With the Patriots preparing for a Super Bowl rematch with the New York Giants, many New Englanders have shown some concern over the injury that tight end, Rob Gronkowski, sustained to his ankle when he was taken down awkwardly during the third quarter of the AFC championship game. With his presence missing at the first practice before the big, some of the local Boston sports writers are having a blast conjuring up speculations and medical information suggestive of doom and gloom for the prolific tight end. With all of this talk surrounding Gronkowski’s injury, it seemed like a perfect platform to generate a discussion demystifying one of the most frequently observed sports injuries: the ankle sprain.
Anyone who’s ever participated in athletics has likely dealt with one of the dreaded ankle issues that are always seem to come at the wrong time. In fact, the ankle is the most frequently injured major joint in the body. Despite the frequency of injury and the common use of the term sprained ankle, there are many people and athletes who are unaware of just what an ankle sprain is. Simply put, an ankle sprain involves the overstretching of the ligaments that hold the bones of the joint in their proper positions. Severe sprains may actually stretch the ligaments with such force that there can be small tears in the structural fibers.
Let’s first take a quick look at the anatomy of the joint to help better understand its role in our lower body movement. The ankle joint (talocrucal) is a hinge joint that is located at the distal end of shin bones (the tibia and fibula) and the upper part of one of the foot bones called the talus. It’s therefore a bit more complicated because of the multiple bone surfaces that are moving around each other. The ends of the shin bones form a deep socket called the maleolar mortise in which not only helps to stabilize the joint , but also serves as the location of a nifty anatomic pulley to help produce the characteristic motion of the ankle.
When we use the word sprain, many people assume that there is one ligament involved in the ankle and that all sprains are affecting this one mysterious fiber. The reality of the matter is that the joint is reinforced by a whole list of ligaments that are positioned to reinforce the positioning of the bones in the joint. Typically we group the ankle ligaments into the terms lateral ligament (made up of three separate ligaments) and medial/deltoid ligament (three continuous parts). These fibrous bands are all susceptible to overstretching, and it’s injury to any one of these ligaments that may produce an ankle sprain.
The major movements that are inherent to the ankle joint are called dorsiflexion and plantarflexion. Although these terms may seem complicated, they’re simply medical jargon for pointing your foot up (dorsiflexion) or down (plantarflexion). When our foot is plantarflexed, we are most susceptible to a bit of wobbling around the joint because of the fact that the shinbones sit a little more loosely in the mortise “pocket” that was described earlier. These wobbling motions are also given the terms eversion or inversion depending on whether you roll your ankle to the outside (eversion) or the inside (inversion).
The majority of ankle sprains (90%) occur as inversion injuries because of the way we tend to twist our weight-bearing leg. The twisting motion at the joint puts a lot of stress on part of the lateral ligament and produces characteristic pain and swelling on the outside of the ankle and subsequent instability of the joint. The less common eversion injuries occur when we roll out ankles outwards and overstretch the deltoid ligament, which produces pain and instability on the inside of the ankle.
To further help us classify and determine the appropriate treatment and prognosis of an ankle sprain, these injuries are also graded on a scale of I-III.
- Grade I: A slight overstretching of the fibers and some injury to the overall integrity. Slight swelling and tenderness.
- Grade II: A partial tearing of the ligament associated with excessive looseness of the joint. Moderate swelling and tenderness with a decreased range of motion.
- Grade III: A complete tear of the ligament, which can be seen by extreme excessive and abnormal movement around the joint. Significant swelling and tenderness along with marked instability.
Most athletes know when they’ve injured their ankle and may even experience a “pop” or “snap” when the twisting motion or lower leg blow is sustained. The pain associated with an ankle sprain really varies with the extent of the ligamentous damage and can range from mild to quite severe. With this said, it can then be understood why treatment of sprains differs between the three grades.
Grade I sprains are typically treated with the RICE technique of applying Rest, Ice, Compression, and Elevation to the injured area for about 48 hours. The only significant difference between grades I and II treatment involves the amount of rest necessary for recovery. Because of the nature of a slightly torn ligament associated with grade II sprains, more time is necessary to recover and the physician or therapist may even suggest immobilization with the use of a boot or splint. Grade III sprains are a bit more intense and typically involve the use of a short leg cast or brace for 2-3 weeks. After that, physical therapy can be indicated to help prevent chronic instability, reduce pain and increase agility.
Yet despite the fact that the different grades receive different treatment plans, all ankle sprains recover in three phases rest/immobilization, restoration of range of motion/strength, and increasing agility to baseline. Essentially, this just indicates that the more severe the sprain, the longer that it will take to cycle through these three phases of recovery.
To quickly return to our beloved tight end, Rob Gronkowski, it was reported that he sustained a high ankle sprain. Simply put, this type of injury suggests involvement of the syndesmotic fibers that are located above the ankle and connect the shinbones to each other. It’s dubbed a high sprain because of the higher location of point of injury and associated pain. Many times these are more difficult to diagnose because of the common lack of swelling that is observed with this kind of injury. In fact, many times the injury is even underestimated by both the player and trainer. Like “regular” ankle sprains, high ankle sprains are broken down into categories: stable and unstable. They simply refer to the severity and displacement of the shinbones.
Although high ankle sprains typically take a bit longer to heal, athletes may recover from these types of injuries in as little as 2-3 days (stable) or as long as 6 months (unstable). It’s many times a matter of day-by-day assessment of pain and range of motion. In the more significant scenarios individuals who sustain substantial, tearing damage to one of the syndesmotic ligaments may have more instability and a separation of the shinbones, which may require arthroscopic surgery to correct. In these cases, screws may be inserted to help hold the bones in their native positions while the ligaments heal.
Hopefully this provides a basic and better understanding of what an ankle sprain is and how a seemingly simple injury can be broken down into many different categories with varying prognoses. With the avid sports media coverage on every aspect of a sport, we commonly are barraged with opinions and diagnoses without ever getting a thorough explanation regarding the variations and details that affect a prognosis. Getting a good grasp on these basics will not only help to spot one’s own injuries, but to sift through some of the misinformation that may be inadvertently distributed by newspapers and journalists.
So as all us in Boston and all of New England are amping up for the big day, it’s only appropriate to offer some final regards regarding the Super Bowl:
SPEEDY RECOVERY TO GRONK AND LET’S GO PATS!!!!! MAKE US PROUD!
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Moore, KL, Agur, AM. (2007). Essential Clinical Anatomy. Philadelphia, PA: Lippincott Williams & Wilkin.
Plowman, SA., Smith, DL. (2008). Exercise Physiology for Health, Fitness, and Performance. Philadelphia, PA: Lippincott Williams & Wilkin.