Reducing the Risk of Ankle Sprains in Athletes

Ankle sprains are very common among athletes and sports participants. What's the best way to prevent an ankle sprain? Is it high top shoes? Wearing a brace of some sort? Taping the ankle? In this report, sports medicine experts review type of ankle injury and goals of treatment. Prevention of both primary (first-time) ankle sprains and reinjury is also discussed.

Treatment is based on an accurate diagnosis. Physicians begin by taking a history and performing an exam. It's important to know what type of ankle sprain is present when creating a plan of care.

There are two major types of ankle sprains: low and high. Low ankle sprains are the focus of this article. Low ankle sprains involve damage to any of the short ligaments that hold the bones of the ankle together and stabilize the ankle.

A high ankle sprain involves the ligaments above the ankle joint. This is called a syndesmosis injury. In an ankle syndesmosis injury, at least one of the ligaments connecting the bottom ends of the tibia and fibula bones (the lower leg bones) is sprained. Recovering from even mild injuries of this type takes at least twice as long as from a typical ankle sprain. A second article on high ankle sprains will be published later.

Low ankle sprains can occur on either side of the ankle. But most often, it's the ligaments along the lateral (outside of the ankle) that are affected. This is because the mechanism of injury is usually plantar flexion (ankle and toes pointed downward) and inversion (toes pointed inward).

Certain ligaments are more likely to be torn or ruptured with lateral ankle sprains. This is because of the angle and orientation of the ligaments as they hold the bones together. For example, the anterior talofibular ligament (ATFL) is strained when the foot and ankle are in a position of plantar flexion, internal rotation, and inversion. Excess load or force in this position increases the risk of sprain.

There are some known risk factors for primary and recurring ankle sprains. Some are modifiable (can be changed to reduce the risk). Others are nonmodifiable risk factors. A high arch and wide foot are examples of nonmodifiable risk factors.

A previous history of ankle sprain is an important nonmodifiable risk factor. Though the injury itself is a nonmodifiable risk factor, the damage done can be changed. Poor balance, decreased strength, and poor proprioception (joint sense of position) are modifiable risk factors that may contribute to recurring ankle sprains. If the athlete did not complete a rehab program after the first sprain, there can be incomplete soft tissue healing and mechanical instability.

Treatment for an acute low ankle sprain begins with nonsteroidal anti-inflammatory drugs (NSAIDs) to control inflammation. Rest, ice, compression, and elevation (RICE) are important at first.

A physical therapist guides the patient through a rehab program of motion, proprioception, and strengthening exercises. Movement and mobility while supporting the ankle with a brace (or some other type of removable, external support) are equally important. This is called functional therapy. Later in the rehab program, sport-specific exercises are added.

Studies show that ankle sprains can be prevented with a program of strengthening and balance work. While it's clear that a program to restore proprioception after the first injury is essential in preventing a second sprain, there's no evidence yet that this type of training can prevent a primary (first-time) ankle sprain. More studies are needed in this area.

Stretching and wearing any particular type of shoe (e.g., high top versus low top shoes, shoes with inflatable air chambers) has not proven effective in preventing ankle sprains. The use of splints or external braces is effective and less costly than taping.

But these preventive measures may not be helpful for athletes who have sprained the same ankle more than three times. Fortunately, chronic injuries of this type are less common than the acute phase of ankle sprain. Ankle instability from repeated sprains may require reconstructive surgery.

Reference: 

Michael J. DeFranco, MD, et al. Differentiating Low and High Ankle Sprains. In The Journal of Musculoskeletal Medicine. September 2008. Vol. 25. No. 9. Pp. 438-443.

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