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Ligaments link bones to other bones and provide support to joints. They allow a normal
range of movement to occur within a joint, but prevent unwanted movement that would
render the joint unstable. In order to fulfill this function ligaments must possess immense
mechanical tensile strength. Ligaments are classified as dense connective tissue, and they
consist of a protein substance called collagen. The organisation of collagen fibres gives
the ligament its tensile strength.
Another function of ligaments is to provide proprioceptive input to the brain that allows a
person to know what position the joints are in, without having to look. This helps to
perform the complex coordinated activities needed for sport.
A normal ligament consists of:
90% Type 1 collagen
9% Type 3 collagen
1% fibroblast cells (the cells that produce collagen)
Type 1 collagen is mature collagen tissue and has the greatest tensile strength. Type 3
collagen is immature collagen tissue and does not provide a great deal of tensile strength
to the ligament. After being laid down by fibroblast cells it takes approximately three
months for Type 3 collagen to mature into Type 1 collagen. As with other cells in the
body, this process of renewal occurs continually.
When ligament tissue is examined under the microscope (see diagram) it can be clearly
observed that the collagen fibres are arranged in a longitudinal pattern to resist the stress
that is placed upon the ligament. The arrangement of the collagen fibres means that a
great deal of force is required to damage ligaments. In a collision sport like football this
force is generated by opposition players or when a player catches his foot in the turf and
his whole body weight goes over one joint. This force produces structural damage to the
joint capsule and ligaments, which is known as a ligament sprain.
Ligament sprains are classified as follows:
GRADE 1 SPRAIN There is damage to a few collagen fibres, producing a local
inflammatory response. This is characterised by pain over the affected ligament.
GRADE 2 SPRAIN There is damage to a more extensive number of collagen fibres. This
produces a more marked inflammatory response characterised by intense pain and joint
effusion (swelling).
GRADE 3 SPRAIN The damage to collagen fibres is such that there is a complete
rupture of the ligament. This produces intense pain, joint effusion and marked joint
instability. Surgery may be necessary to restore joint stability.
As with other soft tissue injuries, ligament healing consists of inflammation followed by
repair and then remodelling.
INFLAMMATORY PHASE
The inflammatory phase follows trauma to collagen fibres and lasts for 3-5 days,
depending on the severity of the injury. Chemicals are released which produce pain, and
there is bleeding in the tissues. This, together with fluid from damaged cells, produces
swelling within the joint, putting pressure on nerve endings and causing more pain.
Rehabilitation time can be greatly reduced by appropriate treatment in this acute stage.
This consists of protecting the injured part from further damage (e.g. the use of crutches),
rest from activity involving the injured part, ice (never apply ice directly to the skin),
compression, elevation and the administration of anti-inflammatory medication.
REPAIR PHASE
The repair phase is mediated by blood clotting over the damaged tissue. Blood platelets
form a mesh to initiate healing. Also present in the blood clot are fibroblast cells, which
proliferate and begin to lay down Type 3 (immature) collagen tissue, between 3-21 days
after the injury. The use of electrotherapy in this phase has been shown to encourage
fibroblast activity that ultimately provides a structurally stronger ligament.
REMODELLING PHASE
The remodelling phase follows the repair phase and can last for up to a year. It involves
maturation of collagen tissue from Type 3 to Type 1 and realignment of collagen tissue.
When it is first laid down, the collagen tissue is haphazard and does not possess a lot of
tensile strength. The ligament gradually becomes stronger through being subjected to
controlled strain in a functional pattern, which aligns the fibres in a longitudinal fashion.
Physiotherapy, in the form of controlled exercises progressing to functional activity, aid
this process of remodelling.
Because the remodelling phase lasts for up to a year, there is a potential weakness in the
ligament and a risk of re-injury. This risk is reduced by providing additional stability with
a strapping, increasing the strength of muscles which also provide support to the joint,
and by doing proprioceptive exercises to increase the patient's sense of joint positioning.
First 3 days healing: If the pain allows, the ankle is pumped forward and back 20 times
each hour. This is done by sitting down with the leg elevated and pushing the toes
forward and back. This facilitates the dispersal of swelling from the ankle. Electrotherapy
treatments such as ultrasound and pulsed short wave diathermy are effective in speeding
the healing process.
Days 3-14: The sub-acute stage begins by bearing weight on the ankle to pain tolerance.
This is graduated from partial weight-bearing with crutches to full weight-bearing
without crutches. A normal walking pattern should be encouraged and there should be no
limping.
Ice treatment is discontinued, but compression bandages are continued to encourage the
dispersal of swelling. When possible the ankle is elevated. Electrotherapy treatment is
continued and augmented with gentle massage to encourage the dispersal of swelling
towards the back of the knee.
Ankle pumping exercises are continued and progressed to being done in water. Exercises
in water are effective because they involve only partial weight-bearing and because the
hydrostatic pressure provided by the water has the effect of encouraging the swelling to
disperse.
Days 15-21: http://www.physioroom.com/injuries/foot/ankle_sprain_exer3.shtml
Days 22-28: Progressive strengthening of the muscles around the ankle should be
continued, as should the proprioceptive exercises. To prepare for a return to functional
activities the intensity of exercise should be increased.
Basic plyometric exercises should be commenced - see our guide to plyometric exercises
>
Jogging should also commence, and should be progressive as follows:
DAY 1 Jog 100 metres, walk 50 metres, with 6 repetitions.
DAY 2 Jog 150 metres, walk 50 metres, with 6 repetitions.
DAY 3
Jog 200 metres, walk 50 metres, with 8 repetitions.
DAY 4 Jog 200 metres, walk 50 metres, with 12 repetitions.
DAY 5 Jog 2000 metres.
Days 28+:
The progression to functional activities can begin once the patient can jog without pain
and is comfortable doing plyometric drills. The idea of this stage is to progress from
gentle exercise to the high intensity at which games are played. All exercises are
preceded by a warm up. As each exercise is a progression they should be completed at
least one day apart.
EXERCISE 1
Variable pace running with the gradual introduction of turns.
This involves running round a 20m diameter figure-of-eight course.
The figure-of-eight course puts very gentle stress on the ankle and
prepares the player for later turning drills. The pace is limited to
walk, jog or half pace running and is determined by the
physiotherapist who shouts out the desired pace. The physiotherapist
also shouts the commands stop and start. This re-introduces the
player to the variable demands of a game of football.
The session should last about 25 minutes.
EXERCISE 2
Variable pace running with gradual turns and various starting
positions.
The player starts at one end of the course and makes a 30m run up to
a 20m diameter semicircle, around which they gently turn before
completing another straight 30m run back to the finish. The pace of
the run is dictated by the physiotherapist and is either a jog or half
pace. The starting position should be different for each run (standing,
lying on back, lying on front, sprint start position, squatting, right
side lying, left side lying, jumping, hopping, facing backwards).
The patient should aim to complete 20 runs.
EXERCISE 3
A progression of exercise 1 - variable pace running with slightly
tighter turns.
Run round a 10m diameter figure-of-eight course. The figure-ofeight course puts stress on the ankle and prepares the player for later
turning drills. The paces used are walking, jogging, half pace
running, and three-quarter pace running, as determined by the
physiotherapist who shouts out the desired pace. The physiotherapist
also shouts the commands stop and start.
The session should last about 25 minutes.
EXERCISE 4
A progression of exercise 2 - variable pace running with gradual
turns and various starting positions.
The player starts at one end of the course and makes a 30m run up to
a 20m diameter semicircle, around which they gently turn before
completing another straight 30m run back to the finish. The pace of
the run is either three-quarter or full pace, as dictated by the
physiotherapist. The starting position should be different for each run
(standing, lying on back, lying on front, sprint start position,
squatting, right side lying, left side lying, jumping, hopping, facing
backwards).
The player should aim to complete 20 runs.
EXERCISE 5
Two 5m diameter circles are placed 30m apart. Travelling at full
pace the player makes a run, with a football at the feet, goes around
the far circle and then back to the finish.
This should be repeated 20 times.
EXERCISE 6 As exercise 5, but single cones are used instead of 5m diameter
circles.
EXERCISE 7
Six cones are placed 5m apart in a straight line. The player completes
a shuttle run, at full pace, turning alternately to the left and right.
This should be repeated 10 times.
Before a gradual return to full training is considered, the patient should be happy with all
normal ball work drills, all types of passing (instep, side foot, front foot, outside of foot,
side foot volley, laces volley, half volley) over all distances, heading, jumping and
heading, and tackling.
Ankle & Foot > Sprained Ankle
summary > full article rehabilitation >
THE INJURY
A sprained ankle is one of the most common injuries caused by participation in sports. It
refers to soft tissue damage (mainly ligaments) around the ankle, usually caused by an
inversion injury (where the ankle is twisted inwards) or an eversion injury (where the
ankle is twisted outwards).
Because of the position of the bones around the ankle, the inversion injury is far more
common. This injury causes damage to the lateral ligaments on the outside of the ankle.
The most commonly injured ligament is the anterior talofibular ligament which, as the
name suggests, joins the fibular and talus bones together. If the force to the ankle is more
severe, the calcaneofibular ligament (between the calcaneus and fibula) is also damaged.
The posterior talofibular ligament is very rarely damaged in comparison to the other two
ligaments.
In the case of an eversion injury the damage occurs on the medial (inside) of the ankle.
The ligament on the inside of the ankle is called the deltoid ligament and is very strong. It
is so strong in fact that the bone on the inside of the ankle can be pulled off, in what is
called an avulsion fracture, before the ligament is damaged.
As well as damage to the ligaments, the capsule which surrounds the ankle joint is also
damaged. The damage causes bleeding within the tissues and the ankle begins to swell up
and can be extremely painful.
Ankle sprains can be classified as follows:
First degree, where only a few ligament fibres are damaged
Second degree sprain refers to more extensive damage to the ligament with associated
swelling
Third degree sprain refers to a complete rupture of the ligament with swelling and a
possible joint dislocation
In the more severe injuries there may be associated bone injury and it is wise to get an xray to determine whether there is a fracture.
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SIGNS AND SYMPTOMS
With a first degree sprain there is pain when turning the foot in or out and also pain when
the damaged area is touched. With a second degree sprain the pain is more severe, there
is swelling all around the area and it is painful to walk. With a third degree sprain the
pain is excruciating and walking is impossible. There is gross swelling and there may be
deformity if the ankle is dislocated.
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TREATMENT
In the first 48-72 hours following the injury it is important the follow the RICE protocol rest, ice, compression and elevation (never apply ice directly to the skin). Ice packs for a
period of twenty minutes every couple of hours may help with the pain but pain-relieving
medication may also be necessary. It is important not to put too much weight on the
damaged ankle, so walking should be avoided if possible.
Where a fracture is suspected an x-ray should be carried out at an accident and
emergency department. If a fracture is found or a Grade Three sprain is diagnosed, the
advice of the attending doctor should be followed. It should be borne in mind that some
hairline fractures do not show up on x-ray until about 10-14 days after the injury, so if the
pain persists medical attention should be sought.
In the case of a Grade Two sprain, crutches should be used to protect the injured ankle.
However, it is important not to be on the crutches for longer than necessary and as soon
as the pain allows the patient should begin to gently put weight through the ankle by
walking.
In the early stages of the injury, ultrasound treatment is effective in encouraging the
healing process and encouraging the formation of scar tissue to repair the ligament.
Ligament damage and repair >
Once the patient is able walk on the ankle, more active rehabilitation can be started.
In ankles that have been repeatedly sprained there is an inherent weakness which may
require surgery. This can now be done arthroscopically where a camera is inserted into
the ankle and flakes of bone and excess scar tissue can be removed.
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PREVENTION
The most effective method of preventing ankle sprains is by improving the muscular
support around the ankle through plyometric training. These exercises combine speed of
movement with strength. The effect of the exercises is to improve the reaction time of the
nervous system. This increases the reaction times of the muscles which stabilise the
ankle, enabling the muscles to contract quicker to correct a twisted ankle before an injury
occurs. However, it is important that these exercises are approached with caution and
they should be started gently.
Basic plyometric drills for ankle strengthening >
Plyometric drills decrease the reaction time of the nervous system in response to external
stimuli. This allows the muscles to contract faster to prevent falling or twisting an ankle.
The technique was first used during the 1960's and 70's by eastern European athletes,
who organised hopping and jumping techniques into specific plyometric drills.
As the athlete plants their foot before jumping, the muscle that will produce the jump is
stretched. As the muscle contracts, the pre-stretched energy is released, producing kinetic
energy (movement) which enhances muscle power. By doing plyometric drills the time
taken for the stretch to be converted into kinetic energy is decreased.
Before initiating plyometric activities there must be a sound strength base, otherwise the
risk of injury is increased. As a general rule the athlete should be comfortable in squatting
60% of their body weight, at a rate of 5 repetitions in 5 seconds, before these exercises
are commenced. The athlete should be able to stand on one leg, with eyes both open and
shut, for 30 seconds and should be able to long jump the distance of their own height.
Ideally, plyometric training should be done under the supervision of a trainer or chartered
physiotherapist.
Once an ankle has been sprained there will always be a slight weakness in the ligament,
although this can be compensated by increasing the muscular stability around the ankle
by practicing the plyometric exercises for ankle strengthening. Support for the ankle can
also be provided externally in the form of straps and braces. In some cases a podiatrist
can provide a functional insert in the sports shoe which tilts the foot in such a way that it
is less likely to twist and cause injury.
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summary > full article rehabilitation >
All figures, marked © Martin Dunitz 2001, have been taken from "Sports Injuries: Their
Prevention and Treatment", 3rd Edn, by Lars Peterson and Per Renstrom, published by
Martin Dunitz Ltd. www.dunitz.co.uk
Recurring Sprains
What is it? Ankle sprains are extremely common. Typically the ankle will twist inwards
(invert) and the ligaments on the outside of the ankle will tear (anterior talofibular
ligaments). The severity of the sprain depends on how much of the ligament tears,
ranging from grade 1 (mild) to grade 3 (complete).
Treatment: Most people will heal after an ankle sprain and with exercises and
rehabilitation will be able to stabilize the joint and prevent recurring sprains. A small
percentage will suffer recurring sprains and the ankle will 'give out' easily, often with a
simple misstep while walking. In these cases surgery may be recommended to repair the
torn ligaments. The most commonly performed repair is called a Brostrom repair and
involves the direct repair and tightening of the original ligament reinforced with other
local tissue.
How to Treat an Ankle Injury
Orthopedic doctors and sports medicine trainers strongly suggest treating most kinds of
ankle sprains using the R.I.C.E. formula. Simply put do the following.
Difficulty Level: Easy Time Required: 48 hours
Here's How:
See a doctor, only a doc and some x-rays can truly evaluate an ankle injury
Rest for 24-48 hours while slowly attempting to put weight on the ankle
Use Ice during the first 48 hours after the injury
Compression is good. Get a wrap, wrap your ankle
Elevate your foot higher than your heart
Tips:
Never ice your injury for more than 20 minutes or place ice directly on the skin
Compression and elevation reduces swelling which will reduce the pain
Take a blood thinning pain killer like aspirin to help reduce the pain and speed healing
Ankle Injuries
The ankle joint supports the body's entire weight. Forces equaling three times the body
weight can impact the ankle while running or jumping. It is the most unprotected of all
the joints. Ankle sprains are the most common sports injury.
Acute ankle injuries include sprains, bone fractures, and joint dislocations. The most
frequent cause of these injuries is an unexpected twist of an ankle. Over 20,000 ankle
sprains occur daily in the United States. A sprain is a stretch, tear, or rupture of one or
more of the ligaments that hold the bones of the ankle joint together.
Severe ankle sprains need medical care and may require x-rays to make sure there is not a
broken bone. Treat sprains with RICE therapy: rest, ice, compression, and elevation.
Apply ice to acute ankle injuries right away. A one-pound package of frozen corn or peas
works nicely because the package molds to the ankle and can be refrozen for re-use later.
Recovery from ankle sprains depends on the degree of the sprain. The recovery period for
mild to severe sprains ranges from 4 to 12 weeks. If the ankle is broken, it may take two
to three months for the bones to heal. You might not be able to return to sports activities
for four months after a broken ankle occurs.
Overuse injuries of the ankle develop slowly. These injuries usually result in irritation of
the long tendons that cross the ankle joint. Overused tendons become irritated, causing
swelling and pain. Excessive sports activity, training mistakes, improper footwear, and
poor form can all cause overuse injuries. If ankle pain occurs whenever you do a certain
sports or fitness activity, it is likely to be an overuse injury.
Early action is key to managing ankle injuries resulting from overuse. Treat overuse
injuries with RICE therapy: rest, ice, compression, and elevation. Take ibuprofen or
aspirin for the relief of pain and inflammation. These medications should not be taken
without approval from your healthcare provider if you have an ulcer, kidney problems, an
allergy to aspirin, or are on a blood-thinning medication.
When all symptoms are gone activity can be gradually resumed. Working the ankle too
early will likely cause re-injury. Remember that recovery can take up to six weeks. Some
conditions may require surgery. After surgery, you generally cannot go back to sports for
12 to 14 weeks.
Use common sense when you exercise. If you feel pain, stop!
Ankle Sprains
The most common type of ankle injury is a sprain. A sprain is stretching and tearing of
ligaments (fibrous bands connecting adjacent bones in a joint.) There are many ligaments
around the ankle and these can become damaged when the ankle is forced into a postion
not normally encountered.
The most frequently seen sprain occurs when weight is applied to a foot which is on an
uneven surface, and the foot "rolls in" (inversion). Because the sole of the foot is pointing
inward as force is applied, the ligaments stabilizing the lateral - or outside - part of the
ankle are stressed. Many patients report hearing a "snap" or "pop" at the time of the
injury. This is usually followed by pain and swelling on the lateral aspect of the ankle.
THE MOST IMPORTANT INITIAL MANAGEMENT OF A SPRAIN IS,
R - rest
I - ice
C - compression
E - elevation
Many of the problems resulting from sprains are due to blood and edema in and around
the ankle. Minimizing swelling helps the ankle heal faster. The RICE regimen facilitates
this.
Rest - no weight bearing for the first 24 hours after the injury (Possibly longer,
depending upon severity)
Ice - apply ice packs using a towel over a plastic bag to the area that is painful. Be careful
to avoid frostbite. Ice should be intermittantly applied for the first 24 hours.
Compression - an ACE bandage or other soft elastic material should be applied to the
ankle to help prevent the accumulaton of edema.
Elevation - elevating the ankle helps in removing edema. By having the foot higher than
the hip (or heart), gravity is used to pull edema out of the ankle.
In the initial 24 hours, it is very important to avoid things which might increase
swelling.
Avoid
hot showers
heat rubs (methylsalicylate counterirritants such as "Ben Gay", etc..
hot packs
drinking alcohol
aspirin - prolongs the clotting time of blood and may cause more bleeding into the ankle.
(Tylenol or Ibuprofen may be taken to help with pain, but will not speed up the healing
process)
WHEN TO SEEK MEDICAL ATTENTION
If the ankle is obviously fractured or dislocated, then medical attention should be sought
immediately. If you are fairly certain that it is sprained then use the RICE regimen and
get a professional opinion regarding diagnosis and treatment. Rice University students are
encouraged to make an appointment with one of the physicians at the student health
service to assess the severity of the injury, determine if X-rays are necessary, and to
receive instruction on proper rehabilitation of the injury.
In some instances a fracture of one of the bones in the leg or ankle may occur along with
a sprain. Pain alone is not necessarily a reliable guide of the presence or absence of a
fracture. Fractures can usually be diagnosed with an X-ray examination.
A student who spains his or her ankle on a Friday night can usually follow the RICE
regimen, and see a physician on Monday or Tuesday.
Because it is not possible to predict or discuss every possible situation that might
arise, it is recommended that the student use common sense in dealing with his or
her injury.
DEGREE OF SEVERITY OF ANKLE SPAINS
Grade I - stretch and/or minor tear of the ligament without laxity (loosening)
Grade II - tear of ligament plus some laxity
Grade III - complete tear of the affected ligament (very loose)
TREATMENT
After the initial 24 hours the patient can begin partial weight bearing using crutches.
Gradually progressing to full weight bearing over several days as tolerated. The patient
should try to use a normal heel-toe gait. An ankle brace may be necessary to protect the
joint from reinjury. As soon as pain allows, rehabilitation exercises should be done.
THE REHABILITATION EXERCISES ARE THE MOST IMPORTANT ASPECT
OF RECOVERING FULL FUNCTION OF THE ANKLE.
A full list of exercises is availble at the student health service. One simple exercise that
can be begun early in the course of treatment is the "alphabet" exercise. This is non
weight bearing and involves trying to draw the letters of the alphabet with your toes.
Most spains heal completely within a few weeks. The more severe the injury, the longer
the time to heal. Often it is necessary to continue rehab exercises for a month or two
following the injury. Grade III injuries are usually managed conservatively rehabilitation exercises, etc. - but a small percentage may require surgery.
The Foot And Ankle
More than 5.3 million visits are made to physicians’ offices each year because
of foot and ankle problems, including 1.6 million visits for ankle sprains and
950,000 visits for ankle fractures. Consider this:
Walking puts up to 1.5 times your bodyweight on your foot.
Your feet log approx. 1,000 miles per year.
As shock absorbers, feet cushion up to one million pounds of pressure during
one hour of strenuous exercise.
How do the foot and ankle work?
Here are some facts from the American Academy of Orthopaedic Surgeons:
Each foot has 26 bones. The ankle bone (talus) and the ends of the two lower
leg bones (tibia and fibula) form the ankle joint, which is stabilized and
supported by three groups of ligaments. Muscles and tendons move the foot and
ankle.
What are the most prevalent foot and ankle injuries?
Ankle sprains. Sprained ankles are one of the most common injuries in sports.
Because the inner ankle is more stable than the outer ankle, the foot is likely to
turn inward (ankle inversion) from a fall, tackle, or jump. This stretches or tears
ligaments; the result is an ankle sprain. The lateral ligament on the outer ankle is
most prone to injury.
Achilles tendon injury. The strongest and largest tendon, the Achilles tendon
connects muscles in the lower leg with the heel bone. Sports that tighten the calf
muscles, such as basketball, running and high-jumping can overstress this
tendon and cause a strain (Achilles tendinitis) or a rupture. A direct blow to the
foot, ankle, or calf can also cause it.
Overuse injuries. Excessive training, such as running long distances without
rest, places repeated stress on the foot and ankle. The result can be stress
fractures and muscle/tendon strains.
Shin splints. Pain in front of the shin bone (tibia) usually is caused by a stress
fracture, called shin splints. Overtraining, poorly fitting athletic shoes, and a
change in running surface from soft to hard puts athletes at risk for this injury.
What activities make people most susceptible to foot and ankle injuries?
Athletes who jump risk ankle sprains because they can accidentally land on the
side of their foot. Extensive running, exercise, or training also can overstress the
ligaments, leading to injury. Contact and kicking sports expose the foot and
ankle to potential trauma—direct blows, crushing, displacement, etc. Especially
prevalent in football, hockey, and soccer—trauma can dislocate a joint, fracture
a bone, stretch or tear ligaments, or strain muscles and tendons.
What other factors make people susceptible to foot and ankle injuries?
Improperly fitting shoes or improper footwear for a particular sport can damage
your feet. Training errors, i.e., running up hills, or running on bumpy roads,
predispose you to serious sprains and strains. If you start a new sport without
proper conditioning, you are at risk.
How are foot and ankle injuries treated?
Most sprains and strains are initially treated with rest, ice, compression, and
elevation. Moderate and severe sprains and strains are often immobilized with a
cast or splint. Severe fractures often require surgical repair.
No one is immune from these injuries, but the American Academy of
Orthopaedic Surgeons developed these tips to help reduce your injury risk:
Warm up before any sports activity, including practice
Participate in a conditioning program to build muscle strength
Do stretching exercises daily
Listen to your body: never run if you experience pain in the foot or ankle.
Wear protective equipment appropriate for that sport
Replace athletic shoes as soon as the tread or heel wears out
Wear properly fitting athletic, dress, and casual shoes
Basketball ankle injuries - this massive Australian enquiry tries to get to the bottom of
ankle injuries in basketball
Since studies carried out with basketball players show that over half of the time missed
from practices and games is due to ankle injury ('A Comparison of the Injuries Sustained
by Female Basketball and Netball Players,' Australian Journal of Science and Medicine in
Sport, vol. 28, pp. 12-17, 1996), it's clear that players, coaches, and team doctors need to
identify the key risk factors for ankle injuries and develop strategies to limit the
likelihood of ankle damage during play.
Traditionally, researchers have suggested that ankle injury history, ankle taping, ankle
bracing, playing-shoe construction and quality, warm-up strategy, and position played on
the court (forward, guard, centre) all play a role in determining whether an injury will
occur, but no one has known which of these factors are most important (or even if all of
the factors really do have an impact on the likelihood of injury).
To gain more understanding of how ankle injuries occur and how they can be prevented,
researchers at three universities in Australia recently observed 10,393 basketball players
(3421 men and 6972 women) during competition. 78 % of these athletes were
recreational players, while 22 % qualified as 'elite' (i. e., able to play successfully on
competitive teams, rather than merely during informal games). The athletes averaged two
games a week, and an injury was defined as 'an action in which a player perceived that
bodily harm had been sustained necessitating stoppage of play, substitution, or a display
of obvious disability' ('Ankle Injuries in Basketball: Injury Rate and Risk Factors,' British
Journal of Sports Medicine, vol. 35, pp. 103-108, 2001).
The rate of ankle injury turned out to be 3.85 per 1000 participations (about one injury
for every 260 games). The average time missed due to injury was 2.2 weeks, and 46 % of
the injuries prevented players from returning to action for one week or more.
Interestingly enough, almost half of the ankle injuries were sustained during landing, with
half of these injuries (about 25 % of the total) occurring as a result of landing on another
player's foot. Sharp twists or turns (30 %), collisions (10 %), falls (5 %), sudden stopping
(2.5 %), and tripping (2.5 %) accounted for the other ankle injuries.
As it turned out, a history of ankle injuries was the best predictor of ankle injury. In fact,
players who had previously injured an ankle were almost FIVE times more likely to
injure an ankle during the study period, compared to previously uninjured athletes. 73 %
of the players who reported an ankle injury during the research had suffered a previous
ankle problem (the average number of prior injuries was 3.5). In contrast, a random
sample of players who were uninjured during the study revealed that just 33 % had at one
time suffered at least one ankle injury (the average for the uninjured players was 2.4
previous injuries).
What does this actually tell us? As is the case in many sports, injuries are usually not
unexpected 'lightning bolts'; they are very often simply recurrences of previous problems.
Basketball players who suffer ankle injuries usually experience them again and again, not
because they are unlucky but because they lack the basic ankle strength and coordination
to stay out of trouble. It's logical that a strengthening programme, especially one that
emphasises the development of improved strength during landing, 'cutting', and sudden
stopping, should help lower the high rate of recurrence. The Australian researchers
reported that only 56 % of the ankle injured players received physiotherapy, and it is
unlikely that these individuals were given basketball-specific strengthening routines for
the lower parts of their legs.
In the Australian investigation, the second-best predictor of ankle injury for basketball
players turned out to be the presence of air cells in the heels of the shoes worn for
practice and competition. In fact, players wearing shoes with air cells were 4.3 times
more likely to hurt an ankle, compared to athletes without the cells.
What should we make of this? First of all, it's quite reasonable to think that mid-sole
construction and composition in basketball shoes should play a role in
preventing/producing injuries. Basketball-shoe midsoles tend to be quite thick, for one
thing. In theory, this exaggerated thickness provides better cushioning, but it also makes
the foot and ankle more unstable, compared to a situation in which the foot is closer to
the ground. In particular, it makes the foot and ankle more prone to the violent side-toside tipping motions which produce ankle sprains and other ankle injuries.
If you doubt this, simply stand in your bare feet and try to turn one of your ankles over by
rolling it to the outside. You'll find that this simple action is actually fairly difficult to
carry out; your bare foot resists this dangerous motion, and much of your foot's sole stays
in contact with the ground, even as your ankle turns considerably. Now, strap on a pair of
basketball shoes and try the same movement. Note how your foot rolls more easily to the
side as the bottom of the shoe lifts off the ground, and note that you fairly quickly reach a
point at which the shoe tips over suddenly, stretching the ligaments on the outside of your
ankle. This is why some experts call modern basketball shoes 'automatic ankle-spraining
devices'.
'He had no hesitation in agreeing that players with a history of ankle injuries were more
likely to be hurt that those with no previous ankle problems'
In a similar vein, if basketball-shoe midsoles contain materials or structures which
facilitate or enhance this side-to-side motion, then the risk of ankle injury should
increase. Are the air cells just such structures, providing less resistance to ankle-twisting
movements than traditional midsole materials? In a March 27 interview with Keith
Mulvihill provided by Reuters Health, Dr Mario Lafortune of the Nike Sports Research
Laboratory in Beaverton, Oregon, said: 'I completely disagree with this hypothesis'.
Lafortune suggested that the Australian study provided more questions than answers, and
that it was difficult to interpret the results. However, he had no hesitation in agreeing that
players with a history of ankle injuries were more likely to be hurt than athletes with no
previous ankle problems, which was the other key Aussie result.
The Australians did find one other injury factor (in addition to prior history and air cells):
players who did not 'complete a general stretching programme' before the game were 2.6
times more likely to injure an ankle, compared to players who did. This finding is a little
difficult to interpret, since few details were provided concerning the stretching. We don't
know whether the stretches were carried out before or after a movement-oriented segment
of warm-up (lay-ups, jogging, etc.), for example, nor do we know whether the stretches
were dynamic and basketball-specific, or perhaps static and general in nature.
Interestingly enough, players with a history of ankle injury were more likely to wear an
ankle brace, compared to athletes with no prior injury; however, wearing an ankle brace
did not significantly reduce the risk of injury. Other factors which were not significantly
related to the occurrence of injury were sex, age, height, weight, games played per week,
amount of training per week, shoe cut (high- or low-top), position played (guard,
forward, or centre), or quarter of the game (some observers have suggested that ankle
injuries tend to be skewed toward the fourth quarter, when players are most fatigued).
Overall, the Australian study was well done, including - as it did - over 10,000 basketball
participations, about four times the number of court-side observations made during
previous research. Although the detected injury rate was high, there was some good
news: almost 80% of ankle injuries are sustained during landing or during sudden cutting
or twisting movements, which suggests that if basketball players improve their
landing/cutting skill and strength, they can significantly reduce their risk of getting hurt.
Various hopping and jumping exercises, sprint drills which include very rapid turns and
numerous changes in direction, one-leg squatting activities, and balance-board routines
should help to drag down injury rates. Research carried out with volleyball players found
a two-fold reduction in ankle injuries after correct landing techniques and bodymovement strategies had been learned ('A Twofold Reduction in the Incidence of Acute
Ankle Sprains in Volleyball after the Introduction of an Injury-Prevention Program: A
Prospective Cohort Study,' Scandinavian Journal of Medicine and Science in Sports, vol.
7, pp. 172-177, 1997). Basketball players with previous ankle injuries should be acutely
attentive to these strengthening activities.
Athletes loose more time from ankle injuries than any other injury. Anatomically it is
comprised of the fibula, tibia, talus and calcaneus. Its bony structure is considered
stable, but the tendons and ligaments that cross the joint are not as strong , especially
those structures of the lateral ankle. Eighty five percent of all ankle sprains occur to the
lateral side. Some athletes may be predisposed to these injuries because of high arches,
tight calf muscles, improper foot wear, and mismanagement of previous injuries. Most
lateral ankle sprains are seen in sports such as soccer, basketball and football. The
incidence of injury also seems to increase on artificial surfaces. It is important that the
severity of these injuries is accurately diagnosed, and that growth plate injuries are ruled
out in the adolescent and preadolescent athlete. In some instances the more severe
injuries may be treated with total immobilization and non weight bearing . A general
rule of thumb is, if the athlete cannot walk off the field without assistance they should be
on crutches. Mild to moderate ankle injuries usually respond to aggressive rehabilitation
and bracing. If athletes are able to pass functional testing without tape or a brace, they
can usually return their sport. However, this is when coaches and athletes seem try to do
too much too soon. It is very important that the athlete pays attention to swelling and
pain, continue to aggressively strengthen the ankle musculature and if the ankle does act
up, modify the athlete's activities.
Background
The ankle joint experiences more weight per unit of area than any other joint in the body.
Ankle injuries are among the most common reasons for visits to clinics and emergency
rooms. The most common mechanism of injury at the ankle is twisting or rotation, which
usually involves inward twisting (inversion) of the foot at the ankle joint. Commonly an
inversion injury will produce a sprain of the ligaments of the ankle or a bony fracture.
The most common types of injuries of the ankle include:
• Sprain - Sudden over-stretching that causes damage to the ligament is a sprain. "Sprain"
should not be confused with "strain".
• Strain - The over-stretching of a muscle causes a strain.
• Dislocation - A dislocation is the displacement of bones at a joint from a normal
position.
• Fractures - A fracture is simply defined as the breakage of a bone.
The Anatomy
The coming together of the large lower leg bones (tibia and fibula) and anklebones
(primarily the talus) make up the ankle joint. The anatomy of the ankle is often thought of
as a simple hinge joint. However, it is more accurately thought of as a saddle joint in
which the bones in the ankle are stabilized by the presence of ligaments. Ligaments
attach bones together and at the ankle joint prevent sideways sliding of the bones. The
names of the ligaments surrounding the ankle include the calcaneotibial and the anteriorand posterior talofibular ligaments. The strongest ligament at the ankle is the deltoid
ligament, which lies on the medial side of the ankle (the side facing the opposite ankle).
The motion at the ankle includes only flexion and extension (upward and downward
movement).
Sprains and Strains
Sprains are the most common injuries of the ankle, and the ligaments that surround the
ankle joint are the most commonly injured ligaments in the body. There are three levels
of severity of sprains. Grade 1 refers to simple over-stretching of the ligaments without
any structural damage, grade 2 refers to partial tearing of the ligament, and grade 3
happens when there is complete tearing of the involved ligament. Usually an inversion
(inward rotation) injury will produce a sprain of the ligaments at the ankle. A similar
injury can occur as the result of outward rotation (eversion). Eversion involves overstretching of the deltoid ligament, which is very strong and unlikely to sprain; therefore,
instead of a sprain severe eversions result in fracture of the bones that are held together
by the deltoid ligament. The most common symptoms of sprain are pain, tenderness, and
swelling in the area of ligament damage. Bruising (contusion) may also occur. Contusion
is the result of damage to the blood vessels and is usually not significant. Loss of function
at the ankle may also be present. X-rays should be done to rule out the existence of a
fracture.
Strains are muscular injuries that are caused by virtually the same mechanisms as sprains;
they, however, signify a more serious injury.
Ankle sprains are usually treated conservatively. Initial treatments of elevation and icing
the area (for about 15 minutes three to four times a day) are helpful. The treatment
regimen, commonly known to physicians and sports trainers as "RICE" (Rest, Ice,
Compression, and Elevation) is often used. Compression is usually accomplished by
wrapping the ankle firmly with an elastic wrap. This treatment is usually done for several
days. Anti-inflammatory medications-such as ibuprofen-and pain medicines-such as
Tylenol-may be helpful in improving pain and minimizing discomfort. Sprains tend to
recur, and for that reason it is important to strengthen the ankle joint by exercising the
muscles and ligaments of the ankle regularly. To prevent injuries, athletes should wrap
their ankles prior to sporting activities, especially those with prior ankle injuries. Strains
are treated conservatively with rest, ice, and pain medications.
Dislocations
Dislocation occurs when one of the bones that form a joint leaves its normal position
within that joint. Dislocations at the ankle joint are almost always accompanied by
fracture of one or more of the bones. Dislocations at the ankle joint are of three types:
posterior (backward), anterior (forward) and lateral (sideways). Posterior dislocations are
the most common, anterior dislocations are less common and are usually paired with a
fracture of the Tibia, and lateral dislocations are almost always associated with fractures
of the lowest parts of Tibia or Fibula (called the malleoli). Dislocations with fractures
frequently require surgical repair under general anesthesia. Simple dislocations must be
reduced. The integrity of the blood vessels and nerves of the ankle need to be carefully
evaluated before and after the dislocation is corrected.
Fractures
Fractures at the ankle and injuries of the ligaments commonly may occur together. A
special type of fracture, known as a spiral fracture, may occur with an eversion or
external rotation injury at the foot. Fractures at the ankle may lead to arthritis after the
broken bone has healed. This phenomenon may occur if the smooth surfaces of the ankle
joint are disrupted. Some fractures may be treated conservatively with a cast and crutches
until they are healed, but some require surgical repair. A consultation with an orthopedic
surgeon is essential in the management of fractures.