What are the main prognostic factors for ankle sprains. How do different treatment approaches impact recovery time. Can chronic ankle instability be prevented after an initial sprain. What percentage of patients experience full recovery from ankle sprains. Which ligaments are most commonly affected in ankle sprains.

The Prevalence and Impact of Ankle Sprains

Ankle sprains represent one of the most prevalent musculoskeletal injuries, with a significant impact on both athletes and the general population. Understanding the scope of this issue is crucial for healthcare providers and patients alike.

• Incidence rate: 11.6 per 1000 exposures
• Prevalence: 11.9%
• Percentage of sports injuries: 10-30%

These statistics highlight the pervasive nature of ankle sprains and underscore the importance of effective management strategies. But what exactly constitutes an ankle sprain?

Defining Ankle Sprains

An ankle sprain refers to the injury mechanism rather than a specific diagnosis. The most common mechanism, accounting for 85% of cases, involves inversion and adduction of a plantarflexed foot. This action typically affects the lateral ankle ligaments, but the injury pattern can vary.

Anatomy of Ankle Sprains: Which Structures Are Most Vulnerable?

Understanding the anatomy involved in ankle sprains is crucial for accurate diagnosis and treatment. Which ligaments are most commonly affected in these injuries?

1. Anterior talofibular ligament (ATFL) – the weakest and most frequently injured
2. Calcaneofibular ligament (CFL)
3. Posterior talofibular ligament (PTFL)

While the lateral ligament complex is most often involved, it’s important to note that ankle sprains can extend beyond these structures. Additional injuries may include:

• Subtalar ligaments
• Transverse ligaments
• Syndesmotic ligaments
• Deltoid ligament (medial side)
• Tendons surrounding the ankle
• Cartilage damage
• Bone bruises

These associated injuries can complicate the clinical picture and affect the prognosis. How do healthcare providers approach the initial treatment of ankle sprains?

Current Treatment Approaches for Acute Ankle Sprains

The initial management of ankle sprains typically follows a conservative approach. The standard protocol includes:

1. Rest
2. Ice
3. Compression
4. Elevation (RICE protocol)

Following this acute phase, treatment progresses to:

• Active range of motion exercises
• Neuromuscular training
• Peroneal muscle strengthening

This conservative approach is successful for a majority of patients. However, recovery times and outcomes can vary significantly. What factors influence the prognosis of ankle sprains?

Prognostic Factors in Ankle Sprains: What Determines Recovery?

Identifying prognostic factors for ankle sprains is crucial for tailoring treatment approaches and setting realistic expectations for patients. While research in this area is ongoing, several factors have been associated with recovery outcomes:

Positive Prognostic Factors

• Early weight-bearing and mobilization
• Adherence to rehabilitation protocols
• Younger age
• Lower body mass index (BMI)
• Absence of concomitant injuries

Negative Prognostic Factors

• High-grade ligament tears
• Previous history of ankle sprains
• Delayed initiation of treatment
• Poor proprioception and balance
• Presence of associated injuries (e.g., syndesmotic involvement)

Understanding these factors can help clinicians identify patients who may be at risk for prolonged recovery or chronic instability. How does this information impact treatment decisions?

Tailoring Treatment Based on Prognostic Factors

Recognizing prognostic factors allows healthcare providers to adopt a more personalized approach to ankle sprain management. For patients with poor prognostic indicators, a more aggressive initial treatment strategy may be warranted. This could include:

• Earlier referral to physical therapy
• More intensive proprioceptive training
• Consideration of supportive devices (e.g., ankle braces)
• Closer monitoring and follow-up

Conversely, patients with positive prognostic factors may benefit from a more streamlined rehabilitation process. How do these approaches impact long-term outcomes?

Long-Term Outcomes and Chronic Ankle Instability

Despite appropriate initial management, a significant proportion of patients experience long-lasting symptoms following an ankle sprain. These persistent issues can lead to chronic ankle instability (CAI), a condition characterized by:

• Recurrent ankle sprains
• Feeling of ankle instability or “giving way”
• Persistent pain and swelling
• Functional limitations

The prevalence of these long-term complications is significant:

• Up to 70% of patients develop long-lasting symptoms
• 5-33% report pain at 1-year follow-up
• 5-25% still experience pain after 3 years
• Re-sprain rates range from 3-34%
• Subjective instability affects 0-33% of patients

These statistics highlight the importance of identifying at-risk patients early and implementing strategies to prevent chronic instability. But what exactly constitutes chronic ankle instability?

Defining Chronic Ankle Instability

Chronic ankle instability is typically diagnosed when symptoms persist beyond 12 months from the initial injury. It can be categorized into two main types:

1. Mechanical ankle instability: Characterized by increased ligamentous laxity
2. Functional ankle instability: Involves impaired proprioception and neuromuscular control without objective laxity

Understanding these distinctions is crucial for developing targeted treatment strategies. How can healthcare providers work to prevent the development of chronic ankle instability?

Strategies for Preventing Chronic Ankle Instability

While not all cases of chronic ankle instability can be prevented, several strategies may reduce the risk of long-term complications:

• Early and appropriate initial management
• Comprehensive rehabilitation programs focusing on:
  • Proprioception training
  • Neuromuscular control exercises
  • Peroneal muscle strengthening
  • Balance and coordination drills
• Patient education on proper ankle protection and injury prevention
• Gradual return to activity with appropriate support
• Regular follow-up to assess recovery progress

Implementing these strategies may help improve long-term outcomes for patients with ankle sprains. But how effective are current treatment approaches in achieving full recovery?

Recovery Rates and Time Frames: What Can Patients Expect?

The recovery process following an ankle sprain can vary significantly between individuals. Current data suggests:

• 36-85% of patients report full recovery
• Recovery time ranges from 2 weeks to 36.2 months

This wide range in recovery rates and time frames underscores the complex nature of ankle sprains and the importance of individualized treatment approaches. What factors contribute to this variability in outcomes?

Factors Influencing Recovery Time

Several elements can impact the duration and completeness of recovery:

• Severity of the initial injury
• Presence of associated injuries
• Timeliness and appropriateness of initial treatment
• Patient adherence to rehabilitation protocols
• Individual healing capacity
• Activity level and demands on the ankle

Understanding these factors can help healthcare providers set realistic expectations for patients and tailor treatment plans accordingly. But what about cases where conservative treatment fails to achieve satisfactory outcomes?

When to Consider Surgical Intervention

While the majority of ankle sprains respond well to conservative management, there are instances where surgical intervention may be necessary. Currently, there are no clear-cut indications for acute surgical treatment of ankle sprains. However, delayed surgery may be considered in cases of:

• Persistent instability despite appropriate conservative treatment
• Recurrent ankle sprains
• Significant ligamentous laxity
• Associated injuries requiring surgical repair (e.g., osteochondral lesions)

The decision to pursue surgical treatment should be made on a case-by-case basis, taking into account the patient’s individual circumstances, activity level, and treatment goals. How can healthcare providers navigate this decision-making process?

Evaluating the Need for Surgery

When considering surgical intervention for ankle sprains, healthcare providers should assess:

• The duration and severity of symptoms
• The impact on the patient’s quality of life and functional abilities
• The results of conservative treatment attempts
• Imaging findings (e.g., MRI evidence of ligament damage)
• The patient’s activity level and future goals

By carefully evaluating these factors, clinicians can make informed decisions about the most appropriate treatment approach for each patient. What are the potential long-term consequences of ankle sprains, particularly in cases of chronic instability?

Long-Term Consequences of Ankle Sprains and Chronic Instability

While many patients recover fully from ankle sprains, those who develop chronic instability may face long-term consequences. These can include:

• Increased risk of recurrent sprains
• Persistent pain and swelling
• Reduced physical activity and sports participation
• Decreased quality of life
• Potential for early-onset osteoarthritis

The link between mechanical ankle instability and subsequent degenerative changes in the ankle joint is particularly concerning. How can healthcare providers work to mitigate these long-term risks?

Strategies for Mitigating Long-Term Risks

To reduce the risk of long-term complications following ankle sprains, healthcare providers can:

• Emphasize the importance of complete rehabilitation before returning to full activity
• Implement comprehensive injury prevention programs
• Provide patient education on proper ankle care and early recognition of instability symptoms
• Consider prophylactic bracing or taping for high-risk activities
• Conduct regular follow-ups to monitor for signs of developing instability

By taking a proactive approach to ankle sprain management and follow-up care, healthcare providers can help patients achieve better long-term outcomes and reduce the risk of chronic instability.

Future Directions in Ankle Sprain Research and Management

As our understanding of ankle sprains and their prognostic factors continues to evolve, several areas warrant further investigation:

• Development of more accurate predictive models for identifying high-risk patients
• Exploration of novel treatment modalities to enhance ligament healing and prevent chronic instability
• Investigation of the role of genetics in ankle sprain susceptibility and recovery
• Refinement of rehabilitation protocols based on individual patient factors
• Long-term studies on the effectiveness of various prevention strategies

Advancing research in these areas may lead to improved management strategies and better outcomes for patients with ankle sprains. What role can emerging technologies play in ankle sprain diagnosis and treatment?

The Role of Technology in Ankle Sprain Management

Emerging technologies have the potential to revolutionize the way we approach ankle sprain diagnosis and treatment. Some promising areas include:

• Advanced imaging techniques for more precise injury characterization
• Wearable devices for monitoring rehabilitation progress and detecting instability
• Virtual reality systems for enhancing proprioceptive training
• Artificial intelligence algorithms for predicting recovery trajectories
• 3D-printed custom orthotics and braces for improved support

As these technologies continue to develop, they may offer new avenues for personalizing ankle sprain management and improving patient outcomes. How can healthcare providers stay informed about the latest advancements in ankle sprain care?

Staying Current with Ankle Sprain Research

To provide the best possible care for patients with ankle sprains, healthcare providers should:

• Regularly review current literature and clinical practice guidelines
• Attend relevant conferences and continuing education courses
• Participate in professional networks and discussion forums
• Collaborate with colleagues to share experiences and insights
• Consider involvement in clinical research studies

By staying informed about the latest developments in ankle sprain management, healthcare providers can ensure they are offering their patients the most up-to-date and effective care strategies.

Prognostic factors in ankle sprains: a review

EFORT Open Rev. 2020 Jun; 5(6): 334–338.

Published online 2020 Jun 1. doi: 10.1302/2058-5241.5.200019

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Author information Copyright and License information Disclaimer

• Ankle sprains are one of the most common musculoskeletal injuries, being the most frequent musculoskeletal trauma among athletes.

• Most of these injuries are successfully treated conservatively; however, up to 70% of patients can develop long-lasting symptoms. Therefore, understanding prognostic factors for an ankle sprain could help clinicians identify patients with poor prognosis and choose the right treatment.

• A suggested approach will be presented in order to positively identify the factors that should warrant a more aggressive attitude in the initial conservative treatment.

• There are some prognostic factors linked to a better recovery and outcome; nevertheless, prognostic factors for full recovery after initial ankle sprain are not consistent.

Cite this article: EFORT Open Rev 2020;5:334-338. DOI: 10.1302/2058-5241.5.200019

Keywords: ankle sprains, prognostic factors in ankle sprains

Ankle sprains are one of the most common musculoskeletal injuries, with an estimated incidence rate of 11.6 per 1000 exposures and a prevalence of 11.9%.^1,2 They are the most frequent musculoskeletal trauma among athletes, representing 10–30% of all sports injuries.^3–5

Whenever we refer to ankle sprains, we are not describing the diagnosis but instead the injury mechanism. Inversion and adduction with a plantarflexed foot is the mechanism in 85% of ankle sprain injuries.⁶ The most commonly affected ligament is the anterior talofibular ligament (ATFL), which is the weakest of the three lateral ankle ligaments, followed by injury of the calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL).^3,6–11 However, injury may not be confined to the lateral ligament complex and may extend to the subtalar, transverse, syndesmosis and/or medial side of the ankle. ⁷ Thus, involvement of the interosseous, cervical, bifurcate, tibiofibular (syndesmotic) or deltoid ligaments is not rare and associated injuries to the tendons around the ankle, cartilage damage and bone bruises are frequently induced in cases of acute ankle sprains.^6,7 These cases represent complex injuries of the ankle joint that have a different natural history from simple ankle sprains, this is, isolated lateral ligament injuries. When referring to ankle sprains, one must not forget that other mechanisms may have occurred, resulting in different patterns of injury.

Current treatment approach involves rest, ice, compression, and elevation followed by active range of motion, neuromuscular training and peroneal strengthening, since a large majority of these injuries are successfully treated conservatively.^1,8,12,13 Ranging from 2 weeks to 36.2 months follow-up, 36% to 85% of all patients reported full recovery.¹ The great variation in recovery time and full recovery rate represents the great variability of such injuries, highlighting the importance of defining prognostic factures in these situations. There are no clear indications for cases demanding acute surgical treatment, hence final treatment may be delayed in some cases because conservative treatment is always attempted before surgery. The goal of this review was to identify prognostic factors that may guide our initial approach and can provide information for the expectations of these patients.

After an acute ankle sprain, up to 70% of patients can develop long-lasting symptoms: feeling of ankle instability (‘giving way’), pain, swelling and recurrent sprains, ultimately resulting in functional limitations.³ The proportion of patients who reported that they still experienced pain at 1-year follow-up or longer ranged from 5% to 33%. After 3 years, 5% to 25% of patients still experienced pain. The occurrence of a re-sprain ranged from 3% to 34% of the patients, and a subjective instability ranged from 0% to 33%.^1,3,14–16 These persistent symptoms are the main features of chronic ankle instability (CAI). Chronic ankle instability is defined as the perception of ‘giving way’ in combination with a history of recurrent ankle sprains, along with the sensation of ankle instability and persistent disability (pain, swelling etc.) that was not resolved in the time-frame from the initial sprain to the 12-month follow-up.¹⁶

Historically, a differentiation has been made between functional ankle instability and mechanical ankle instability or a combination of these. Mechanical ankle instability corresponds to an augmented laxity and has been linked to subsequent degenerative changes of the ankle.³ In functional instability, objective joint laxity is not increased, but functional insufficiencies such as impaired proprioceptive and neuromuscular control are present.

Chronic ankle instability has often been referred to as the insufficiency of the lateral ligament complex, but recently, attention to associated ligament injuries has brought authors to describe terms such as ‘global ankle instability’, ‘rotational ankle instability’, and ‘multidirectional ankle instability’, to define complex multiligament ankle injuries. Such definitions are relatively recent to the orthopaedic community, thus evidence using these concepts is lacking. Insufficient diagnosis may be the reason for such different outcomes and for the unclear indication of which injuries may benefit from early surgical repair.

Understanding prognostic factors for an ankle sprain could help clinicians identify patients with a poor prognosis and choose the right treatment. Conversely, identifying patients with a good prognosis could have benefits for healthcare, health cost and resource use. Many prognostic variables are proposed (see ).

Table 1.

Prognostic factors and their relationship to clinical outcome

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Despite insufficient evidence to recommend any factor as an independent predictor of outcome,¹⁴ there were some prognostic factors linked to a better recovery and outcome: young age, low activity level, low grade injury, good functional status, good neuromuscular function and no other associated injury. ^{14,17,18,20,25,28}

Thompson et al¹⁴ concluded that higher baseline age was associated with poor recovery in short, medium and long-term follow-up periods. Sports activities at a high exercising level (training three times a week or more) was a significant prognostic factor for residual symptoms in comparison to a low exercising level (training less than three times/week) and no sports activities.^1,14,17 De Bie et al¹⁸ concluded that prediction for two-week recovery can be given based on initial functional score, where patients with better functional status experience faster recovery and no long-term sequelae. This conclusion was corroborated by Thompson et al’s study, which states that measures of functional ability explained the larger part of the variance of recovery,¹⁴ and Kobayashi et al¹⁹ observed that normal muscle activity patterns are important for a good outcome after injury.

Langner et al,²⁰ using 3 Tesla Magnetic Resonance Imaging (3T MRI) evaluation found three baseline prognostic factors associated with greater time to return to sports activities: greater number of injured ligaments determined by MR, more severe MR grading of injury, and presence of a bone bruise. However, other authors argue that injury grade does not seem to be a strong predictor for the course of lateral ankle sprains.¹ Relation between degree of injury and CAI has been matter of debate: only a minority of patients with CAI have an isolated injury to the ATFL while the majority have two or more injuries.^9,14,20 Although bone bruises may represent a bad sign in terms of prognosis, their natural history is generally good, with normalization of the MR appearance within 6 to 12 months after trauma.⁶ Subchondral bone oedema may represent a cartilage injury, which may carry a different outcome.^6,11 Prognostic factors associated with a bad outcome are systemic laxity,^12,25 joint geometry,^12,17,26 re-sprain,^25,28 limb/foot malalignment^17,26,27,29 and multiligament injuries.^14,20,25,28

Some anatomic factors may predispose to CAI – hindfoot varus, pathologic ligament laxity, and an osseous configuration of the ankle joint where the talus is less restrained in the ankle mortise. ¹³ A larger talar radius (a flatter talus), and a tibiotalar sector ≤ 82º (the angle of the lines drawn from the centre of the talus to both the anterior and posterior margins of the distal tibia, indicating the tibial coverage of the talus) (), reflects less restraint of the talus in the tibia, which are significantly correlated with CAI and could, therefore, be considered intrinsic risk factors for CAI after an ankle sprain.¹⁵ Other factors such as a frontal curvature ≥ 2 mm, and an anterior position of the talar centre of rotation to the anatomical axis of the tibia ≥ 4 mm ()²⁷ may also represent risk factors for CAI.

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Measurements of the osseous ankle configuration on lateral radiographs – TibCOR = distance between the tibial axis and the talar center of rotation. Sector = tibiotalar sector (the angle of the lines drawn from the center of the talus to both the anterior and posterior margins of the distal tibia, indicating the tibial coverage of the talus).

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Measurements of the osseous ankle configuration on frontal radiographs FroCu = depth of the frontal curvature of the talus.

Hubbard-Turner and colleagues¹² concluded that a significant relationship between mechanical ankle laxity and a decrease subjective function of the ankle exists. Increased laxity, caused by improper ligament healing, may lead to neuromuscular impairment, altering ankle joint stability. In another study, Medina McKeon et al²⁸ have concluded that after the first sprain, tissue damage alone is not a good prognostic indicator; however, there is higher risk of a new and more severe ankle sprain.

At the time of the initial sprain, limb/foot malalignment, such as a posterior fibular position, a varus plafond, or a cavus foot may predispose patients to chronic ankle instability.²⁶ The evaluation of a plantarflexed first ray is also important to mention since it explains why the cavus is forefoot driven and the flexible cavovarus foot. ²⁹

Lastly, there is not an homogeneous conclusion about gender and body mass index (BMI) effects on prognosis.^{1,14,17,21–24} Regarding gender, some studies demonstrate that men have an increased risk of residual symptoms compared with women.¹ On the other hand, others observed slower and incomplete recovery in the female gender.^14,21 Although high BMI is linked to a higher risk of ankle sprain,^22–24 the effect on the injury’s prognosis is not as clear. Weight-bearing ability after injury is related to a better short-term prognosis.¹⁴

Poor outcomes may also be related to associated injuries () in a stable ankle or an ankle that has healed properly, where pain is the only reported symptom – osteochondral lesions are present in up to 89% of ankle sprains with chronic instability.^3,30 It is well known that subtalar disorders, for example, sinus tarsi syndrome or subtalar instability, are the major causes of chronic ankle pain after an inversion ankle sprain. ⁷

Table 2.

Ankle sprain associated injuries

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Various forms of peroneal tendon pathology, including tenosynovitis, tendon or retinaculum rupture and dislocation can result in chronic symptoms following an ankle injury. ^5,33 In patients undergoing surgery for chronic lateral ankle instability, 77% had peroneal tenosynovitis, 54% had an attenuated peroneal retinaculum, and 25% had a peroneus brevis tear.³³ Chronic peroneal tenosynovitis is often misdiagnosed initially as an ankle sprain in patients with a history of inversion injuries.⁵

Ankle sprain is the leading cause of impingement syndromes.^5,34 It is estimated that the incidence of anterolateral impingement syndrome is 3% following ankle sprains, and, in this condition, the synovial membrane hypertrophies and scars in response to repeated sprains, causing severe morbidity and pain, particularly amongst athletes and the younger population.⁵ Despite evidence of the limitations of its efficacy, nonsurgical treatment remains the initial approach to the management of impingement syndromes.³⁴ However, most patients will be subjected to surgical approaches to treat this syndrome, mainly when it affects normal activities of a daily living or athletic performance. ³⁴

The exact incidence of peroneal nerve palsy following ankle sprain is unknown, but peroneal nerve injury associated with inversion ankle sprains has been reported.³⁵ Peroneal nerve injury results in a weakness of ankle musculature, which is evident during rehabilitation.³⁵ Conservative and surgical treatments have been described for peroneal nerve palsy. In all cases, complete recovery occurred within 3 weeks to 6 months after the ankle sprain, and there was no convincing evidence that the early surgical exploration of the nerve is indicated.³⁵

The authors suggest a systemized approach to the patient with an acute ankle sprain (). Early evaluation, despite limited clinical exam, can determine many prognostic factors. The positive identification of these factors should warrant a more aggressive attitude in the initial conservative treatment. An orthotic with functional brace, or even a rigid fixation in high-grade/low-functional cases, should be emphasized in these cases. Weight-bearing progression should also be delayed. The threshold for radiography should be low and performed with weight-bearing as tolerated. Ultrasound can be considered where there is a suspicion of associated injuries such as peroneal tendon dislocation.

Table 3.

Approach to the patient with an acute ankle sprain

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Note. BMI, body mass index; AP, anteroposterior; FADI, Foot and Ankle Disability Index; FAAM, Foot and Ankle Ability Measure; US, ultrasonography; MRI, magnetic resonance imaging.

The value of stress radiographs in the acute clinical setting is questionable because the findings are severely influenced by the radiographic technique, the amount of force applied to the joint and the patient’s cooperation.²⁰ However, the stability of the ankle joint could be influenced by its osseous configuration and this can be calculated with an X-ray.

Delayed evaluation (day 4 to day 14) is of the utmost importance. At this point it is possible to understand the character of the injury, depending on the recovery from day 1. It is also possible at this point to conduct a good physical exam, and full characterization of ligament injury, laxity and associated lesions must be made. Magnetic resonance imaging (MRI) can be considered in severe cases with bad evolution or when an associated lesion is suspected. According to several studies, the MRI seems to be a good initial instrument to demonstrate the anatomy and extent of injuries of the ligamentous complex.^18,20 It has a correlation among surgical findings and it is a significant predictor of the clinical outcome.^9,20 However, MRI fails to show the dynamic function of the ligaments.³⁶

It is true that conservative treatment provides excellent clinical outcomes in the majority of acute injuries, but comprehensive characterization of the injury can provide better guidance for the timing of weight-bearing progression, start and progression of the rehabilitation programme, and orthotic wear-off. Future studies should further refine the diagnosis of ankle sprains, defining which ligaments are injured and distinguishing ligament injury from pathologic ligament laxity. The authors believe that with such characterization it will be possible to define patients who would benefit from initial surgical treatment.

Prognostic factors for full recovery after initial ankle sprain are not consistent, thus it is still unknown who benefits from acute surgical treatment. Nevertheless, many factors have been identified that increase the probability of a poor outcome. Currently, early surgical treatment may be considered for: high-level/high-demand athletes, severe injuries (bone bruise, multiligament, persistent pain, re-sprains) and associated injuries (bony avulsion or cartilage injury).

ICMJE Conflict of interest statement: MRS reports consultancy for Arthrex outside the submitted work.

The other authors declare no conflict of interest relevant to this work.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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causes, symptoms and treatment in the article of the traumatologist Sapunkov S.

A.

Above the article of the doctor

Sapunkov Sergey Alexandrovich

worked

literary editor
Vera Vasina,

science editor
Matvey Shiltsin

And

chief editor
Margarita Tikhonova

Publication date November 24, 2021Updated July 26, 2022

Disease definition. Causes of the disease

Sprain (Sprain) is a tear in the structures that stabilize the joint. It usually occurs due to sudden movements that exceed the normal amplitude of the joint ^[1] . It is manifested by limitation or, conversely, by excessive mobility of the joint, swelling, bruising, pain during movement and pressure on the damaged area.

In everyday life, joint pain that occurs after a fall or an unsuccessful movement is called “tendon sprain”, “ligament sprain”, “muscle sprain”, but this is not the same thing.

Ligaments are connective tissue structures that connect bones and stabilize the joint, whether the person is running or lying down. They contain many nerve endings that allow you to determine the position of the joint, the range of motion, etc.

Tendons are connective tissue structures that attach muscles to bones. Sometimes tendons act as active joint stabilizers, that is, they hold the bone in the joint during movement.

Muscles are organs that consist of muscle tissue that can contract under the influence of nerve impulses. Contracting and relaxing, they play the role of active stabilizers of the joint, provide movement and correct spatial arrangement of the bones that form the joint.

Causes of sprains

Sprains most often occur when a person twists their leg while walking, stumbles or falls. In addition, people who are actively involved in sports periodically encounter such damage. Injuries can occur when lifting heavy loads, swinging or throwing a ball

Factors contributing to sprains:

• obesity;
• diabetes mellitus;
• age – the older the person, the higher the risk of ligament damage;
• features of the structure of the foot – flat feet or high instep;
• uncomfortable shoes;
• unpreparedness for sports load.

These factors reduce the ability of the ligaments to withstand stress, which increases the risk of injury.

Consult your doctor if you experience similar symptoms. Do not self-medicate – it is dangerous for your health!

Sprain symptoms

Sprain is manifested by the following symptoms:

• Pain during movement in the joint, increases when trying to turn the joint to the injured side.
• Pain when pressing on the area of ​​the stretched ligaments and their attachment to the bones.
• Pain when trying to lean on a leg with damaged ligaments. In rare cases, it is not possible to step on the foot at all.
• Gradually increasing edema. Sometimes it reaches large sizes, for example, the girth of the leg can increase by 2-3 cm.
• Hematoma (bruise), redness and fever of the skin in the area of ​​injury. Often a hematoma appears on the second day and is located just below the site of injury.
• In case of an injury of moderate severity, the mobility of the joint is significantly limited. Because of the pain, it is impossible to make a movement in the joint, for example, the arm does not bend or unbend at the elbow.
• With a complete rupture of the ligament, the joint becomes excessively mobile and unstable, which is especially noticeable after the edema subsides. Mobility, as a rule, is accompanied by pain symptoms of varying strength – from mild discomfort to sharp pain.
• With moderate to severe trauma, sometimes you can hear a pop – this is a sign of a torn fiber in the ligament ^[3] .

Children’s sprains

Children’s ligaments are more elastic than adults’, so they are less likely to be injured. Symptoms in children and adults are the same. The cause of the injury is the same – an unsuccessful load on the limbs.

The pathogenesis of sprains

Ligaments look like hard white strips of tissue firmly attached to bones ^[1] . They consist of water (by 60–70%) and dry matter. Up to 80% of the dry matter is collagen type I and II protein. In addition, the ligaments contain the protein elastin. Transforming, like a spring, from a spherical structure into a spiral structure, elastin allows the ligaments to resist stretching.

The bundles also contain fibroblasts. Their number may vary even in different parts of the same bundle. The more fibroblasts, the faster the tissue recovers from injury.

Ligaments are permeated with small vessels and nerve cells. They provide the flow of blood and nutrients, as well as innervation – the connection of organs and tissues with the central nervous system with the help of nerves.

Damage to ligaments and blood vessels triggers a progressive reaction that gradually leads to healing of the ligaments.

Restoration of ligaments takes place in three stages:

1. Inflammatory stage.
2. Recovery stage, or collagen production.
3. The stage of remodeling, or the rebuilding of new tissue.

Inflammatory stage

The first stage lasts 8-10 days. First, a hematoma is formed and an inflammatory reaction occurs, in which the fibrin protein begins to accumulate. Its clots form the basis of a thrombus, which is formed during blood clotting. Within 2–3 days after injury, the fibrin clot fills with cells, including protein-producing fibroblasts. The clot and dead tissue are then replaced with a soft and loose fibrous matrix containing type III collagen, plenty of water and glycosaminoglycans.

Glycosaminoglycans are carbohydrates that are part of the intercellular substance of connective tissue. Together with collagen and elastin fibers, glycosaminoglycans form a connective tissue matrix – the main substance of the ligaments.

Within 3-4 days, vascular bundles from the surrounding tissue grow into the damaged area and provide blood flow. A clot of fibrin penetrated by blood vessels is called granulation tissue. It fills the defect and slightly spreads into the surrounding tissue. The strength of the granulation tissue is low, it can easily break.

Recovery stage

Over the next few weeks, the number of fibroblasts increases. They continue to produce fibrous tissue cells containing a lot of type III collagen. Collagen in the injured area is synthesized 3-4 times faster than in intact tissue. Most collagen is produced from the 4th to the 12th week after injury. Gradually, the concentration of type I collagen in the tissues increases and the amount of water decreases. The higher the collagen content, the stronger and more inelastic the new tissue becomes.

Remodeling stage

An excess of inelastic tissue with a poorly organized structure forms in the damaged area. Remodeling, or restructuring, strengthens this tissue – cells are replaced, excess matrix is ​​removed. The concentration of collagen and the diameter of its fibrils increase, the ratio of type I and type III collagen changes: there is more type I collagen.

As a rule, tissue begins to remodel in the first few weeks after an injury. There are fewer fibroblasts in them, collagen molecules are ordered. A few months after the injury, the tissue structure stabilizes, presumably due to the response to stress.

Major tissue remodeling lasts 4–6 months after injury, but minor tissue changes can last for years. Over time, collagen is stabilized by cross-links, its molecules gather into fibers, as a result, the strength of ligaments and tendons increases ^[1] .

Classification and stages of development of sprains

Degrees of damage to the ligaments:

• Sprain I degree (light) is a slight stretch, i. e. a microscopic rupture of the ligament fibers. This injury causes mild pain and swelling around the injured joint.
• Grade II sprain (moderate) is a partial tear of a ligament that causes moderate pain and swelling.
• Grade III sprain (severe) is a complete tear of the ligament. Such an injury is characterized by sharp pain and a feeling of mobility that is unusual for this joint ^[4] .

The most commonly injured ligaments are the ankle, knee and wrist joints, fingers and hand.

Ankle sprain

Among knee ligament injuries, the most common injury is to the ligaments of the outer group: calcaneofibular ligament, anterior and posterior talofibular ligament.

These ligaments are usually damaged when the foot is rotated inward, i.e. when the leg is twisted. Such an injury is accompanied by abnormal mobility in the joint.

As a rule, an x-ray of the ankle joint is taken after the examination. During treatment, cold is applied to the leg, the segment of the leg is immobilized, the load is removed from it with the help of crutches or canes, and physiotherapeutic procedures are performed. Usually the leg is fixed for three weeks, rehabilitation lasts up to 12 weeks.

If the ligaments are repeatedly injured, we can talk about instability of the ankle joint. It is manifested by a feeling of instability in the damaged joint when walking or playing sports. As a rule, surgical treatment is indicated in such cases.

If the patient feels that the bones are shifting in the ankle joint and there is abnormal mobility, then this is a sign of a torn ligament. In this case, it is necessary to visit an orthopedic traumatologist, in some cases, surgery is required.

Knee sprain

Anterior cruciate ligament injury accounts for 40–50% of all knee ligament injuries ^{[11] [16]} .

The anterior cruciate ligament stabilizes the knee joint. As a rule, it is damaged when playing playing and contact sports (for example, football and wrestling) ^[5] . The risk of such an injury is higher in women. This is most likely caused by differences in ligament structure, pelvic tilt, general joint laxity, hormonal levels, and slower muscle response ^{[6] [7]} .

If the ligament is partially damaged and the joint is stable, conservative treatment is acceptable. Complete rupture often requires ligament replacement. The treatment takes into account the desired level of activity of the patient.

The most common consequence of an injury is joint instability, due to which the patient cannot play sports and sharply reduces his usual physical activity. With conservative treatment of an anterior cruciate ligament injury, the risk of meniscus rupture and the development of arthrosis increases. The operation also does not completely protect against meniscus injury, in addition, there is a risk of rupture of the repaired ligament.

The posterior cruciate ligament also stabilizes the knee, but it is much less likely to be injured than the anterior cruciate ligament ^[1] .

Sprains of the internal and external lateral ligaments are successfully treated with conservative methods. If this treatment fails, the knee joint is stabilized surgically.

Wrist, finger and hand sprains

Wrist sprains are a common type of household and sports injury. As a rule, it occurs with a direct traumatic action, for example, when pulling and twisting the finger, pulling and hitting the hand.

As a rule, the injury is manifested by severe pain when moving the hand. In most cases, these sprains are treated conservatively. In some cases, such as after an injury to the collateral ligaments of the thumb, thumb instability may develop ^[1] .

Sprain complications

Conservative treatment relieves acute symptoms, but joint instability may persist. It is manifested by instability when walking or playing sports.

Synovitis can also occur periodically, in which fluid accumulates in the joint cavity. Synovitis is accompanied by tissue edema and a feeling of fullness in the joint during movement.

After an injury, blockades in the joint may appear – the patient feels something foreign in it, cannot bend or straighten the limb. Such blockades can be easily removed by yourself ^[1] .

With persistent and prolonged instability of the joint, post-traumatic osteoarthritis may develop. The disease is manifested by classic symptoms of age-related wear of the joint: morning stiffness, pain (including at rest and at night), external deformation of the joint with bone growths. It also increases the risk of re-injury to the joint ^[1] . Most likely, relapses are associated with less elasticity of new ligaments.

All these complications are caused by changes in the tissues of the ligament after sprain. They are not always preventable with surgery. Surgical treatment in most cases stabilizes the condition, for example, after cruciate ligament surgery, the lower leg stops moving forward or sideways. However, all the risks of complications after surgery remain, and such patients often require joint arthroplasty.

Diagnosis of sprains

There is no single algorithm for diagnosing sprains. The most commonly used radiography, ultrasound, computed and magnetic resonance imaging.

Doctors often treat a sprain as a minor injury, so when making a diagnosis, it is not always indicated which sprain is damaged. Most often, only x-rays are performed to rule out concomitant bone damage.

X-ray

X-ray is the main method of primary diagnosis in injuries of bones and joints. The examination is inexpensive, it can be done in almost any clinic. However, soft tissues are difficult to distinguish on x-rays, so this method only excludes concomitant bone injuries in sprains ^[12] .

Film radiography is now increasingly being replaced by digital methods. The main advantage of digital radiography is the ability to quickly acquire images. Images can be printed on a special printer, saved and recorded on digital media.

Ultrasound

Ultrasound, ultrasonography and sonography are different names for the same method. Like radiography, ultrasound is performed in the primary diagnosis of injuries of the musculoskeletal system.

Ultrasound is based on the machine generating acoustic waves, or ultrasound. These waves pass through the tissues of the body unevenly. Having reached the border of two different media, for example, adipose tissue and muscle, the waves partially pass through the tissues, and partially dissipate. The image of tissues is created on the basis of reflected waves.

Ultrasound accuracy is quite low. It depends both on the device and on the diagnostician: many parameters need to be adjusted manually. In addition, the method has physical limitations associated with the depth of penetration of sound waves into tissues: at a large depth, the quality of visualization decreases. Also, during ultrasound, the area of ​​​​contact of the sensor with the surface of the body is limited, which is why the picture of damage is incomplete.

The advantages of ultrasound are the ability to assess the state of tissues during movement, the absence of radiation exposure, the availability and low cost of examination ^[1] .

Computed tomography

Computed tomography (CT) scans use x-rays at different intensities to pass through different types of tissue. The bone tissue is very dense, therefore it absorbs these rays well and its structure is clearly visible in the pictures. Soft tissues on CT images are visualized worse, therefore, if their damage is suspected, orthopedic traumatologists rarely use this method.

The advantage of CT is the speed of diagnosis, which is especially important when examining children – they do not have to lie still for a long time, as in MRI. In addition, CT allows you to evaluate the results of the operation, including after injuries of ligaments and tendons.

Magnetic resonance imaging

MRI plays an important role in the visualization of sports injuries and other injuries of the musculoskeletal system. Unlike CT, MRI does not use x-rays, i.e. there is no radiation exposure.

Magnetic resonance imaging provides the most contrasting images of soft tissues, so damage to muscles, tendons, ligaments, cartilage and bone marrow can be assessed. Pictures can be taken in any plane, which allows you to adapt the method to each specific pathology.

Disadvantages of MRI are the relative high cost, the risk of claustrophobia and the need to be in a stationary position for a long time (30 minutes or more).

It is usually recommended to start with the most available methods: radiography and ultrasound.

Sprain Treatment

Sprain First Aid:

1. Rest and secure the arm or leg with an elastic bandage or orthosis. Fixation allows you to reduce pain during movement. With minor injuries, an elastic bandage is applied for 7–10 days. For severe injuries close to complete rupture of the ligament, prolonged fixation (more than a month) may be required. In this case, rehabilitation and physiotherapy exercises begin to be carried out before the removal of the orthosis.

2. Apply cold to the injury site to reduce swelling and pain. You need to try to apply cold as quickly as possible. You can use an ice pack or cold compress. The first two days they are applied 4-8 times a day for 15-20 minutes. Ice should not be applied directly to the skin, there should be a thin towel between them ^[14] . This method is effective in the first 4-5 days after the injury.

3. Elevate limb to reduce soft tissue swelling.

4. Pain can be relieved with non-steroidal anti-inflammatory drugs . For the same purpose, physiotherapy procedures are used in the future.

5. Relieve the injured arm or leg. This may require a cane or crutches. The term of their application depends on the localization of the injury, it can be more than a month.

As a rule, minor damage to the ligaments does not lead to serious consequences. The patient can be treated at home, but only after consulting a doctor.

Therapeutic exercise

Physical activity is allowed after the ligaments are restored. Different groups of ligaments require different times for this: from three weeks to several months. If it is necessary to improve tendon-muscle sensitivity and balance, it is recommended to do exercise therapy with a specialist. Physical activity after the healing of the ligaments is not harmful, but, on the contrary, is useful – they help strengthen the ligaments.

Platelet-rich plasma treatment

Ligaments tend to heal slowly. This is due to their limited blood supply and a small number of cells capable of restoring them. In addition, not every type of damage can be successfully treated with conservative methods. That is why in the field of traumatology, orthopedics and sports medicine, biological therapy procedures, or regenerative medicine, have become popular in recent years. This includes the use of platelet-rich plasma (PRP), which is taken from the patient himself. Plasma contains substances that accelerate healing. Since it is taken from the patient himself, it does not lead to the development of allergies. PRP drugs are usually classified according to their white blood cell count. Plasma with the lowest white blood cell count is considered more effective – it causes less inflammatory reactions at the injection site ^[1] .

Surgical treatment

If the patient continues to complain of abnormal mobility, pain or other movement discomfort, then surgical treatment is recommended. Operations are divided into two types: anatomic reconstruction of the ligament (for example, reconstruction of the anterior cruciate ligament) and stabilizing interventions (for example, reconstruction of the anterior talofibular ligament). Operations help to restore the function of the joint.

Forecast. Prevention

The success of treatment and recovery time depend on the degree of damage to the ligaments.

Prevention of such injuries is quite difficult: their risk depends on previous injuries, muscle response time and other properties of the body.

Sprains of ligaments and tendons are most often associated with their insufficient “warm-up” before training, excessive loads, sudden movements or their unusually large amplitude.

Load planning and adherence to training regimen significantly reduces the risk of injury. Training should be regular, it is necessary to carefully consider their duration, intensity and stick to this plan.

Each workout is recommended to start with a warm-up, during which the muscles, ligaments and tendons “warm up”.

At the end of the workout, you need to do a few cool-down exercises, most often stretching. These exercises allow you to return mobility and increase the range of motion in the “clogged” muscles, i. e., relieve muscle hypertonicity.

Proper exercise technique is also important for injury prevention. A professional coach or an experienced athlete will help to work it out. Even in those cases when a person is going to do sports on his own, at first it is better to train under the supervision of an experienced mentor ^[13] .

The right choice of clothes, shoes and equipment will help to avoid discomfort and injury during training:

• for running you need shoes with a hard sole and arch support that absorb shock loads well;
• for playing indoor sports, the sole must be soft and non-slip;
• clothing should be comfortable, not restrict movement, absorb sweat well and allow the body to “breathe”;
• appropriate equipment is selected for each sport – wristbands, weightlifting belts, belts, straps, etc.; a trainer or consultant in a specialized store will help you choose equipment.

Preventive measures for people who do not play sports: wear comfortable shoes, avoid slippery surfaces, such as sanding paths during the cold season.

Sprain: causes, symptoms and recommendations for the treatment of the disease. Dr. Peter

The key cause of a sprain is trauma to the joint and surrounding tissues, overstressing, overstretching or overstretching the muscles and tendons. Athletes and overweight people often suffer from such an injury. Signs and symptoms of sprains include pain, swelling, bruising, and decreased range of motion.

The main treatment (first aid) for all sprains is rest, ice, compression, elevated position of the injured area. Most sprains heal completely with adequate treatment, although the risk of re-injuring the same area later is increased.

Sprain: Causes

A sprain is an injury to the bands of tough, elastic connective tissue that connects one bone to another. Damage, stretching, tearing of the muscle or tendon, the tissue that connects the muscle to the bone, is possible.

These injuries can occur anywhere in the body, but are most common in the lower and upper extremities—ankle, knee, elbow, or wrist. The most common sprain site is the ankle joint. An ankle sprain can occur when the foot bends inward (inversion) or when it twists outward (eversion).

The most common muscle strains are in the lumbar spine (lower back) and the hamstring muscle at the back of the thigh.

The cause of the sprain is an injury to the joint (the flexible connection between bones). Twisting or excessive force overstretches the ligaments (eg, hyperextension or hyperflexion) and can cause ligamentous tissue tears. The severity can vary from mild to severe depending on the extent of the damage.

A sprain can occur when a person twists their ankle or knee, or falls on their elbow or shoulder. Muscle damage is usually the result of overstretching or overuse of muscles and tendons.

Sports that involve jumping, such as basketball, volleyball, are at increased risk of sprains and dislocations of the foot, knee, and ankle.

Gymnastics, tennis, and golf are at increased risk for sprains and dislocations of the hands, wrists, elbows, rotator cuff, and arms.

Contact sports such as hockey and football carry an increased risk of sprains and dislocations of any type, including fingers and toes and the neck.

Endurance sports such as running and triathlon have a higher risk of strain due to overuse.

Sprains are more common in people who are overweight, those who play sports for the first time, those with neurological problems or balance problems may be at higher risk of sprains when falling.

Sprain: symptoms

Sprains, as a rule, give symptoms localized in the injured joint. At the time of injury, you can feel a tear or crack in the joint. Pain usually occurs immediately, and depending on the severity of the injury, it is sometimes impossible to move the affected limb. Signs and symptoms of sprains include:

• pain,

• joint and soft tissue swelling,

• bruising,

• joint instability, 900 03

• reduced range of motion (total immobility of the affected area).

If muscles and ligaments are involved, muscle spasms, muscle weakness and bruising may occur. They may occur but may be delayed by several days.

The risk of stretching

The prognosis of a sprain depends on the severity and location of the injury. Most sprains and deformities heal completely with adequate treatment, although there is a higher risk of re-injuring the same area.

Sprain Diagnosis

Most sprains and deformities are diagnosed based on the history and physical examination. The doctor will examine a joint or muscle group and move it through its normal range of motion, looking for pain, tenderness, weakness, or instability.

If there is a possibility of bone damage or fracture, an x-ray may be ordered. Magnetic resonance imaging (MRI) is sometimes needed to determine the exact extent of the injury because deformities and strains occur in soft tissues and are not detected on conventional x-rays.

How to Treat a Sprain

There are many treatment options for sprains, depending on the severity of the injury. Generally, mild sprains can be treated on their own with a combination of home remedies and over-the-counter medications. More serious injuries may require physical therapy or surgery, depending on the doctor’s advice.

The main treatment (first aid) for all sprains is rest, ice, compression and elevation of the affected area. To manage pain, over-the-counter pain relievers are helpful: non-steroidal anti-inflammatory drugs (NSAIDs) help reduce pain, inflammation, and swelling.

Some sprains may require physical therapy to help heal tissues to maintain mobility and strengthen muscles and tendons.

For more severe sprains or strains, a medical examination may be required if symptoms or pain do not improve with home treatment of the injury. Joint or limb splinting or immobilization (plastering the limb) may be required to heal the injury. Some serious sprains may require surgery.

Sprain Prevention

Many sprains can be prevented. To reduce the risk of injury:

• Strictly follow the instructions of the trainer when playing sports.