Although athletes are more susceptible, ankle injuries can easily happen to anyone. After all, we use our ankles every day when we walk, run or jump
Retiring national badminton player Ronald Susilo has injured it. So have several international soccer players. And chances are, you may have injured it too at some point. The “it” is the ankle, the most commonly injured joint in athletes.
“I have sprained my ankle about four times, twice during badminton practice,” said Ronald Susilo. “The worst sprain happened while I was playing basketball. It got better in two weeks, but I didn’t do a lot of strengthening exercises after that,” he added.
“Then I went and played soccer using running shoes. These did not have enough support for the activity and the injury worsened,” he said.
The 30-year-old shuttler took another month to recover from the injury and needed crutches to move around for two weeks.
Nestled between three bones – the tibia, fibula and talus – the ankle joint works together with the other foot joints to provide mobility as you walk, run and jump.
The ankle is also held together by bands of elastic fibre called ligaments.
Said Dr Tan Ken Jin, an associate consultant at the Division of Orthopaedic Sports Medicine at National University Hospital (NUH): “In a sprain, one or more groups of the ligaments are injured, usually those on the outer side of the foot.”
Said Ms Eleanor Chew, a physiotherapist at Singapore General Hospital: “Sprains happen when the foot twists, rolls or turns beyond its normal motions, usually when it is turned inwards.”
Any sport that is weight-bearing or involves jumping or direction changes, increases the likelihood of ankle injuries, said Dr Tan.
Examples include soccer, basketball and tennis.
The symptoms of a sprain include pain and swelling, said Dr Lim Kay Kiat, a consultant orthopaedic surgeon at Changi General Hospital. In more severe sprains, bruising will be evident and there may even be difficulty in walking,” he said.
The “Rice” method of treatment
Once a fracture is ruled out, simple sprains are treated using the “Rice” method, Dr Tan said.
Rice stands for rest, ice, compression and elevation. This means letting the joint rest and icing it for 20 minutes every two hours.
“However, you should avoid icing to the point of pain,” he added.
Compression – like a bandage – should be applied and the ankle should be slightly raised to allow blood to flow away from the injury.
Apart from sprains, other ankle injuries include ligament tears and fractures.
Ligament tears, which can also be caused by falls, inflict significantly more pain and swelling than sprains.
Unlike sprains, which can take up to a week to heal, ligament tears need about one-and-a-half months to recover and can have long-term effects on the ankle, said Dr Tan.
“When the ligament heals, it becomes loose. That will make the ankle prone to instability and future sprains. It’s like a rubber band that’s overstretched – it’s not taut any more,” he said.
The worst ankle injuries are fractures and most have to be treated surgically, said Dr Tan.
Surgery, using screws and metal plates, is needed to align the cracked bones.
“If the bones heal while they are out of position, it will compromise joint function,” said Dr Tan.
It is usually unnecessary to place the ankle in a cast after an operation, said Mr Durai Muragan Chinnasamy, a senior physiotherapist at NUH. But if the fracture is managed conservatively – that is, without an operation – a cast is needed.
In either case, patients are sent for physiotherapy where they learn to walk without putting weight on the injured ankle, using crutches.
Said Ms Toh Mei Kwan, the principal physiotherapist at the Ang Mo Kio-Thye Hua Kwan Hospital: “Often, we focus on the most limiting factor for a patient first. For example, if the joint is too stiff and limits mobility, then we first restore the ankle’s range of motion, in conjunction with mobility training.”
A fractured ankle may need up to three months for complete recovery.
Besides trauma, ankle pain can also be caused by chronic conditions.
“Rheumatoid arthritis is an autoimmune disease which affects multiple joints, including the ankle. Symptoms include joint pain, stiffness and swelling,” said Dr Lim.
Another condition, osteoarthritis, is a result of cartilage degeneration of the joint, said Dr Lim.
To treat ankle arthritis, activity modification and medication are first recommended, said Dr Tan.
If such a treatment does not help, the next step would be to fuse the ankle bones to eliminate joint movement, he said.
“But it means that the other joints in the foot would have to work harder,” he said.
A third option would be ankle replacement, which is not the first choice of treatment if symptoms are not severe, said Dr Tan. In ankle replacement, the worn-out surfaces of the joints are replaced by metal.
“The advantage is that you retain some mobility and the other joints don’t work so hard. The downside is that it’s a relatively new procedure, so we do not have good long-term results yet,” said Dr Tan.
Answers to your FAQs
Professor Inderjeet Singh Rikhraj, a senior consultant of orthopaedic surgery at Singapore General Hospital and Dr Ben Tan, the head and senior consultant sports physician at Changi Sports Medicine Centre, provide answers to some frequently asked questions on the ankle:
1. Is it possible for the ankle to wear out?
Prof Inderjeet: Yes. However, it is not easy for this to happen as the ankle cartilage is extremely resistant. There is usually a cause, like a previous severe fracture, recurrent sprains or an infection of the ankle joint.
2. Can I ignore a sprained ankle and allow it to heal on its own?
Dr Tan: No. A typical ankle sprain is usually one where there is an isolated tear of the anterior talofibular ligament (ATFL).
The consequences are loss of strength in turning the ankle outwards and proprioception, or the sense of body position awareness.
Patients will find that their ankles are “clumsy” and weak, even for weeks after the swelling has gone down. They tend to have recurrent sprains.
Strengthening and balance exercises are needed to regain ankle stability and prevent future sprains.
A sprained ankle can also comprise injuries apart from the ATFL tear – some of these can be serious and you will need to see a doctor to exclude these injuries.
3. Is Tui Na, a form of Chinese massage, an effective way of treating sprained ankles?
Dr Tan: When we do deep massage over the torn ligament or manipulate the joint – like in Tui Na – we may increase the bleeding in the area and separate the torn edges further, reducing the chances of the ligament regaining its integrity.
In ankle sprains, we need to address the instability by doing active balance and strengthening exercises, since position awareness and strength are not derived from Tui Na.
4. If I have injured my ankle, what activities should I avoid and for how long?
Prof Inderjeet: First, it is best to have your ankle injury examined and treated. All sporting activities should be avoided until the injury heals.
Sprains: It depends if the injury is acute or chronic. If acute, it is best to rest, ice, compress and elevate the ankle before undergoing physiotherapy. For chronic sprains, physiotherapy is recommended.
If patients improve with physiotherapy, they can gradually go back to doing sports.
If there is no improvement, surgical repair of the ligaments is recommended.
Fractures: Surgical treatment is usually recommended, followed by physiotherapy. It may take about six months to a year before you can resume sporting activities.
Ankle arthritis: Activity levels are dictated by the pain experienced by patients. If the pain is mild, they are advised to limit activities to low-impact sports, like swimming or cycling.
However, if the pain is severe or bothersome, it is recommended that patients undergo surgery.
5. What if my ankle still hurts a month after I injure it?
Dr Tan: Then it is unlikely to be a simple isolated ATFL tear and you need to see your doctor. Most isolated ATFL tears feel much better within two weeks.
6. I have injured my ankle more than once. What are the consequences?
Prof Inderjeet: Repeat injuries to the ankle typically leave it in poorer condition and predispose it to arthritis.
It is therefore recommended that the ankle injury be diagnosed and given the appropriate treatment.
7. I have ankle arthritis. Can I go for ankle replacement surgery?
Prof Inderjeet: Ankle replacement is generally suited for ankle arthritis patients who are above 50, do not do heavy manual work and are not overweight. It is not for the active, the young or manual workers who lift heavy loads. An ankle prosthesis is an artificial joint and can wear out with heavy usage.
8. Do I need to take supplements for ankle health?
Prof Inderjeet: No. Glucosamines have been recommended for joint health. However, there is no evidence that glucosamines help for the ankle joint.