By Jeffrey R. Dugas, MD
Medical Director, USA Cheer
Andrews Sports Medicine and Orthopaedic Center
This past spring I worked with members of Team USA, the team that represents America at the International Cheer Union World Championships in Orlando, Florida. Prior to the onset of training, each Team USA member had to pass a pre-participation physical examination (PPE). During these examinations, the most commonly reported injury among the team members each year are ankle sprains. Most of the athletes have suffered some form of ankle sprain during their years of cheerleading, and several have had repeated injuries, causing them to use braces on their ankles when cheering. The information contained in this writing is meant to give the reader some insight into ankle sprains and the common treatment options for return to activity.
Ankle sprains occur as the result of a twisting mechanism at the ankle, which is common in nearly every form of sport activity, including cheerleading. The most common type of sprain involves an injury to the ankle as the result of “rolling over” or “inverting” the ankle. This type of injury occurs when the foot becomes inverted (bottom of the foot pointing towards the other leg), placing a large tensile stress on the ligaments on the outside of the affected ankle. Depending on the amount of stress/energy imparted to the tissues, one or more ligaments may be affected. The more ligaments that are affected, the higher grade the injury. Also, ligament tissue may be partially (sprain) or completely (torn) disrupted.
The ligaments around the ankle tear in a predictable sequence with inversion type injuries. The first ligament to experience the stress of such an injury is the Anterior Talo-Fibular Ligament (ATFL), and is involved in nearly every inversion-type injury. This ligament is on the Anterior (front) Lateral (outside) part of the ankle. The next affected ligament is typically the Calcaneo-Fibular Ligament (CFL), which is on the direct outside (lateral) aspect of the ankle, originating at the underside of the end of the fibula. The next affected ligament is typically the Posterior Talo-Fibular Ligament (PTFL), which is the Posterior (back) stabilizing ligament at the same level as the ATFL. These three ligaments make up the vast majority of the stabilizing tissue of the Lateral ankle.
With higher-energy injuries, the stress of the injury may progress to the point that the Medial (inside) ligament complex is damaged. This large broad ligament is called the Deltoid ligament, and it spans the entire inside of the ankle, attaching to the end of lower portion of the tibia. Finally, the last stabilizing structure of the ankle is called the Syndesmosis. This ligament actually connects the two bones of the lower leg (Tibia and Fibula). When this ligament is injured, the discomfort is typically felt at the front of the lower leg, and may be detected by squeezing the two bones together at the mid- to lower-leg area. The presence of an injury to the syndesmosis indicates a higher level of injury which must be respected. If this injury allows the bones of the lower leg to separate, the end result can be a long-term disaster with early osteoarthritis of the ankle joint, which is a very difficult problem to manage in an active person.
Finally, the ligamentous structures of the ankle are not the only ones at risk. Some ankle injuries involve the articular (cartilage) structures of the joint itself. Small or large fragments of cartilage may be sheared from the surface of the bone, and the bone itself may be damaged. These conditions are also typically due to higher-energy injuries, and must be detected early in the treatment period.
Although many ankle sprains are minor, and are treatable with Rest, Ice, Compression, and Elevation (RICE), some require more advanced diagnostic accuracy and management. If an athlete has difficulty bearing weight on an ankle that has been injured, further evaluation of the injury is certainly warranted. If the athlete has discomfort with lateral movements (side to side) but can bear weight, it is likely that the RICE approach with possible stabilizing brace may be enough to return the athlete to normal function. Oral Non-Steroidal Anti-Inflammatory (NSAID) medications may be taken to decrease pain and inflammation. The addition of supervised Physical Therapy (PT) will often decrease the time to return to performance, and is generally part of our regimen for treatment of ankle sprains. When indicated, we prefer a lace-up type brace for the affected ankle, and we ask the athlete to use the brace for all weight-bearing activity for 6 weeks after the injury. This period corresponds to the amount of time the body takes to return the injured tissue to normal strength. Following the initial 6 weeks of brace use, the athlete is directed to use the brace for another 6 weeks for any exercise (including all cheer activities). It is during these first 12 weeks after injury that the risk of re-injury is greatest.
For athletes who cannot bear weight on their injured ankle, crutches and an immobilizing boot are the treatment of choice initially. Gentle range-of-motion exercises to regain mobility and decreases swelling are initiated in the first few days after injury with the physical therapist. If the athlete is not able to progress to weight-bearing within the first 7-10 days, further diagnostic imaging with MRI is warranted to rule out an articular (Cartilage) injury. The presence of these conditions may warrant evaluation by a Sports Foot and Ankle Specialist, as the proper management of these conditions is of paramount importance to the long-term health of the ankle.
Even in the most elite athletes like those members of Team USA, ankle sprains are common. Early recognition and proper management of these injuries typically results in early return to activity with no long-term risk. Delayed treatment, or chronic recurrence of these injuries may lead to long-term problems with severe consequences. We recommend that any ankle sprain which does not respond to typical conservative treatment over the first few days following the injury be evaluated by a Sports Medicine-trained physician or certified Athletic Trainer (ATC) to prevent ongoing problems with these common injuries.
About the Author
Jeffrey R. Dugas, M.D., treats all types of orthopedic sports injuries, including injuries of the shoulder, elbow and knee. He also performs total joint replacement surgery of the shoulder and knee. He maintains a special interest in throwing athletes, since much of his research concentrates in this area. He is certified in cartilage and meniscus transplantation for the treatment of arthritic defects of the knee. He is board certified in Orthopaedic Surgery and the sub-specialty of Sports Medicine.