Ankle injuries represent one of the most common forms of injury within both the general population and athletic population. They can be acute injuries, such as an ankle sprain or fracture, but they can also be chronic over-use type injuries, such as tendinopathies and inflammatory conditions.
An injured ankle can also lead to many problems down the road (Hiller et al, 2016), including chronic pain and/or altered function. Understanding the differences between the multitude of ankle injuries can lead to an accurate diagnosis of the injury, ultimately leading to the development of an optimal rehabilitation program to ensure full recovery and mitigation of future injuries.
A visit to your local physiotherapist is highly advised if you suspect you sustained an ankle injury, as their knowledge and expertise will provide a safe and effective approach to treatment. Nevertheless, this article will discuss some of the most common ankle injuries and the general approach to treatment for those injuries.
What is the most common ankle injury and why?
The most common ankle injury is a lateral ankle sprain, also known as an inversion ankle sprain. In a study conducted by Fallat et al (1998), they found that a lateral ankle sprain represented 71.7% of total injuries assessed in a group of 693 individuals with an average age of 34 years who reported twisting their ankle in an acute fashion.
There are numerous ligaments on the outside of the ankle that are commonly injured in a lateral ankle sprain. This study showed that they are rarely injured in complete isolation. For example, the anterior talofibular ligament (ATFL), which is commonly regarded as one of the most vulnerable ligaments in the body, was injured in isolation 16% of the time during a lateral ankle sprain, followed by the posterior talofibular ligament (PTFL) being injuried in isolation 2% of the time, and the calcaneofibular ligament (CFL) being injured in isolation 1% of the time. Compare this with the ATFL and CFL being injured together 34% of the time, and all three ligaments being injured together 31% of the time.
The reason that a lateral ankle sprain is the most common ankle injury is multifactorial, and as such, there is no single answer to this. However, there are some aspects of the ankle that lead to slightly more vulnerability compared to other joints in the body.
The base of support during single leg stance is quite small – it’s the area of the foot that has direct physical contact with the ground. Now consider the fact that an entire person’s body weight is moving over top of the foot and ankle joints and the ankle has to help control this motion without moving into the extremes of range of motion.
This is a fairly difficult task that we take for granted in everyday life, but especially with rapid change-of-direction movements or on uneven surfaces. Consider someone who is running and plants their foot to change direction. Typically, that foot will be planted in order to allow for a push-off in the opposite direction, which requires substantial resistance to inversion. If the muscle and tendons that resist inversion cannot withstand the load, they will fail, and a sprain occurs resulting in damage to the lateral ankle ligaments and potentially bones as well.
Furthermore, the range of motion available for ankle inversion, which is the movement that occurs during a lateral ankle sprain or “rolling the ankle”, is about double what is available for eversion. This motion primarily occurs at the subtalar joint, which is the articulation between the talus and the calcaneus (heel bone).
The talocrural joint, which is the ankle joint above the subtalar joint and primarily responsible for dorsiflexion and plantarflexion, has geometry such that it inherently resists eversion in a standing position, but not as much for inversion (Brockett and Chapman, 2016).
A sprained ankle is typically treated conservatively, meaning physiotherapy is one of the primary options. Treatment usually focuses on providing an optimal healing environment and gradually restoring ankle range of motion in the early stages.
As recovery continues, strengthening of the peroneal muscles, which reinforce the outside of the ankle, as well as strengthening numerous other muscles that provide general ankle stability, will be a high priority. This is especially important in recurring ankle sprains associated with increased laxity of the lateral ankle ligaments following injury, which is why balance exercises are often introduced as soon as safely possible.
This strengthening may start in a non-weight bearing fashion with resistance bands to begin with, and then gradually progress to more functional activities that incorporate movement of the entire body over the injured ankle in a weight-bearing capacity.
For athletes, re-training sport-specific movements will be required in the advanced phases of rehab, and balance and proprioception will be highly important as well, especially if uneven surfaces are involved in the task demands.
Other Ankle Sprains
While a lateral ankle sprain is by far the most common soft tissue injury in the ankle, it’s definitely possible to injure other ligaments in the ankle as well. High ankle sprains, also knowns as syndesmotic ankle sprains, are the next most common type of sprained ankle especially in athletes, followed by medial ankle sprains (Doherty et al, 2014).
High ankle sprains involve injury to the anterior inferior tibifibular ligament (AiTFL), the posterior inferior tibiofibular ligament (PiTFL), and/or the tibiofibular syndesmosis. These ligaments are more vulnerable to forced dorsiflexion of the ankle, particularly when combined with external rotation of the foot.
The mechanism of injury for a high ankle sprain is forced dorsiflexion and external rotation of the foot, particularly in a weight-bearing position. This mechanism of injury often occurs in contact sports whereby an athlete will have their foot planted in a dorsiflexed position and they either twist or someone falls on the back/outside of their leg. If the damage is severe, treatment will often require 4-6 weeks in a walking boot, followed by restoration of range of motion, strength, and functional movement patterns, similar to the general process of rehabbing a lateral ankle sprain.
A medial ankle sprain occurs with forced eversion of the ankle and involves injury to the deltoid ligament, which can happen when the foot is planted with the foot in an externally rotated position and the body moving over top of the foot. It can also occur in sports when the foot is planted and someone falls more on the inside of the leg. In daily life, this may happen if slipping off a step or curb where the outside of the foot is still in contact, forcibly opening up the inside of the ankle.
Medial ankle sprain treatment is very similar to lateral ankle sprain treatment, just with more of a focus on the ligaments and muscles on the inside of the foot and ankle. Treatment is still largely conservative with a focus on restoring strength and mobility, especially in a manner specific to the demands on that individual’s ankle.
An ankle fracture, also known as a “broken ankle”, is also a very common ankle injury. Fractures often occur with a similar mechanism of injury as a sprained ankle. In this case, the load exceeds the bone’s capacity, resulting in structural deformation of the bone.
The fibula is the most commonly fractured ankle bone (Jindal et al, 2016). It can be fractured in isolation, or if associated with a sprained ankle, can sometimes come in the form of an avulsion fracture, whereby the ligament or tendon pulls away from its attachment site bringing a piece of bone with it.
Broken bones are typically sustained with trauma, rather than being considered osteoporotic types of fractures. In addition to simply experiencing enough force on the bone for it to fracture, increased body weight and/or BMI has shown to be a likely risk factor in the sustainment of a broken ankle, as this will increase the force applied to the ankle during a fall (Greenfield and Eastell, 2001).
If an ankle fracture is severe enough, a surgeon may elect to perform an open reduction internal fixation (ORIF) on the broken bone. This is a common procedure to fix fractures, and in the simplest of terms, uses rods, plates, and/or screws to fixate the fracture allowing it to heal appropriately. In some cases, the hardware is eventually removed in subsequent surgery, but sometimes it’s not, and this is often determined by the patient’s preferences.
Otherwise, ankle fractures are treated in a similar manner as sprains; however, much more caution is practiced for the first 8-12 weeks, which is a typical healing timeline of a fracture in a healthy individual. The early stages often involve non-weight bearing exercises that limit the stress on the healing bone. Once the fracture is both clinically healed (i.e. can push on it and it doesn’t hurt), as well as healed on x-ray, then physical therapy becomes a little more fun with interesting and fitness-oriented exercises.
Tendinopathies are another set of very common ankle injuries that often afflict active individuals, especially those who experience sudden increased in activity. This can include the weekend warrior who is taking advantage of the Spring weather to get back into running, as well as elite athletes who rest during the offseason and then return to full training regimes. Of all foot and ankle injuries recorded, tendinopathies account for approximately 9% of injuries requiring missed time from a sport in elite college athletes (Hunt et al, 2012).
Achilles tendinopathy is the most common type of tendinopathy in the ankle, and prevalence of this injury tends to increase with age. This injury can cause pain in the Achilles tendon, with the pain located at its insertion point on the posterior aspect of the calcaneus (heel bone), and even higher up in the calf muscle (Wang et al, 2022).
Achilles tendinopathy typically caused by repetitive loading, especially if there is a sudden increase in activity, or if it is combined with a high rate of loading, and can ultimately be a risk factor for sustaining an Achilles tendon rupture. As such, Achilles tendinopathy is common in sports like gymnastics, long distance running, track and field, and basketball (Want et al, 2022).
Tendinopathies of the foot and ankle, especially Achilles tendinopathy, are typically treated through physiotherapy. The goal is to strengthen the tendon in order to withstand the load placed on it, while also allowing the tendon to heal and organize its collagen fibers in a manner that is conducive to withstanding load. A strategic calf and Achilles strengthening program can allow for symptom reduction and mitigation of future injuries, and as such, represents the primary method of treatment for this common ankle injury (Habets et al, 2017).
Plantar fasciitis, sometimes known as policeman’s heel, is similar to a tendinopathy, but involves the connective tissue on the sole of the foot. This is a passive tissue, meaning it cannot be actively contracted like a muscle. It runs from the heel of the foot to the forefoot, and acts as a tensile support for the arch of the foot. As such, it experiences some amount of stress and strain with walking. It is estimated that approximately 4-7% of the population will experience plantar fasciitis (Luffy et al, 2018).
The plantar fascia is actually quite robust and is also protected by a thick layer of dense subcutaneous tissue. While it is equipped with the necessary material properties to withstand typical loads experiences during walking and running, a sudden increase in activity that stresses the plantar fascia, or repetitive activities with reduced rest and/or relative weakness around the ankle, can lead to pain and dysfunction within the plantar fascia, ultimately leading to pain on the heel or bottom of the foot.
Plantar fasciitis is typically treated conservatively to begin with. Physiotherapy will include strategies for short term pain relief, for example, soft tissue release, or self-management strategies at home like rolling on a frozen bottle of water. Additional modalities in the clinic can also have a beneficial effect, such as shockwave therapy and dry needling. Additionally, it’s often advised to wear shoes with good medial arch support or comfortable orthotics
A combination of calf stretching with a plantar fascia focus and strengthening of the ankle and foot intrinsic muscles represents a more long term solution to minimizing pain. This will enable the individual to support the plantar fascia, ultimately allowing it to heal, but also building resiliency for longer term injury prevention. Muscles like the foot intrinsics, tibilias posterior and anterior, flexor hallucis longus, gastrocnemius and soleus, among others, are typically targeted during rehab.
Muscle strain are very common injuries in general. When the load placed on a muscle exceeds its capacity to withstand that load, structural damage to the muscle fibers occurs, which is why many people call it a “torn muscle” or “pulled muscle”. Pain will then occur with active contraction and passive stretching of the muscle.
With regards to the ankle joint, the most commonly strained muscle group is the calf, with strains occurring either in the gastrocnemius, soleus, plantaris, or a combination of those muscles. Additionally, the Achilles tendon can also be strained. This would be more of an acute injury, as opposed to something more chronic like a tendinopathy. In it’s most severe form, a full Achilles rupture can occur, whereby it is fully torn and surgery may be required.
Calf strains are more common with increasing age and in those with previous calf injuries (Green and Pizzari 2017). They can occur during daily activities, but more often than not, they are associated with sporting injuries, particularly sports involving running or a high rate of loading, such as jumping. If the muscle is overstretched, or if the transition from lengthening to contracting is too rapid, the muscle or tendon may become damaged.
In addition to calf strains, peroneal strains can be common especially when a laterally sprained ankle occurs. Given the peroneal muscles support the lateral ankle and reinforce the ATFL/CFL/PTFL ligaments, excessive inversion may damage multiple structures that resist this motion. For example, someone with a torn ATFL may also report pain and weakness in the peroneal muscles or tendons.
The general treatment strategy for muscle strains is physiotherapy. A progressive approach to strengthening may be implemented. For example, sub-maximal contractions of the affected muscle in a non-lengthened position, followed by strengthening through a comfortable range, and eventually training the muscle to perform contractions specific to the individual’s task demands, such as return to sport or work.
The above ailments represent some of the most common ankle injuries in the general population and sporting population alike. This information can help to understand previous, current, or future injuries, which may come in handy when looking for the appropriate treatment options.
Overall, lateral ankle sprains are easily the most common ankle injuries, but nevertheless, consulting with a physiotherapist in person can help identify the severity of injury and allow for the development of an optimal treatment plan.
While less common, the other ankle injuries listed are often seen in clinical settings with a wide array of causes, afflicting the Average Joe or the elite athlete. All of these injuries can be treated conservatively, except for rare and severe cases that occasionally require surgery or other medical intervention.
For more detailed information on these injuries, feel free to check out our other articles that dive into the specifics of assessment and treatment for these ankle injuries.
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