Recurrent ankle sprains can be disabling for those engaged in sport or the general population alike. In a sport such as tennis, reliable footwork and stability are essential to achieve the rapid change in speed and direction required to navigate the court. Whilst much of the population is glued to the technical shots and results at Wimbledon and other summer tennis tournaments, A year on foot at the ISEH is inevitably drawn to Andy Murray’s ankles and their ubiquitous ankle braces as Mr Michael Oddy, ISEH Consultant Trauma & Orthopaedic Surgeon reports
Lateral ankle sprains of the talofibular and calcaneofibular ligaments account for approximately three-quarters of ankle soft tissue ligament injuries and whilst many are managed without patients seeking any medical or physical therapy attention, the injury burden overall represents up to ten percent of all attendances to Accident & Emergency departments. There is naturally a spectrum of injury severity which means that no one treatment protocol necessarily is applicable in all cases. For the severe inversion tilting sprain, with significant bruising, swelling and difficulty bearing weight, a few weeks of immobilisation in a plaster cast or pneumatic walker boot provides useful protection to rest the injured joint. Thereafter, progressive range of movement therapy and joint position proprioceptive training are effective in regaining function, strength and stability. The sequelae of a severe ankle sprain with ligament injury can result in persistent pain due to joint synovitis, scar tissue impingement or joint cartilage damage, stiffness due to swelling and scar tissue arthrofibrosis or chronic ankle instability.
Chronic ankle instability encompasses a heterogeneous group of problems including recurrent ankle sprains to the same joint, apprehension during a variety of activities, or episodes of giving way leading to uncontrollable ankle inversion inward tilting but without the signs of an acute sprain. Chronic ankle instability can result from a combination of mechanical defects in the actual integrity of the lateral ligaments leading to excessive joint laxity and also functional or coordination problems due to weak or poorly controlled muscles unable to protect the vulnerable healing ligaments against further injury. The latter functional instability needs specific neuromuscular or proprioceptive joint position training physical therapy combined with exercises to achieve a full range of movement and strength and is not a surgically treatable problem.
Mechanical instability due to ligament deficiency leads to a joint with increased laxity or abnormal movement under stress and can be improved with surgery if joint stability cannot be achieved with intensive and prolonged physical therapy. Ankle surgery with a direct anatomical Broström repair of the anterior talofibular and calcaneofibular ligaments is an effective procedure, although chronic ligament attenuation can mean the tissue is of poor quality and supplementation with a commercially available synthetic internal repair brace is a useful means of augmentation. Other non anatomic surgical reconstruction techniques using tendon from the ankle, knee or tissue tendon banks are usually reserved for revision cases and have traditionally resulted in a stiffer and less physiological joint function. The choice of surgical repair or reconstruction may depend on the duration of chronic instability and the physical demands likely to be placed on the joint.
Recovery from all ankle ligament surgery requires further extensive physical therapy to prevent functional instability and taping or bracing may be needed. A return to competitive sport would be unlikely before at least three months post operation. Undoubtedly some joints remain vulnerable and the need for long-term bracing may provide the physical support and joint position feedback to prevent or at least contain further instability. Chronic ankle instability can be a distressing problem which significantly delays or precludes return to normal sporting function, or at worst, giving way during normal walking. The real significance lies in the risk of joint osteochondral damage which can occur with recurrent sprains and in the longer term, the development of osteoarthritis of the ankle.
Whilst taping, bracing or proprioceptive physical therapy training are all employed effectively after acute sprains and chronic instability, it is controversial as to their role in prevention of sprains in the uninjured joint. The message from A Year on Foot at the ISEH to those tennis aficionados watching on a steep terrace or other eponymously named grassy bank at Wimbledon is clear; do take your eye off the ball and watch your footing on the uneven ground if you want to avoid Andy Murray’s ankle accessories.