Ankle Sprain

Probably the most common reason to see an orthopedic surgeon in the office visit is for an ankle sprain. Why do they happen, what happens and how can we prevent them?

The ankle is a joint made up of 3 bones. The lower part of the tibia (the big bone), the inner part of the fibula (the thin small one) and the talus which is the bone that flexes and extends between the other two.

ankle-sprain

This makes up what is called the mortise of the ankle where bone restricts the talus from moving out of joint. You can see there is cartilage in between the bones which allow a smooth gliding motion when you move the ankle. The ankle can flex or move down when you point your toes or extend when you lift your toes up. It can rotate a small amount in its mortise. It everts which is when the joint tilts to the small toe side and inverts which is when it tilts towards the big toe side. Inversion injuries are the most common type of injury when discussing ankle sprains.

inversion-ankle-injuries

The ligaments are the stabilizers that prevent the ankle joint from slipping out of the socket. There are a multitude of ligaments around the joint. The three lateral ones that attach to the fibula are the most frequenty injured, anterior and posterior talofibular and calcaneofibular.

ankle-injury

These are what are injured during an inversion injury. A sprain is when the ligament tears. It can tear a little (partial) or a lot (complete). It has blood vessels in it so when it rips, the blood vessels pour blood out like an open faucet which causes the swelling. I do not recommend anti-inflammatories. The body is going to get rid of this swelling on its own as it has always done for thousands of years before them and antiinflammatories are not going to decrease the amount of bleeding that occurs. If anything because of their antiplatelet effect they can increase bleeding. They also decrease scar strength and formation in several studies.

ankle-ligament-tears

The inversion injury is the most common you can have something called a high ankle sprain that can occur when the stronger stouter ligament between the tibia and the fibula is injured. This can take sometimes 3-4 times longer to heal than a regular ankle sprain. If the sprain is severe enough and the ligament between the bones are completely torn and not attached as opposed to only partially torn, then there can be a separation between the bones of the ankle. This requires the ankle to be fixed together surgically to allow the ligaments to grow back at their normal length and to prevent arthritis. This is what a complete rupture looks like:

ankle-rupture

abnormal wide mortise

reduction and fixation of mortise

Studies show that for typical ankle sprains surgery does not make things better faster. For the widened ankle joint, surgery is indicated.  Rehab and PT will help typical ankle sprains. Range of motion exercises, strengthening, and balance or proprioceptive exercises are helpful. When the ligaments tear there are nerve endings in the ligaments also that allow a person to determine where there foot is located in space. When you have chronic tears or multiple injuries, people’s proprioception is lost and people have difficulty with walking on uneven surfaces because they feel like their ankle can give way. That is fixable if it is bad enough by tightening up the ligaments or creating new ones.

CrossFitters can get ankle sprains with any running and misstepping especially when overfatigued. There are always things hanging out on the floor like weights, weight clips, jump ropes than can cause your foot to roll unevenly and possibly evert. So always keep extraneous stuff out of the way.  Box jumps are other potential hazards. As you are having trouble getting up to the top towards the end of a WOD your shin may hit and cause you to land unevenly. Also coming down from the box or the pull up bar can be troublesome especially after multiple reps. You almost have to actively think about planting your foot if you have any history of instability in that ankle.

Here is a summary of a study of basketball players looking at 10,000 athletes. (1) Players with a history of ankle injury were almost five times more likely to sustain an ankle sprain. (2) players wearing shoes with air cells in the heel were 4.3 times more likely to injure an ankle than those wearing shoes without air cells; (3) players who did not stretch before the game were 2.6 times more likely to injure an ankle than players who did.  So what can you do? If you have a loose ankle joint seek professional care, wear a brace that is comfortable and protective, go for flatter shoes, and stretch out before your WOD. For those with an acute injury seek care first to make sure there is not a fracture and here are some helpful exercises for your ankle’s health. Happy CrossFitting and remember to find some balance.

Ankle Range of Motion Exercises

  • Toe Circles
    Move your ankle through it’s entire range of motion (up and down, in and out, and in circles). Move only the ankle and not the leg.
  • Alphabet Exercise
    With your leg extended, try to write the alphabet in the air with your toes.

Ankle Strengthening Exercises

Once you have good range of motion, joint swelling is controlled and pain is managed, you may begin strengthening exercises.

  • Step Ups
    Begin one a short step and slowly step up in a controlled manner while focusing on contracting the muscles of the foot, ankle and leg. Turn around and slowly step down in the same manner. Repeat 20 times several times per day.
  • Towel Curls
    While seated and bare foot, place a small towel on a smooth surface in front of you. Grab the towel with your toes. Keep you heel on the ground and curl your toes to scrunch the towel as you bring it toward you. Let go and repeat until you’ve moved the towel to you. Repeat the action in reverse to push the towel away from you.
  • Isometric Exercises
    Gently push against an immovable object in four directions of ankle movement — up, down, inward, outward. Hold 5 seconds and repeat 10 times, several times a day.
  • Tubing Exercises
    Use elastic tubing to create gentle resistance as you move through a full range of motion. Wrap the elastic band around the ball of the injured foot and resist the band as you move your ankle up, down, inward and outward. These exercises incorporate the four movements of the foot: inversion, eversion, plantar flexion and dorsiflexion. Perform 3 sets of 15 repetitions for each movement.
  • Toe Raises
    Stand with your heel over the edge of a step. Raise up on the ball of your foot, hold for 3 seconds and slowly lower your heel to the start position. Repeat 20 repetitions several times a day.
  • Heel and Toe Walking
    Walk on your toes for 30 seconds. Switch and walk on your heels for 30 seconds. Build up to one minute on toes and heel alternate for 5 to 10 minutes. Perform several times per day.

Ankle Balance | Proprioception Exercises

After you are able to place your full weight on the injured ankle without pain, you may begin proprioceptive training to regain balance and control of the ankle joint.

  • One-leg Balance
    Try to stand on one leg for 10 to 30 seconds. Increase the intensity by doing this with your eyes closed.
  • One-leg Squat
  • Balance Board Ball Toss
    While balancing on a wobble board, balance board, or Bosu Ball, catch and toss a small (5 pound) medicine ball with a partner.
  • Balance Board with Half-squats
    While balancing on a wobble board, perform 10 slow, controlled half-squats.
  • Step up onto Balance Board
    Place a balance board (or soft pillow or foam pad) 6 to 8 inches higher than your starting point. Step up 10 times.
  • Step down onto Balance Board
    Place a balance board (or soft pillow or foam pad) 6 to 8 inches lower than your starting point. Step down 10 times.
  •  One-Leg Squat and Reach

Ankle Agility | Plyometric Exercises

  • Lateral Step Up and Down
    Step up to a step of bench, sideways and then step down sideways.
  • Plyometric Exercises:
    • Single Leg Hops
      Hop forward and concentrate on “sticking” the landing.
    • Single Leg Spot Jumps
      Hop from spot to spot on floor.
    • Reactive Spot Jumps
      Place numbered pieces of tape on floor and as a partner calls out a number, hop to that number.
  • Sports-specific Skills and Drills
    Sports-specific drills can be added as long as return to sports guidelines are followed.

6 Comments

  1. Ouch ..sounds painful!

  2. Great article. I have seen a crossfitter go down with an ankle inversion in the middle of a WOD on Box Jumps landing on a bar.

  3. Painless cracking is said to be nitrogen bubbles that snap. Painful cracking or feelings that something is getting stuck should be examined.

  4. What does it mean when the ankle cracks when you walk? Also my ankle cracks loudly when I put the foot in an inverted position and draw a backward C with the big toe. Growing up I had multiple sprains and now it feels like the calcaneous is a little loose? Thanks for your time and this blog!

  5. Sean,

    I liked the ABCs. I used it all the time for warming up and helping my platoon mates get over their ankle illnesses.

  6. Thanks Doc!! Good and helpful stuff. See you in a couple of weeks – hopefully without this boot but that 3-4x longer healing process…I’m not holding my breath.

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About Me

Dr. Sean Rockett is an Orthopedic Surgeon specializing in Sports Medicine. His group is Orthopedics New England with offices in Dedham, Natick and Newton, Massachusetts. Dr. Rockett is a CrossFit Level 1 Trainer and has been a CrossFitter at CrossFit New England since 2007. Dr. Rockett is on the Medical Team for the CrossFit Games and the Northeast Regionals.

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