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Ankle Sprains and Soccer / Football

How physiotherapy can help the world’s most common sports injury in our country's most loved game by Mark Waller

Standing, walking, running, jumping, and changing direction. Five different types of movements. These movements are not just done in daily living or occur when playing soccer, they are five movements which are all done with the use of our ankles.


Ankle Sprains are the world’s most common sports related injury. Ankle sprains being so common that they are accountable for nearly one third of all sporting injuries. Studies have shown that 58.5% of professional football players have suffered some sort of ankle sprain in their careers (Martin, et al., 2021).


When you have done reading this article, you will have the understanding of the basic anatomy of the ankle, what ankle sprains actually are, how they occur so easily in the beloved game, why physiotherapy is so important when managing an ankle sprain and what you can expect when you have physiotherapy for an ankle sprain.


What are Ankle Sprains

An ankle sprain is an injury in which part of the ankle is forced into movement out of its normal range. This is caused by an external force or pressure acting on the ankle. When the joint is sprained and forced into this position it results in pressure being put on the ligaments in the area and they are overstretched. Ankle sprains are classified according to their severity (Lynch, 2003)

· Grade 1 – injury where ligament stretching is not evident.

· Grade 2 – injury where ligament stretching is evident but the ligament is intact.

· Grade 3 – injury in which there is complete rupture of a ligament.


Mechanism of Injury and its relevance to soccer

The most common ankle sprain is a lateral ankle sprain where the foot turns inward, and the ankle rolls outwards resulting in the lateral ankle ligaments being stretched and possibly torn as a result of the body suddenly shifting over the planting or weight taking foot. This results in a combination of plantar flexion and over inversion and damage to the ATFL, CFL and PTFL.


A second mechanism of injury which is not as common is a medial ankle sprain which results in hyper eversion occurring and damage to the deltoid group of ligaments. (Hubbard & Hicks-Little , 2008)


Soccer is a high paced game in which the ankle joint takes multidirectional high volumes of force and pressure. Whether its running, jumping and landing, tackling, kicking, changing direction and even being tackled, the ankle can easily give in, twist or be pushed into hyper movement positions where the ligaments are stretched. Often occurring with an external force being applied to the medial side of a player’s ankle as the foot is about to plant onto the ground (Walls, et al., 2016).


Ankle sprains account for 67% of all foot and ankle injuries in soccer players. During the 2004 Olympics and 2010 FIFA World Cup ankle sprains where the most common reported injury that footballers experienced. A separate study has shown that over a four-year period 20% of all injuries in an English Premier Club reports were ankle related. (Walls, et al., 2016).


Not only are ankle injuries very common in soccer, but it will also result in players being forced out of training and playing fixtures for periods of time. Along with this issue, an ankle injury will result in the player being at higher risk of injuring the same ankle months down the line (Martin, et al., 2021).


The scary fact of this matter is that studies show that for such a common injury, that not only takes an athlete out of playing but also results in the athlete being at a much higher risk of re-injury occurring, only 6.8% -11% of individuals seek medical care for their injury end up being referred to a rehab specialist for treatment. (Martin, et al., 2021).


In order for an athlete to recover and get back to or as close to their previous peak after an ankle sprain, a major aspect of that recovery is the use of physiotherapy.


Physiotherapy and Ankle Sprains from soccer – What you can expect.


Seeing a physiotherapist after an ankle sprain is crucial for return to play / function. Not only does it help manage the swelling, pain and reduced functioning of the ankle, it will help put the ankle through the correct re-training and rehab so that all the correct muscles are strengthened correctly, and mobility is brought back to what it once was so that the risk of re-injury is reduced as much as possible.


When seeing a physiotherapist for your ankle sprain they will do an assessment and then, based on their findings, give the respective and necessary treatment that is suitable for the type and class of sprain as well as how acute the injury is.


Assessment - the initial assessment and one or two after will include:

· Subjective interview – when, what and how

· Swelling observations

· Range of motion (mobility) – passive and active

· Biomechanics testing

· Posture and gait assessment

· Muscle strength and length testing

· Sports specific and functional testing at a later stage – outcome measures used to test balance, proprioception, agility and other sports specific requirements (power, explosive strength, jumping)


The assessment will allow for the therapist to gather information and findings on the ankle sprain. The information found will be compared to the norm and from here on a necessary treatment approach / programme will be used.


Physiotherapy treatment of ankle sprains will include the following:

· Stretching – passive and active

· Manual therapy

· Electrotherapy

· Cryo / Thermotherapy

· Balance and proprioception training (ankle stability has a big effect on these two factors)

· An exercise programme that would be personally created for the athlete based of the muscle strength and biomechanics assessment in order to strengthen the necessary muscles. This will not only include muscles around the ankle but also muscles associated with the knee and the hip. Studies have shown that hip extensor, adductor and abductor strengths are all associated with ankle sprains as weakness of these muscles are shown to be risk factors for ankle sprains in athletes (Martin, et al., 2021).

· Return to play programmes that take a step-by-step approach at getting an athlete from day of injury to full return to play with contact safely and comfortably with no limitations.


Ankle injuries can be tough but with the correct treatment from a physiotherapist, they can be overcome and get you back on the field as soon as possible.


Background information – The Basic Anatomy of the Ankle

The ankle joint consists of three main bones, two bones of the leg - the tibia and fibula - in junction with one bone of the foot, the talus, which is also in junction with another bone of the foot called the calcaneus.


The tibia and fibula are held together by a strong ligament namely the tibiofibular ligament. The joint acts as a “hinge-joint” allowing dorsiflexion (upward) and plantarflexion (downwards) movement (Golano , et al., 2010).

The joint between the talus and the calcaneus, is what allows for the sidewards movement of the ankle being inversion (results in big toe moving inwards and upwards) and eversion (results in the big toe moving in a downwards and outwards direction). (Golano , et al., 2010).


On either side of the ankle joint there is a bony structure visible to the naked eye – this is the malleoli. On the lateral side a lateral malleolus (the distal end of the fibular) and on the medial side the medial malleolus (the distal end of the tibia). The ankle joint also consists of a network of several ligaments all serving different functions. These ligaments include the following:

Medially:

· Deltoid Ligament – attached from the medial malleolus and connects to the talus (posterior tibiotalar ligament – PTTL), calcaneus (tibiocalcaneal – TCL) and navicular bones (Tibionavicular TNL). The deltoid ligaments are in place to resist over eversion of the foot.

Laterally:

· Anterior Talofibular Ligament (ATFL) – stretching from the lateral malleolus to the lateral surface of the talus.

· Posterior Talofibular Ligament (PTFL) – attaching the lateral malleolus to the posterior surface of the talus.

· Calcaneofibular Ligament (CFL) – extending from the lateral malleolus to the calcaneus.


Lateral ligaments of the ankle are all in place to prevent over inversion.


References

Golano , P. et al., 2010. Anatomy of the Ankle Ligaments : A pictorial Essay. Knee Surgery, Sports Traumatology,Arthroscopy, 18(5), pp. 557-569.

Hubbard, T. & Hicks-Little , C., 2008. Ankle Ligament Healing After an Acute Ankle Sprain : An Evidence-Based Approach. Journal of Athletic Training, 43(5), pp. 523-529.

Lynch, S., 2003. Assessmnet of the Injured Ankle in the Athlete. Journla of Athletic Training, 37(4), pp. 406-412.

Martin, R. et al., 2021. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprain revision 2021. Journal of Orthopaedic and Sports Physiscal Therapy, 51(4).

Walls, R. et al., 2016. Football Injuries of the Ankle : A Review of injury mechanisms, diagnosis and management. World Journal of Orthopedics, 7(1), pp. 8-19.

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