The Athlete - Persistent ankle pain after a sprain 

Most cases of an ankle ligament sprain will resolve with treatment. However a sprain is a common injury in which if inappropriate rehabilitation or none at all can, increase the chances of re-occurrence. This will be explained further on. 

A sprained ankle can sometimes be a more difficult injury to deal with than a fracture due to the injury mechanism. The ligaments become lengthened; range of motion can decrease due to swelling and later scar tissue, the strength of the muscles decrease. All this affects the proprioception of the joint. Proprioception helps the dynamic and functional stability of the joint (balance); it gives the body awareness of joint position. Injury can disrupt this feedback. 

An outline of rehabilitation for the ankle should consist of range of motion exercises particularly dorsi-flexion, strengthening starting from a fully plantar flexed position to include the peroneal muscles, and proprioceptive retraining. Other exercises should be tailored to the individuals needs. 

If rehabilitation was appropriate but symptoms still persist about 3-6 weeks after the start of the problem other causes need to be looked at like possible fracture, tendon dislocation, impingement syndromes, sinus tarsi syndrome to name but a few which can occur with a sprain of the ankle.  

The difficult ankle – instability

It is not always clear to the therapist why a client may get persistent ankle sprains. Although if you never got treatment for your injury or your rehabilitation was not appropriate it leaves you open to re-injury. 

The possible causes of re-injury

Structural changes

Ligament laxity – ankle ligaments heal well but laxity can still persist in the ankle complex. A loss of scar tissue formation and altered mechanics during the tissue repair phase (starts from day 3 and continues for 3-6 weeks) of injury may result in the ligament healing in an elongated position. Leaving the joint unstable, even when maturation (scar tissue strengthening stage) has occurred. If the ligaments are lax it can change the position of the bony structures i.e. the fibula this would reduce the involvement of the peroneal muscles which act to stabilise the ankle dynamically. 

Limited range of motion – restriction of motion can affect the joints ability to distribute weight evenly through the body. If dorsi-flexion is limited the ankle can not fully reach the needed range of the close packed position during the stance phase of walking, the ankle will achieve this end range by using inversion (weight goes on to the inside of the foot flattening the arch – pronation) instead stressing other structures. 

Functional instability

In some people there may be no structural impairments but the ankle is still unstable during functional movements. A number of factors can contribute to this. 

Impaired proprioception – problems may occur in been able to feel errors in detecting ankle position prior to ground contact, or inability to set appropriate muscle force levels to provide joint stability prior to landing from a jump. This impairs the ability to accept the load and transfer load during challenging tasks. 

Muscle weakness- ankle strength is an important aspect of ankle rehabilitation as damage and pain can decrease muscle activity.  

Postural changes – the body can modify its posture control after injury to maintain balance. That’s why it is important to keep or achieve a normal walking gait as soon as the ankle is able to bear weight. 

Altered movement – the body is very good at anticipating movement. The muscles are prepared for muscle activity. For example if you walk on an uneven surface the ankle muscles react quickly to changes under foot to control balance. When injury occurs this reaction time can be lost. 

Conclusion

If you leave your ankle sprain unattended you are leaving yourself prone to further ankle sprains. Some may get treatment but receive inappropriate rehabilitation. This can develop altered motor control which leaves them open to re-injury. Sports therapists have an appreciation to structure comprehensive rehabilitation plans that not only aim to just manage the acute sprain but also avoid further chronic events.

The above article if for information purposes only. If you are interested further there are plenty of journal articles to read on the subject.