Ankle sprain: treatment, timing and prevention of instability in Tashkent

What is really breaking?

The outer side of the ankle is held in place by three ligaments that run from the fibula to the bones of the foot. In the vast majority of cases, the foot rolls inward, and the first to be affected is the anterior talofibular ligament - the weakest of them. For more severe injuries, the calcaneofibular ligament is attached, and for very severe injuries, the posterior ligament is attached. The inside of the joint is protected by the strong deltoid ligament, so rolling outward is less common, but usually means more serious damage.

The word “extension” has been established historically, but it does not accurately describe what is happening. The ligament consists of dense bundles of collagen fibers that have almost no stretch: their elongation limit is only a few percent of their length. Beyond this boundary, the fibers do not stretch further, but break - first single ones, then more and more. It is important to understand this for a practical reason: since we are talking about tissue rupture, it means that there is a healing phase with its own deadlines, which cannot be shortened by desire. Collagen takes weeks to restore, and in the first month the new tissue is noticeably weaker than the original, even after the pain has already passed.

1. Первая степень: надрыв отдельных волокон. Умеренная боль, небольшой отёк, ходьба возможна, сустав стабилен. Восстановление занимает 1–3 недели.
2. Вторая степень: частичный разрыв связки. Выраженный отёк, синяк, боль при опоре, появляется небольшая избыточная подвижность. Восстановление 3–6 недель.
3. Третья степень: полный разрыв. Значительный отёк и кровоподтёк, опора болезненна или невозможна, сустав нестабилен. Восстановление занимает 2–3 месяца и требует наблюдения врача.

Fracture or sprain

It is impossible to distinguish one from the other by eye: both cause pain, swelling and bruising, and sometimes with a non-displaced fracture the swelling is less than with a severe sprain. Therefore, traumatologists around the world use a simple set of signs that answers the only question - whether an x-ray is needed.

• Pain when pressing on the posterior edge or apex of the lateral malleolus
• Pain when pressing on the posterior edge or tip of the inner malleolus
• Inability to take four steps immediately after injury and in the doctor's office
• Tenderness at the base of the fifth metatarsal
• Pain in the navicular area on the inner edge of the foot

The presence of at least one sign is an indication for the image. When sprained, the area in front of and below the ankle is painful, that is, the soft tissue, not the bone itself: this is a simple guideline, but it does not replace the examination. Children have an additional feature - their growth zones are weaker than the ligaments, so where an adult receives a sprain, the child often receives a fracture along the growth zone, invisible on a regular picture. A child with pain over the bone should definitely be seen by a doctor.

First aid: what has changed

The classic “rest, ice, pressure bandage, elevation” regimen was the standard for many years, but the approach has changed. Today it is known that prolonged complete rest slows down recovery: tissues heal better with dosed loads that direct collagen fibers along tension lines. Ice is still useful in reducing pain, but it should be applied briefly and in the first day or two, rather than for weeks.

1. Первые часы — прекратить нагрузку, приподнять ногу выше уровня сердца, приложить холод через ткань на 15–20 минут с перерывами.
2. Эластичная или компрессионная повязка для ограничения отёка, не пережимающая стопу до онемения.
3. Со второго-третьего дня — дозированная ходьба с опорой на ногу настолько, насколько позволяет боль, при необходимости с тростью или костылями и в ортезе.
4. Движения стопой вверх-вниз с первых дней, если они не вызывают резкой боли, — это профилактика тугоподвижности и отёка.
5. Осмотр травматолога в первые дни, особенно если есть хотя бы один признак of списка выше.
6. Через 3–5 дней — начало полноценной программы восстановления, а не ожидание, «пока пройдёт».

Treatment: Why a cast is usually not needed

Long-term observations have shown that functional treatment - an orthosis plus early loading and exercises - gives a better result than long-term plaster immobilization, even with complete rupture of the external ligament. The cast leads to muscle weakness, joint stiffness, and loss of sense of foot position for several weeks, and after it is removed, the person has to rebuild not only the ligament, but everything else. Rigid fixation today is used briefly and for specific indications.

An important conclusion follows from this: the absence of plaster does not mean the absence of treatment. Quite often, a person leaves the doctor with an orthosis and a list of exercises, perceives it as “nothing serious” and does nothing. Meanwhile, it is the exercises that constitute the treatment here, and the orthosis is only a temporary insurance for the period until the ligament cannot withstand the lateral load. Wearing it without exercise is as pointless as taking half a course of medicine.

• Semi-rigid orthosis with lateral stabilizers - the main remedy for the first 2-6 weeks, depending on the degree
• Early dosed load on the leg according to tolerance
• Anti-inflammatory drugs for a short course as prescribed by a doctor if pain prevents movement
• Short-term rigid fixation - in case of severe rupture, damage to the tibiofibular joint, severe swelling and impossibility of support
• Surgical treatment for a fresh injury is rare: it is discussed in high-level athletes and in cases of associated injuries
• Surgery is often needed not for a fresh rupture, but years later, when chronic instability has developed

A separate situation is persistent pain 6–8 weeks after injury with a seemingly ordinary sprain. In this case, they look for what was missed: osteochondral damage to the cartilage of the talus, damage to the tibiofibular joint, dislocation of the tendons of the peroneal muscles, fracture of the process of the talus. An MRI and a follow-up examination are appropriate here, rather than another course of ointments.

The main thing: balance training

The ligaments contain receptors that continuously inform the brain about the position of the foot. When the ligament ruptures, some of these receptors die, and the brain stops recognizing in time that the foot goes inward - the muscles do not have time to react, and the person twists the leg again. This is the main mechanism of chronic instability, and it can only be restored by training. This is why balance exercises are not a nice-to-have addition, but a key part of treatment that has been proven to reduce the incidence of re-injury.

1. Первый этап: восстановление подвижности — движения стопой во всех направлениях, мягкое растяжение икроножных мышц.
2. Второй этап: сила — подъёмы на носки, отведение стопы наружу с резиновой лентой, работа малоберцовых мышц, которые активно защищают сустав от подворачивания.
3. Третий этап: баланс — стойка на одной ноге сначала с открытыми, потом с закрытыми глазами, затем на нестабильной поверхности. Начинать можно уже в первые недели.
4. Четвёртый этап: динамика — ходьба по неровной поверхности, выпады, прыжки на одной ноге, смена направления движения.
5. Общая длительность программы — 6–12 недель, независимо от того, как быстро ушла боль.
6. Возвращение к бегу и спорту — когда стойка на одной ноге с закрытыми глазами уверенная и нет отёка после нагрузки.

The peroneal muscles, which run along the outer surface of the lower leg, deserve special attention. They are the ones that turn the foot outward and are the main active protection against tucking: the ligament holds the joint passively, and the muscle has time to work and prevent the foot from moving away. After injury, these muscles almost always weaken because the person instinctively spares the outer side. A simple exercise, moving the foot outward against the resistance of a rubber band, performed daily, does more to prevent re-injury than all ointments and warming treatments combined.

When spraining is no longer harmless

Chronic ankle instability occurs when an injury leaves behind both mechanical weakness of the ligaments and loss of control over the position of the foot. A person begins to twist his leg at the slightest provocation, avoids uneven surfaces, and the joint gradually wears out: each twisting is a microtrauma of the cartilage. Over the years, this leads to ankle arthrosis, which is much more difficult to treat.

• Tucks are repeated several times a year or more often
• Feeling of uncertainty and failure when walking on uneven surfaces
• Constant or recurrent pain along the outer surface of the joint
• Intermittent swelling without obvious trauma
• Clicking and jamming in the joint - a loose fragment of cartilage is possible
• The habit of choosing only high shoes and avoiding activity

When instability has developed, a full course of rehabilitation is first prescribed - for some patients this is sufficient even after years. If the program does not help, surgery is discussed: restoration of the external ligaments with one’s own tissue. At the same time, the joint is examined arthroscopically, because with long-term instability there is almost always associated cartilage damage.