can be added with progressively increasing the height of the jumps and advancing from two legs to single leg as strength increases. These exercises will help the climber prepare for landing while bouldering.
3. Balance and proprioception: See details under the prevention section above
4. Trigger points:   Check for any trigger points, especially of the peroneal muscles as stated above

peroneal trigger points
peroneal self trigger point/myofascial release
Hold gentle-moderate direct pressure for 2-3+ minutes on any area that feels tight or tender and feel for a release
Repeat 2-3 times per day

 

5. Functional support:   Bracing and taping for stability have both been shown to decrease the risk of recurrence after the initial ankle sprain.2,3
6. Joint mobility:   Joint mobilizations, including mobilizations with movement, typically performed by a physical therapist, chiropractor, or osteopath, have been shown to be beneficial when range of motion is difficult to regain.1,3,10

 

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

1 Kaminski TW1, Hertel J, et al; National Athletic Trainers’ Association. National Athletic Trainers’ Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013 Jul-Aug;48(4):528-45.
2 Chinn L, Hertel J. Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med. 2010 Jan;29(1):157-67, table of contents.
3 Lin CW1, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010 Mar;18(1):22-8.
4 Buda R1, Di Caprio F, et al. Foot overuse diseases in rock climbing: an epidemiologic study. J Am Podiatr Med Assoc. 2013 Mar-Apr;103(2):113-20.
5 Schöffl V, Küpper T. Feet injuries in rock climbers. World J Orthop. 2013 Oct 18;4(4):218-228. eCollection 2013. Review.
6 Sefton JM1, Yarar C, et al. Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2011 Feb;41(2):81-9.
Herman K, Barton C, et al. The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC Med. 2012 Jul 19;10:75. doi: 10.1186/1741-7015-10-75. Review.
Schweizer A1, Bircher HP, et al. Functional ankle control of rock climbers. Br J Sports Med. 2005 Jul;39(7):429-31.
McKeon PO1, Ingersoll CD, et al. Balance training improves function and postural control in those with chronic ankle instability. Med Sci Sports Exerc. 2008 Oct;40(10):1810-9.
10 Travell J, David S. Myofascial Pain and Dysfunction, Vol 1: The Trigger Point Manual. Williams and Wilkins, Baltimore, 1983. pp.355-367.
11 Skjong CC1, Meininger AK, Ho SS. Tendinopathy treatment: where is the evidence? Clin Sports Med. 2012 Apr;31(2):329-50.
12 Hess GP, Cappiello WL, Poole RM, et al: Prevention and treatment of overuse tendon injuries. S p o r t s M e d 8 : 371–384, 1989.
13 Bondesen BA1, Mills ST, et al. The COX-2 pathway is essential during early stages of skeletal muscle regeneration. Am J Physiol Cell Physiol. 2004 Aug;287(2):C475-83.
14 Lu H1, Huang D, et al. Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. FASEB J. 2011 Jan;25(1):358-69.
15 Arnold L1, Henry A, et al. Inflammatory monocytes recruited after skeletal muscle injury switch into antiinflammatory macrophages to support myogenesis. J Exp Med. 2007 May 14;204(5):1057-69.
16 Smith C1, Kruger MJ, et al. The inflammatory response to skeletal muscle injury: illuminating complexities. Sports Med. 2008;38(11):947-69.
17 Mishra DK1, Fridén J, et al. Anti-inflammatory medication after muscle injury. A treatment resulting in short-term improvement but subsequent loss of muscle function. J Bone Joint Surg Am. 1995 Oct;77(10):1510-9.
18 Cottrell, and O’Connor, P. Effect of Non-Steroidal Anti-Inflammatory Drugs on Bone Healing. Pharmaceuticals, Vol 3, No 5, 2010.
19 Magra M, Maffulli N. Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe. Clin J Sport Med. 2006 Jan;16(1):1-3.
20 Kerkhoffs GM1, van den Bekerom M, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012 Sep;46(12):854-60.
21 Vuurberg G1,2,3, Hoorntje A, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018 Aug;52(15):956.

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