Ankle complaints

Training with knee pain

The fast facts:

  • In 85% of all cases, the ankle swings inward
  • Common in adolescents between the ages of 14 and 25
  • Men sprain their ankle more often than women
  • In 5% of the cases, there may be a bone fracture in the ankle
  • In 11-18% of all cases, the syndesmosis is affected
  • Within 2 weeks, symptoms often decrease structurally
  • In the Netherlands most ankle injuries occur during soccer

    Ankle injury

    When you sprain your ankle, you often tear or strain one or more ankle ligaments. In the Netherlands, most ankle injuries occur on the soccer field. This happens with or without an opponent in the vicinity. With a tear of the ankle ligaments, the talofibular ligament is usually affected first. This is the ligament that is most forward anatomically. It is the first ligament to be stretched in a sprain moment. Depending on the severity of the injury, the other ankle ligaments will also be injured. In 5-20% of all cases that end up in the emergency room with an ankle injury, we speak of a bone fracture. Should an ankle fracture be suspected during the first physical therapy appointment, we will use the Ottawa ankle rules. This is a means to assess whether there is a reason to request an X-ray. Further injury that can occur as a result of inversion trauma is injury to the syndesmosis. This is a structure of fibers that runs from the tibia to the fibula. This syndesmosis is very important in the stability of the ankle joint. In theory, the syndesmosis holds the tibia and fibula together. In approximately 11-18% of all inversion traumas, there is injury to the syndesmosis. When there is injury to the syndesmosis, recovery takes significantly longer. In general, the duration of recovery depends on several factors. When no other structures are affected, the greatest decrease in pain occurs within the first 2 weeks. A small group of people will have complaints for a longer period of time. Often, these are complaints of instability, meaning the feeling when you fall through your ankle. The chance of an ankle injury is bigger when you have had an earlier injury to your ankle. A good rehabilitation after an ankle injury is crucial and will contribute to preventing a new injury.



    Cruciate ligament injury

    Anatomy and function of the ankle joint

    A joint is a place in the body where several bone parts come together. In the ankle, this is the tibia (upper leg) with the fibula (calf bone) and the talus (ankle bone). We also call this joint the upper ankle joint. Between these bone parts is cartilage which has a very smooth surface so that it can move smoothly. To be able to steer the ankle joint well, there are different types of ligaments in and around the ankle. On the inside and outside are ligaments that provide passive stability. Ties, bones, capsules and the position of joints provide passive stability you have no control over this. Active stability is controlled by muscles and tendons. Here you do have control. The active and passive stability together determine how strong a joint is.



    Diagnosis of ankle injury

    • In most cases, there is damage to the anterior ankle ligament the talofibular ligament anterius
    • The other ankle ligaments calcaneofibular ligament and posterior talofibular ligament are affected with a more severe ankle injury
    • In a few cases, there is also damage to the syndesmosis, which is a structure that connects the fibula to the tibia

    A distinction is made between mild, moderate and severe ankle ligament injury when there is no fracture.

    Grade 1 is only a strain. The ankle is usually tender for a few days but often recovers without problems within 1 to 2 weeks at most. 

    Grade 2 here there is a partial tear of the ankle ligaments. This is characterized in particular by severe swelling and bluish discoloration within a few days. 

    Grade 3: This is a complete tear of one or more ligaments. The risk or further injury in the ankle is greatest here. Think of a fracture of one of the bone parts or damage to the syndesmosis. Often within a day there is considerable swelling and bluish discoloration. Walking will also be difficult or even impossible here. 

    Directly after the injury, it is often not possible to make a statement about the severity. Within 3-5 days we can already make a better statement about this. The reason is the swelling and the actuality. Due to the pain, many tests are not reliable. When there is pressure pain on the outside of the ankle together with an enlarged sliding drawer(read more) then there is a chance for 90% that it is damage to the ankle ligament(s). 


    Physical testing for ankle injuries

    There are a number of described tests to understand possible ankle ligament damage:

    Front slide drawer:

    The front slide drawer is a test to test the clearance of the ankle ligaments. The person lies supine on the treatment couch. The foot and ankle come outside the treatment couch. The examiner covers the person's heel and with the other hand the tibia is fixed about 10cm above the joint. The foot is allowed to point forward 10-15 degrees for a maximum relaxed position of the joint. After this, the examiner pulls the foot forward in relation to the tibia. The test is positive when the foot can move more than 1cm forward relative to the unaffected side.

    Squeeze test from syndesmose:

    The person sits on the treatment couch with his legs hanging down. The examiner grasps the lower leg on both sides. The examiner starts at a higher position of the lower leg and squeezes the tibia and fibula toward each other. The examiner grabs different points closer and closer to the ankle joint. With severe injury to the syndesmosis, the bone parts deviate from each other which will produce recognizable pain for the person. 

    Exorotation click test: 

    The person sits with the legs hanging off the treatment couch. With one hand, the examiner holds the lower leg in the same position. With the other hand, the examiner holds the foot in a neutral position while turning the foot outward. If there are recognizable symptoms, the test is positive. What kind of injury is present depends on the location of the experienced pain. On the front side, there may be syndesmosis injury. On the inside, the inner ankle ligament can have damage. If the pain is felt on the outside, the injury is on the outside of the ankle.

      Surgical intervention or conservative treatment

      • Ankle injuries are not operated on in the vast majority of cases.
      • Sometimes when there is persistent instability, surgery can provide a solution.
      • In some cases, there is a complex fracture that needs to be repaired. 

      In people who are highly active and would like to play a sport where you have to jump, turn or cut with chronic instability, surgery can be an added value in most cases. However, the reason for this persistent instability must then be clarified. 

      Knee Osteoarthritis
      Kevin van Geel

      Rehabilitation specialist Casper Bolkenbaas

      The different stages of treatment serious ankle injury

      Successful rehabilitation consists of several phases and steps. Good strength, stability and control are necessary to safely return to your sport. Both after an operative procedure and with a conservative policy.

      After an injury where there is damage to tissue, in this case the ankle ligaments or other structures of the ankle, several phases of tissue repair take place. Immediately after the occurrence, the inflammatory phase starts. Here, the body goes to work to clear out damaged tissue in the affected area and make room for new. This phase is characterized by pain, swelling, blue discoloration, warmth and the inability to bear weight. In this phase, it is important to rest. The physiotherapist mainly advises on the policy and expectations of the recovery. In addition, some exercises can be given to restore the mobility of the ankle joint.

      The inflammatory phase takes about 7-9 days on average and runs into the proliferative phase. In this phase, new connective tissue is created. This tissue is not yet strong enough and may therefore not be heavily loaded. During the transition from the inflammation phase to the proliferation phase you will notice that symptoms such as bluish discoloration, pain, etc. will decrease. Also, the possibility to move more increases. 

      In the remodeling phase, as the name implies, the newly created connective tissue is modeled. Thus, the collagen tissue (laid down in the proliferation as type 3) is transformed to type 1. The difference is that type 1 collagen tissue is much stronger than type 3 tissue. Under pressure and tensile forces demanded of the various connective tissue structures in the remodeling, the body ensures that tensile strength of the fibers becomes stronger to accommodate as many forces as possible. This makes that in this phase of recovery, the load capacity increases but also really built up must become. We do this in different phases from basic strength to sport specific training. 

      Acute phase:
      In this phase, we focus primarily on symptom reduction. There is often swelling, pain and reduced mobility of the ankle joint. Manual techniques with exercises to increase mobility are most common in this phase. 

      Strength and stabilization phase:
      In this phase there is more of a build up in strength. Stabilizing exercises are also addressed. General fitness may also be worked on in between.

      Sport-specific phase:
      The final phase focuses particularly on maximum strength, jumping power and explosiveness. This is all necessary to be able to change direction quickly within your sport. We also work towards a competition condition so that you can continue to perform under fatigue. The quality of movement must remain good under these conditions. The chance of re-injuring your ankle is much greater under fatigue.

      Rehabilitation at Fysio Fitaal

      Severe ankle injuries can be annoying, especially after surgery. Our specialists will guide you in this process as well as possible and motivate you where necessary. Fysio Fitaal works with specialists in the field of sports rehabilitation. The combination of expertise, extensive facilities and passion for sports makes us the right place for you.

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