Ankle sprains are one of the most common injuries in soccer. They can side-line any player from training and competing and are difficult to prevent from coming back. Lateral ankle sprains are an injury to your ligaments on the outside of your ankle. A medial ankle sprain is when your ligament on the inside of your ankle is injured. It is often associated with a fracture of your fibula (outside lower leg bone) or other bones in your ankle. This type of sprain occurs much less frequently than a lateral ankle sprain and may take twice as long to heal. Injury to the front and/or back lower ligaments of your ankle is a syndesmotic sprain. This often occurs from hyperdorsiflexion (pointing the toes up too far) and eversion (pointing the toes out).

Mechanism of Injury

• A lateral ankle sprain is usually from inversion with plantarflexion (turning the toes in while pointing them down), a position similar to when your soccer player is kicking a ball on the top of the foot.
• A medial ankle sprain is usually from eversion with dorsiflexion (turning the toes out while pointing them up).

There are 3 degrees of ankle sprains:

• 1st degree involves minimal swelling, point tenderness, no ligament laxity, no limp or difficulty hopping. Athletes typically recover in 2-10 days.
• 2nd degree has more swelling specific to the ankle, increased ligament laxity, a limp and your soccer player is unable to heel raise, hop, or run. Typical recovery time is 10-30 days.
• 3rd degree includes a lot of swelling, tenderness on both the inside and outside of the ankle, even more ligament laxity, and your player cannot put any weight on the ankle. Recovery can be anywhere from 30-90 days. 

Signs and Symptoms

Lateral Ankle Sprain

• Significant swelling within 2 hours because of the rich blood supply.
• Tender to the touch over your athlete's outside ankle ligaments, bruising that drains into his foot.
• Different levels of instability (depending on grade).
• Positive tests for ligament laxity of his outside ankle ligaments.
• X-ray shows no signs of fracture.

Medial Ankle Sprain

• Pain/swelling over the inside of your soccer player's ankle.
• Tender to the touch over her inside ankle ligament.
• Bruising.
• Positive test for ligament laxity of her inside ankle ligament.
• X-ray needed to rule out avulsion fracture (bone fragment pulled away from the bone) or fracture of her inside ankle bone, or top of her ankle.

Syndesmotic Sprain

• Positive tests for front/back ligament laxity and severe swelling (possibly fracture) in your player's lower leg.
• Pain and swelling over his front/back ligaments and his lower leg space.
• Specific X-ray may show abnormal joint space in his lower leg.
• Recovery time is longer compared to other sprains.
• Need to rule out fracture and avulsion.

On-Site Management

P.R.I.C.E.

PROTECT the area from further injury by avoiding soccer exercises that produce pain. A boot can be worn for 4 weeks with a syndesmotic ankle sprain. 

REST: cutting back on the amount of soccer training can be difficult, but key to recovery. Gradually return to any agility or jumping activities.

Place ICE on the athlete's ankle for 10-20 minutes every 1.5 to 2 hours for the first 2 to 3 days or until the pain goes away. 

COMPRESS the area by having a trainer or physiotherapist use an ankle wrap with a tensor. This helps decrease swelling and bleeding.

ELEVATION is important to encourage blood flow to the heart for healing.

Medical Referral

When there is a severe 2nd, 3rd degree ankle sprain or a syndesmotic sprain, it is important that you and your soccer player seek medical attention to rule out fracture. A doctor may prescribe anti-inflammatory medication to help with pain and swelling. Your player should also get a medical referral to a therapist for proper evaluation of running/jumping biomechanics and footwear (i.e. soccer cleats). The therapist can direct your athlete to proper treatment and strengthening activities for return to soccer play.

Rehabilitation

Your soccer player should seek out a therapist to assist with evaluation.

Running/Jumping. Ensure that proper posture both in running and jumping are being used.

Footwear. Evaluate the athletic shoes (i.e. turf shoes and soccer cleats) being used. Do they need to be replaced or do orthotics need to be introduced?

A therapist may use ultrasound and laser treatment to reduce pain and swelling and promote healing. Friction massage is another treatment to promote healing and reduce scar tissue development. The therapist will also prescribe a full ankle/soccer specific rehabilitation program to strengthen the joint and help prevent future ankle sprains.

Return to Activity. 

This is a gradual process and may take some time. In general, the longer your player has symptoms before she starts treatment, the longer it will take to rehabilitate. The following is a list of guidelines to follow when returning to soccer activity. It is important to work towards:

• Full range of motion in the affected ankle compared to the unaffected ankle.
• Full strength of the affected ankle compared to the unaffected ankle.
• The ability to jog straight ahead without pain or limping. 
   

Some tests your soccer player's therapist may consider for your player's return to soccer play:

• Lateral hop test: The athlete will stand on the “uninjured” leg and hop as far as possible in an outside direction with three continuous hops. He then stands on the “injured” leg and hops back to where he started, using three continuous hops.
• Single leg stance (Modified Rhomberg Test): The athlete will stand and balance on the uninjured leg with her arms crossed over the chest. Then she stands and balances on the injured leg to compare.
• Heel rocker test: The athlete leans backward against a wall and pulls the toes and front of both feet off the ground while rocking backward on his heels. He raise the toes repeatedly off the ground until full exhaustion.
• Ankle joint dorsiflexion: With a measuring device, your therapist will measure her range of motion with the knee straight and bent.
• Test for joint laxity: A manual anterior drawer stress test (for ligaments of the ankle) will be applied to his injured and non-injured ankle.
• Stair run: Your therapist will observe her running down stairs without holding on to the handrail.

For competitive soccer player's, the list may be extended to include the following drills that can be performed on the soccer field:

• The athlete can sprint straight ahead on the field without pain or limping.
• The athlete can do 45-degree cuts, first at half-speed, then at full-speed. He can do 20-yard figures-of-eight, first at half-speed, then at full-speed.  
• The athlete can do 90-degree cuts, first at half-speed, then at full-speed.
• The athlete can do 10-yard figures-of-eight, first at half-speed, then at full-speed.
• The athlete can jump on both legs without pain and can jump on the affected leg without pain. (Pierre Rouzier, M.D).

Prevention

To prevent an ankle sprain from becoming chronic soccer players could consider including the following:

• Taping. Protect the injured ankle by taping it or using an ankle support during soccer activity.
• Tape can also be used during the rehabilitation phase to protect the joint and give balance feedback to the ankle without risking further injury. When partial weight bearing an ankle support or taping method can protect the outside ligaments (allowing them to rest), this ensures forwards and backwards motion during soccer play is allowed to keep the rest of the joint healthy.

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Author: Andrea Bulat