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Ankle Sprains in the Runner
Ankle sprains are one of the most common
joint injuries runners experience. The injury can occur when one rolls
over a rock, lands off a curb, or steps in a small hole or crack in the
road. Usually the sprain is only mild, but on occasion it may seriously
injure the ligaments or tendons surrounding the ankle joint. Management
of this injury relies on early and accurate diagnosis, as well as an
aggressive rehabilitation program directed toward reducing acute
symptoms, maintaining ankle stability, and returning the runner to
pre-injury functional level. General Anatomy of the Ankle The
ankle is comprised of three main bones: the talus (from the foot), the
fibula and tibia (from the lower leg). The three bones together form a
mortise (on the top of the talus), as well as two joint areas (on the
inside and outside of the ankle), sometimes called the "gutters". The
ankle is surrounded by a capsule, as well as tissue (the synovium) that
feed it blood and oxygen. Some of the more important structures that hold the ankle together are the ankle ligaments. Most
ankle sprains involving the ligaments are weight bearing injuries. When
a runner's foot rolls outward (supinates) and the front of the foot
points downwards as he or she lands on the ground, lateral ankle sprain
can be a result. It is usually this situation that causes injury to the
anterior talo-fibular ligament. However, when the foot rolls inwards
(pronates) and the forefoot turns outward (abducts), the ankle is
subject to an injury involving the deltoid ligament that supports the
inside of the ankle. This can occur when another runner steps on the
back of the ankle, as at the beginning of a race, or when a runner
trips and falls on the runner in front of him. Diagnosis When
assessing an ankle sprain, your podiatrist will want to know the
mechanism of injury and history of previous ankle sprains. Where the
foot was located at the time of injury, "popping" sensations, whether
the runner can put weight on the ankle are all important questions
needing an answer. If past ankle sprains are part of the history, for
example, a new acute ankle sprain can have a significant impact. The
physical examination should confirm the suspected diagnosis, based on
the history of the injury. One looks for any obvious deformities of the
ankle or foot, black and blue discoloration, swelling, or disruption of
the skin. When crackling, extreme swelling and tenderness are present,
together with a limited range of motion, one may suspect a fracture of
the ankle. A feeling of disruption on either the inside or the outside
of the ankle may indicate a rupture of one of the ankle ligaments. To
check for ankle instability, the runner should be evaluated while
weight bearing. Manual muscle testing is also valuable when checking
for ankle instability. One of the more critical tests that a runner
should be able to perform before allowing resumption of activity is a
"single toe raise" test. If the runner is unable to do this, one might
suspect ligamentous injury or ankle instability. X-rays
help rule out fractures, "fleck fractures" inside the ankle joint,
loose bodies, and/or degenerative joint disease (arthritis). Stress
X-rays are taken when ligamentous rupture or ankle instability is
suspected. When a stress test is taken of your ankle, don't be
surprised if the same test is performed on the other ankle. This is
done to compare the two ankles, particularly in cases of ligamentous
laxity (loose ligaments). In the past, more
commonly, ankle arthrography has been used. This involves injecting a
dye into the ankle joint as it is X-rayed. This helps determine if a
rupture of a ligament or tear of the ankle capsule has occurred.
However, this procedure does involve some discomfort during the
injection process, and, on rare occasions, an allergy to the dye occurs. Other diagnostic tests include computerized tomography (CT Scan) to discover injuries of the bone, and magnetic resonance imaging (MRI)
to isolate and diagnose specific soft tissue injuries (ligaments,
tendons, and capsule). The MRI is very specific, and gives a clear-cut
view of these important structures. Treatment Treatment
of an acute ankle injury usually begins with an aggressive physical
therapy program that controls early pain and inflammation, protects the
ankle joint while in motion, re-strengthens the muscles, and
re-educates the sensory receptors to achieve complete functional return
to running activity. Modalities that decrease pain and control swelling include icing, electrical nerve stimulation, ultrasound, and/or iontophoresis patches.
Easy, mild motion, with the limits of pain and swelling, can actually
reduce the effects of inflammation. A continued passive motion (CPM)
machine can be very helpful in decreasing pain and swelling. Resumption
of running activity is usually dependent on the runner's limits of pain
and motion, and is begun to tolerance. As the runner improves, diagonal
running can be prescribed. It is important to protect the runner with
braces such as air casts, ankle braces, etc., which help to allow
motion at the ankle joint under weight bearing. Home exercise
programs are very helpful for the post-ankle sprain runner.
Proprioception re-education is critical for both the acute as well as
the chronic ankle sprain. It may involve using a simple tilt board or
more sophisticated proprioceptive training and testing devices. For
the acute grade III lateral ankle sprain, or complete deltoid tear,
complete immobilization is usually recommended for at least four weeks.
Afterwards, a removable cast is used to restrict motion and allow for
physical therapy. If the ankle does not respond and ankle instability
is diagnosed, surgical intervention may be required. Today, ankle arthroscopy
a much less invasive procedure than other surgery, allows the ligament
to be stabilized with tissue anchors. This eliminates an extended
period of immobilization, joint stiffness and muscle atrophy.
Post-operatively, this primary ligament repair is protected for
approximately a two-to three-week period of time in either a cast or
removable cast boot, with daily-continued passive motion, cold therapy,
and controlled exercise. At three weeks, a simple air cast or
ankle brace is applied for an additional three weeks while therapy and
rehabilitation is progressing. At six weeks, these devices are used
only during running and other athletic activity as a safeguard. As the
runner resumes strength and proprioceptive capabilities, the devices
are discontinued. Conclusion When an acute or
chronic ankle sprain is not treated, as unfortunately is all too often
the case, repeated ankle sprains may occur. Because chronic ankle
injuries do not show acute inflammation even when the ankle is weak and
unstable, this may set the runner up for another ankle sprain when
least suspected. A successive sprain may be more severe than the first,
and cause an even more significant injury. The most important
point to keep in mind when talking about ankle injuries, then, is to
prevent the condition from becoming chronic or recurrent. So the
next time you roll over that stone, or land in that small hole, make
sure that your simple ankle sprain is just that: "simple". If you
don't want to have a swollen ankle all the time while running, don't
ignore early warning signs. If you have any doubts about its
seriousness, have your podiatrist check your injury.
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