As of December 16th, Rotoworld is reporting 11 ankle sprains approximately 28 games into the 2019/20 NBA season. In September of 2019, the American Journal of Sports Medicine published a longitudinal study to describe the epidemiology of ankle sprains among NBA players. The study began with the 2013/14 through 2016/17 seasons. Data was collected through the league’s electronic medical record system. During the study period, there were 796 ankle sprains among 389 players. Ankle sprains affect approximately 26% of NBA players on average each season. They can be categorized as high, low, medial (inside) or lateral (outside). Eighty percent of the 796 ankle sprains reported in this study were lateral so I’ll limit this blog to the lateral ankle sprain.
Ankle sprains like any soft tissue injury are classified as 1st degree (mild), 2nd degree (moderate) or 3rd degree (severe).
1st degree is some stretching of the ligament with minor pain, no loss of strength or range of motion and no loss of time.
2nd degree is a partial tear of the ligament with significant pain, some loss of strength and range of motion and some loss of time.
3rd degree is a complete tear of the ligament with severe pain, complete loss of strength and range of motion and significant loss of time.
The medical term for the ankle joint is the talocrural articulation. In carpentry terms, the ankle is a mortise and tenon joint. The mortise is formed by the ends of the tibia (inside of the ankle) and fibula (outside of the ankle). The tenon is the bone that fits in between the tibia and fibula called the talus. The inside of the ankle bears more weight than the outside. Under the talus is the calcaneus or heel bone to form the subtalar joint. The ankle joint is held together by a capsule and ligaments.
The lateral (outside) aspect of the ankle is reinforced by three ligaments:
The anterior talofibular ligament is a weak band that connects the front of the talus to the fibula. It is the most commonly injured ankle ligament whose function is to prevent the talus from moving forward from the tibia and fibula (mortise). It also prevents the ankle from rolling in (inversion).
The posterior talofibular ligament is a strong band that runs horizontally across the back of the ankle to connect the back of the talus to the fibula. It prevents the talus from being displaced backward and is rarely injured because of the greater boney stability at the back of the ankle.
The calcaneofibular ligament is a cordlike ligament that connects the calcaneus (heel bone) to the fibula. It helps the anterior talofibular ligament from the ankle rolling in (inversion). It also prevents the talus from tilting.
The medial (inside) aspect of the ankle is reinforced by the anterior tibiotalar ligament, the posterior tibiotalar ligament, the tibionavicular ligament and the tibiocalcaneo ligament. Collectively these ligaments form a strong broadband that are referred to as the deltoid ligament to provide stability to the medial (inside) aspect of the ankle. It is very difficult to injure the deltoid ligament and I’ll address medial ankle sprains in a future blog.
As reported, 80% of NBA ankle sprains were lateral (inversion) sprains. In the general population, that number is actually higher (85%) with a recurrence rate of about 70%. Previous injury may compromise the strength and integrity of the ligaments and interrupt sensory nerve fibers. The mechanism of injury of a lateral ankle sprain is landing on a foot that is inverted (rolled in) along with plantar flexion (foot pointed towards the floor) and internal rotation (foot rotated towards the midline of the body). The athlete can sustain this injury from simply landing on an inverted foot or someone else’s foot.
When evaluating the lateral ankle sprain the athlete will almost always present themselves with pain over the anterior talofibular ligament. Depending on the severity of the sprain, there may also be damage and pain over the calcaneofibular ligament and the posterior talofibular ligament. In severe lateral ankle sprains, I often saw residual pain on the medial side of the joint. This is the result of the talus impinging on the end of the tibia resulting in damage to the articular cartilage or a bone bruise. In my experience, after the torn ligaments were healed, medial pain was the last to be resolved.
I’m often asked how do professional athletes return so quickly from ankle sprains. Professional athletes have the best acute care. Acute care is what the athletic trainer does to prevent swelling and inflammation from an acute injury. For an ankle sprain that includes ice, compression and elevation.
I’ve seen severe ankle sprains blow up with swelling before I could get the player from the court to the training room. Although most people think that ice is the most important thing in acute care I think compression is. If you can control the swelling the body will heal itself quickly. The reason for this is that you will not lay down new cells (fibroblasts) until the body has reabsorbed all the damaged cells and the fluid that has leaked out of the cells and into the spaces between the cells (interstitial spaces).
The best way to accomplish this is to apply a compression wrap and put the ankle into an ice bucket for no longer than 20 minutes depending on how cold the ice submersion is. Ice will help control swelling but maybe, more importantly, it will slow down the metabolism of undamaged cells to reduce the amount of cellular death. The reasoning behind this is that the body’s defense mechanism to an acute ligament tear in the ankle is to reduce blood flow to that area. The reduction of blood flow will increase cellular death due to a hypoxic reaction (lack of oxygen to the cell). Slowing down the metabolism to the undamaged cells will protect them from the hypoxic reaction by requiring less oxygen to survive. The reduction of cellular death translates into an expedited healing curve and a reduction of time loss.
After the ice submersion with compression, the athlete is placed into a dry compression wrap. This is hard on the athlete because the ankle wants to swell and by preventing it from doing so the athlete will experience severe throbbing pain. Keeping the wrap on for extended periods of time will prevent swelling. Kobe Bryant was the best at handling that pain which generally lasts from 24 to 48 hours post-injury. Almost all athletes will ask for the wrap to be removed at some point. When that point comes, you should remove the wrap, immediately ice the ankle for 20 minutes and then re-wrap it. Keep doing this over and over until the ankle has stopped swelling.
Whatever residual swelling that the athlete has must be pumped out. This can be done a number of ways. I was partial to the Normatec pneumatic pumping system. Normatec uses a pulsed compression boot/sleeve to move fluids out of limbs and into the lymphatic system. I also liked the Marc Pro electro-stimulation system. Marc Pro uses electrodes to contract muscles to push fluids out of the extremities through the venous return. Probably the most effective for me was my hands. Commonly referred to as effleurage I would apply a massage cream to the end of the foot and would literally use my hands to push the swelling out of the foot/ankle and up the lower leg. Most definitions of effleurage use the words gentle massage. To do it correctly, there is nothing gentle about it and it can be uncomfortable to the athlete as you roll your hands over the injured structures. There can also be significant internal bleeding at the site of the torn tissue. The iron in the blood is an irritant and tender to touch but it must be pumped out of there to speed up healing time.
Once the inflammatory process in under control, the body will go into overdrive to lay down scar tissue over the torn ligaments. Next is beginning the rehab process to restore stability and function to the foot and ankle. I think it is important to see a good physical therapist or athletic trainer to accomplish this. It’s more than just doing strengthening exercises. The ankle needs to be stable but the foot needs to be mobile so there are mobilization techniques that are important to full recovery. For instance, when Kobe Bryant injured his ankle during the 2000 NBA finals he also suffered from cuboid syndrome which is the displacement of a small bone in the foot that is commonly displaced with lateral ankle sprains. Even though we controlled the swelling and restored strength and stability, it wasn’t until I manipulated his cuboid that he was able to return to play. This is not something you can do on your own. You need a professionally trained physical therapist or athletic trainer to accomplish this.
These professionals will help control the inflammatory process, regain full range of motion of the ankle and return strength and power. The last part of the puzzle prior to return to play has to do with neuromuscular compromise. It is integral to develop neuromuscular control to the foot and ankle prior to return to play. Failure to do so will result in re-injury and chronic instability.
Prophylactic taping and bracing for ankle sprains has been a controversial topic for a long time with studies on both sides of the efficacy line. My personal opinion is you should tape or brace if you have an unstable ankle or you feel psychologically better with your ankles stabilized during competition. If you have a stable ankle and don’t feel the need for taping then don’t.
Although I believe both taping and bracing may provide ankle stability it also changes one’s foot mechanics and where the loads go up the kinetic chain during walking, running and jumping. This could lead to other injuries and stress reactions. The last consideration is that prophylactic strapping or bracing may not completely prevent an ankle sprain but it may reduce the severity. If the odds are 26% of NBA players will sustain an ankle sprain during the season than that probability should be considered in the decision.