Skręcenie stawu – Patofizjologia i mechanizm

Skręcenie stawu
Patofizjologia i mechanizm

Skręcenie stawu skokowego to uraz polegający na przekroczeniu fizjologicznej elastyczności więzadeł, prowadzący do uszkodzenia włókien kolagenowych. Stanowi około 14% urazów sportowych, z czego 80% to skręcenia boczne spowodowane gwałtowną inwersją lub supinacją stopy. Więzadła boczne, zwłaszcza więzadło skokowo-strzałkowe przednie (ATFL), są najczęściej uszkadzane, a ich lokalizacja (wewnątrzstawowa lub pozatorebkowa) wpływa na proces gojenia ze względu na różnice w ukrwieniu. Skręcenia klasyfikuje się na trzy stopnie: I (minimalne uszkodzenie włókien), II (częściowe rozerwanie) i III (całkowite rozerwanie), z objawami takimi jak obrzęk, zasinienie, niestabilność i ograniczenie funkcji. Mechanizmy urazu obejmują nieprawidłową pozycję lądowania i opóźnioną reakcję mięśni strzałkowych, co prowadzi do nadmiernej inwersji i uszkodzenia więzadeł bocznych, a także urazy przyśrodkowe i wysokie skręcenia zespolenia piszczelowo-strzałkowego.

Definicja i ogólna charakterystyka skręcenia stawu

Skręcenie stawu to uraz, który polega na rozciągnięciu lub rozerwaniu więzadeł – twardych pasm włóknistej tkanki łącznej, które łączą dwie kości w stawie. Więzadła są elastycznymi strukturami, które zwykle rozciągają się w swoich granicach fizjologicznych, a następnie wracają do normalnej pozycji. Skręcenie występuje, gdy więzadło zostaje zmuszone do rozciągnięcia poza swoją normalną granicę elastyczności, co prowadzi do uszkodzeń włókien kolagenowych.¹²

Skręcenia stawu skokowego są jednymi z najczęstszych urazów układu mięśniowo-szkieletowego, stanowiąc około 14% wszystkich urazów związanych z aktywnością sportową. Około 80% skręceń to urazy więzadłowe spowodowane gwałtownym inwersją lub supinacją stopy. Szacuje się, że dziennie około 25 000 osób doświadcza skręcenia stawu skokowego.³⁴

Skręcenia stawu mogą dotykać sportowców i osoby nieuprawiające sportu, dzieci i dorosłych. Mogą wystąpić podczas uprawiania sportu i aktywności fizycznej, ale również podczas zwykłego stąpnięcia na nierówną powierzchnię lub zejścia pod kątem.⁵

Patogeneza skręcenia stawu

Patogeneza skręcenia stawu wiąże się z działaniem nadmiernych sił na więzadła, które przekraczają ich fizjologiczną wytrzymałość. Więzadła są zbudowane z włókien kolagenowych, które można znaleźć w różnych układach (równoległym, skośnym, spiralnym itp.) w zależności od funkcji stawu. Mogą być pozatorebkowe (położone poza torebką stawową), torebkowe (przedłużenie torebki stawowej) lub wewnątrzstawowe (położone w torebce stawowej). Lokalizacja ma istotne znaczenie dla gojenia, ponieważ przepływ krwi do więzadeł wewnątrzstawowych jest zmniejszony w porównaniu do więzadeł pozatorebkowych lub torebkowych.⁶

Włókna kolagenowe posiadają około 4% strefę elastyczną, w której włókna rozciągają się przy zwiększonym obciążeniu stawu. Jednak przekroczenie tej granicy elastyczności powoduje zerwanie włókien, co prowadzi do skręcenia. Ważne jest, aby rozpoznać, że więzadła dostosowują się do treningu poprzez zwiększenie przekroju poprzecznego włókien. Gdy więzadło jest unieruchomione, szybko słabnie. Normalna codzienna aktywność jest ważna dla utrzymania około 80-90% właściwości mechanicznych więzadła.⁷

Mechanizm uszkodzenia więzadeł

Ostre skręcenia typowo występują, gdy staw jest nagle zmuszony do przekroczenia swojego funkcjonalnego zakresu ruchu, często w sytuacji urazu lub kontuzji sportowych. Najczęstszą przyczyną skręceń ogólnie są powtarzające się ruchy (przeciążenie).⁸

W przypadku skręceń stawu skokowego istnieją dwie główne przyczyny, które powodują uraz inwersyjny:

Nieprawidłowa pozycja lądowania z lekko odwróconym lub supinowanym stawem skokowym, co powoduje, że siła reakcji podłoża działająca na boczną krawędź stopy kieruje się przyśrodkowo i nie przechodzi przez środek stawu skokowego, tworząc tym samym energiczne skręcające momenty obrotowe do wewnątrz, a następnie nadmierną inwersję, co finalnie prowadzi do dużych naprężeń więzadeł, które rozrywają więzadła boczne.⁹
Reakcja mięśni strzałkowych, które funkcjonują jako przeciwdziałanie inwersji stawu skokowego, jest zbyt powolna (60-90 ms), aby nadążyć i dostosować się do nagłej, wybuchowej inwersji, która następuje w ciągu 50 ms po zetknięciu stopy z podłożem.¹⁰

Stabilność stawu zależy zarówno od skurczu mięśni, jak i od wkładu więzadeł, dlatego gdy mięśnie są nieaktywne, stabilność stawu opiera się głównie na więzadłach. Ponieważ więzadła mają właściwości lepkoelastyczne, nagłe gwałtowne rozciągnięcie może je rozerwać.¹¹

Mechanizmy skręcenia stawu skokowego

Skręcenia stawu skokowego różnią się w zależności od mechanizmu urazu (urazy o wysokiej i niskiej energii), pozycji stopy oraz siły rotacyjnej działającej na staw i stabilizujące struktury więzadłowe.¹²

Skręcenia boczne (lateralne) – najczęstszy mechanizm skręcenia stawu skokowego, stanowiący około 85% wszystkich przypadków. Występuje przy inwersji stopy w pozycji zgięcia podeszwowego, zewnętrznej rotacji kości piszczelowej oraz supinacji w stawie podskokowym. W miarę obrotu stopy najpierw uszkadzane jest więzadło skokowo-strzałkowe przednie (ATFL), następnie więzadło piętowo-strzałkowe (CFL) i więzadło skokowo-strzałkowe tylne (PTFL), w zależności od ciężkości urazu.¹³¹⁴

ATFL zwykle składa się z dwóch pasm, które są rozdzielone przez gałęzie tętnicy strzałkowej przeszywającej. ATFL jest wewnątrzstawowe, ma najniższą odporność na uszkodzenia i jest najważniejszym więzadłem w stabilności skokowo-strzałkowej. Jest pod maksymalnym napięciem, gdy staw skokowy jest w zgięciu podeszwowym. CFL jest pozatorebkowe, grubsze i silniejsze niż ATFL, i jest kolejnym uszkadzanym więzadłem w urazie zgięcia podeszwowego/inwersji. PTFL jest najsilniejszym z trzech więzadeł i najmniej podatnym na uszkodzenie, ponieważ jest napięte tylko w skrajnych przypadkach zgięcia grzbietowego.¹⁵

Skręcenia przyśrodkowe (medialne) – powstają w wyniku nadmiernej ewersji i zgięcia grzbietowego. Mechanizm ten powoduje uszkodzenie więzadła trójkątnego (deltoidowego), które składa się z więzadła piszczelowo-skokowego przedniego, więzadła piszczelowo-skokowego tylnego, więzadła piszczelowo-łódkowego i więzadła piszczelowo-piętowego.¹⁶¹⁷

Wysokie skręcenia stawu skokowego (syndesmosis) – dotyczą więzadeł zespolenia piszczelowo-strzałkowego, które łączą dystalne końce kości piszczelowej i strzałkowej. Stanowią około 10% skręceń stawu skokowego, ale powodują bardziej upośledzającą dolegliwość i wymagają innego leczenia niż typowe skręcenia stawu skokowego. Mechanizmem urazu jest nadmierne zgięcie grzbietowe i ewersja stawu skokowego z wewnętrzną rotacją kości piszczelowej.¹⁸

Do urazu wysokiego skręcenia stawu skokowego dochodzi najczęściej w wyniku wymuszonej rotacji zewnętrznej stopy. To, co dzieje się podczas ruchu rotacji zewnętrznej w połączeniu z dużą siłą, to fakt, że kość skokowa (kość stawu skokowego) powoduje oddzielenie dalszej kości piszczelowej i strzałkowej.¹⁹

Innym, rzadszym mechanizmem urazu wysokiego skręcenia stawu skokowego jest hiperdorsifleksja. Zgięcie grzbietowe stawu skokowego to ruch, w którym palce stopy są cofnięte w kierunku goleni w łańcuchu otwartym lub gdy kolano przesuwa się za palce stopy w łańcuchu zamkniętym. Podobnie jak w przypadku mechanizmu urazu rotacji zewnętrznej, nadmierne zgięcie grzbietowe powoduje, że najszersza część kości skokowej nadmiernie obraca się w stawie skokowym, co może doprowadzić do rozdzielenia dalszych części kości piszczelowej i strzałkowej.²⁰

Klasyfikacja skręceń stawu

Skręcenia stawu klasyfikuje się według stopnia ciężkości od I do III, w zależności od stopnia uszkodzenia włókien więzadłowych i nasilenia objawów klinicznych:²¹²²²³

Stopień	Charakterystyka	Objawy kliniczne
Stopień I (łagodne)	Minimalne (włókna są rozciągnięte, ale nienaruszone, lub tylko kilka włókien jest rozdartych)	Lekkie rozciągnięcie i pewne uszkodzenie włókien więzadła Łagodny obrzęk Brak lub niewielka utrata funkcji Brak niestabilności stawu Pacjent obciąża kończynę przynajmniej częściowo
Stopień II (umiarkowane)	Częściowe (od kilku do prawie wszystkich włókien jest rozdartych)	Częściowe rozerwanie więzadła Umiarkowany do silnego obrzęk z zasinieniem Umiarkowana utrata funkcji Łagodna do umiarkowanej niestabilność stawu Pacjenci zwykle mają trudności z obciążaniem
Stopień III (ciężkie)	Całkowite (wszystkie włókna są rozdarte)	Całkowite rozerwanie więzadła Natychmiastowy i silny obrzęk z zasinieniem Umiarkowana do ciężkiej niestabilność stawu Pacjent zwykle nie może obciążać kończyny (lub nie bez silnego bólu) Może być związane z trwałą niestabilnością

Chociaż natężenie objawów różni się, ból, zasinienie, obrzęk i stan zapalny są powszechne dla wszystkich trzech kategorii skręceń.²⁴

Patofizjologia skręcenia stawu skokowego

Stabilność stawu skokowego jest utrzymywana zarówno przez strukturę kostną, jak i kompleks więzadłowy. Więzadło skokowo-strzałkowe przednie jest głównym ogranicznikiem rotacji wewnętrznej i przywodzenia kości skokowej, gdy staw skokowy nie jest obciążony, podczas gdy zarówno struktura kostna strzałki, jak i więzadło piętowo-strzałkowe ograniczają przywodzenie kości skokowej przy obciążonym stawie skokowym.²⁵

Zgięcie podeszwowe i inwersja to najczęstszy mechanizm skręceń stawu skokowego, który prowadzi do urazu więzadła skokowo-strzałkowego przedniego, a następnie więzadła piętowo-strzałkowego. Uszkodzenie więzadeł bocznych stawu skokowego może powodować niekorzystne zmiany w układzie nerwowo-mięśniowym, który zapewnia dynamiczną stabilizację stawu.²⁶²⁷

Patologia chronicznej niestabilności stawu skokowego

Chroniczna niestabilność stawu skokowego (CAI – Chronic Ankle Instability) może być spowodowana niestabilnością mechaniczną, niestabilnością funkcjonalną lub, co najbardziej prawdopodobne, kombinacją tych dwóch zjawisk.²⁸

Niestabilność mechaniczna stawu skokowego występuje w wyniku zmian anatomicznych po początkowym skręceniu stawu skokowego, które prowadzą do niewydolności predysponujących staw skokowy do kolejnych epizodów niestabilności. Może być spowodowana przez:²⁹³⁰

Patologiczną wiotkość, która może skutkować niestabilnością stawu, gdy staw skokowy jest umieszczony w podatnych pozycjach podczas czynności funkcjonalnych, co prowadzi do kolejnych urazów struktur stawowych
Zmiany artrokinematyczne
Podrażnienie błony maziowej
Rozwój zmian zwyrodnieniowych

Niestabilność funkcjonalna jest spowodowana niewydolnością propriocepcji i kontroli nerwowo-mięśniowej. Po skręceniu stawu skokowego może dojść do uszkodzenia mechanoreceptorów w więzadłach i torebce stawowej, co prowadzi do deficytów w propriocepcji, równowadze i kontroli nerwowo-mięśniowej.³¹

Interakcje między niewydolnością mechaniczną a niewydolnością funkcjonalną oraz relacje między konkretnymi niewydolnościami nie zostały jeszcze w pełni wyjaśnione. Poszczególne objawy niestabilności funkcjonalnej stawu skokowego nie występują w izolacji, ale prawdopodobnie są wszystkie elementami złożonego paradygmatu patoetiologicznego.³²

Rola propriocepcji w patogenezie skręceń stawu

Propriocepcja to złożony proces, który jest koordynowany przez impulsy aferentne i eferentne, działające jako pętle sprzężenia zwrotnego. Oznacza to subtelne dostrojenie między układem nerwowym a mięśniowo-szkieletowym, pozwalające na świadomość własnej pozycji stawu (czucie pozycji stawu) i ruchu stawu (kinestezja). Ten mechanizm informacji zwrotnej nerwowo-mięśniowej może zostać przerwany na skutek urazu i nieprawidłowości, ale interwencja chirurgiczna i rehabilitacja mogą go przywrócić.³³

Uszkodzona propriocepcja jest związana z niestabilnością funkcjonalną i nawracającymi skręceniami. Deficyty propriocepcji mogą być zwiększone przez długotrwałe nieobciążanie lub unieruchomienie i mogą prowadzić do dalszych urazów, jeśli nie zostaną skorygowane.³⁴³⁵

Po urazie stawu skokowego może dojść do uszkodzenia receptorów rozciągających, które wykrywają, kiedy staw jest nadmiernie rozciągnięty i może być podatny na uszkodzenie. W konsekwencji uszkodzone stawy mogą być bardziej podatne na ponowny uraz, ponieważ są mniej zdolne do wykrywania (i korygowania) pozycji stawu, gdy staw jest zmuszony do przekroczenia normalnego zakresu ruchu.³⁶

Mechanizmy towarzyszących urazów i powikłań

Skręcenia stawu mogą prowadzić do różnych powikłań i urazów towarzyszących, które mogą komplikować proces gojenia i przyczyniać się do długoterminowej dysfunkcji.³⁷

Uszkodzenia chrząstki stawowej

Powtarzające się skręcenia stawu skokowego mogą wywierać nadmierny nacisk na powierzchnię chrząstki i powodować uraz kompresyjny lub ścinający – znany jako ubytek chrzęstno-kostny. Jeśli pozostawi się go bez leczenia, może ostatecznie utworzyć krater w stawie skokowym, co może prowadzić do wcześniejszych zmian zwyrodnieniowych.³⁸

Urazy, które powodują niestabilność stawu, predysponują do powtarzających się obciążeń stawu, które mogą uszkodzić chrząstkę stawową i doprowadzić do choroby zwyrodnieniowej stawów.³⁹

Przewlekła niestabilność stawu

Między 50% a 70% osób, które doznają bocznego skręcenia stawu skokowego, rozwinie przewlekłą niestabilność stawu skokowego, która charakteryzuje się utrzymującym się bólem, niestabilnością, nawracającym urazem i trwałym upośledzeniem czynnościowym.⁴⁰

Osoby, które doznały skręcenia stawu skokowego, są bardziej narażone na ponowny uraz tego samego stawu, co może prowadzić do niepełnosprawności i przewlekłego bólu lub niestabilności w 20-50% przypadków.⁴¹

Skręcenie III stopnia może być związane z trwałą niestabilnością. Możliwe powikłania skręceń stawu skokowego i leczenia obejmują nieprawidłową propriocepcję. Może wystąpić nierównowaga i osłabienie mięśni, które powodują ponowny uraz. Jeśli sytuacja ta powtarza się wielokrotnie, może utrzymywać się przewlekła niestabilność, uczucie „uciekania” stawu skokowego (duża wiotkość) i przewlekły ból.⁴²

Wpływ na neurofizjologię stawu

Uraz więzadeł bocznych stawu skokowego prowadzi do niekorzystnych zmian w układzie nerwowo-mięśniowym, który zapewnia dynamiczną stabilizację stawu skokowego. Wyjaśnia to, dlaczego po jednym skręceniu stawu skokowego, jeśli nie zostanie prawidłowo zrehabilitowany, istnieje prawdopodobieństwo, że urazy te będą się powtarzać.⁴³

W przypadku osoby z urazem funkcjonalnym, manewry kliniczne oceniające niestabilność mogą nie wykazywać nieprawidłowości. Dzieje się tak, ponieważ istnieją receptory czuciowe specjalnie związane ze ścięgnami, znane jako narządy ścięgniste Golgiego, które są bardzo wrażliwe zarówno na napięcie, jak i nacisk.⁴⁴

Jednym z głównych postępów w zrozumieniu przewlekłego bólu po urazie typu whiplash w ciągu ostatnich dwóch dekad było odkrycie, że centralna sensytyzacja odgrywa ważną rolę w utrzymywaniu się objawów. To zjawisko może również mieć znaczenie w przypadku przewlekłego bólu po skręceniach stawu.⁴⁵

Podsumowanie patogenezy skręcenia stawu

Skręcenie stawu to złożony proces patofizjologiczny, który rozpoczyna się od nadmiernego obciążenia więzadeł, prowadzącego do ich uszkodzenia, a następnie kaskady zjawisk obejmujących reakcję zapalną, zaburzenia propriocepcji i potencjalnie długotrwałą niestabilność stawu. Kluczowe mechanizmy patogenetyczne obejmują:⁴⁶⁴⁷

Przekroczenie fizjologicznej granicy elastyczności więzadeł, prowadzące do mikrouszkodzeń lub makrouszkodzeń włókien kolagenowych
Rozwój obrzęku, wynaczynienia krwi i stanu zapalnego w obszarze urazu
Zaburzenie mechaniki stawu na skutek uszkodzenia struktur stabilizujących
Upośledzenie propriocepcji i kontroli nerwowo-mięśniowej
W przypadku braku odpowiedniego leczenia – rozwój przewlekłej niestabilności stawu, zarówno mechanicznej jak i funkcjonalnej
Potencjalne zmiany degeneracyjne chrząstki stawowej w wyniku nawracających epizodów niestabilności

Warto zauważyć, że chociaż większość skręceń stawu skokowego jest skutecznie leczona metodami zachowawczymi, nawracająca niestabilność i związane z nią defekty można zaobserwować u 25-40% pacjentów. Rozpoznanie tych możliwych współistniejących urazów i odpowiednie skierowanie do specjalisty ortopedy/medycyny sportowej jest obowiązkowe, aby złagodzić ryzyko długoterminowych niekorzystnych wyników.⁴⁸

Kolejne rozdziały

Zapraszamy do dalszego czytania naszego leksykonu.

Wybierz kolejny rozdział z menu poniżej, aby otworzyć nową podstronę kompedium wiedzy i uzyskać szczegółowe informację o leku, substancji lub chorobie.

Materiały źródłowe

#1 Sprains – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/sprains/symptoms-causes/syc-20377938
A sprain is a stretching or tearing of ligaments the tough bands of fibrous tissue that connect two bones together in your joints. […] A sprain occurs when you overextend or tear a ligament while severely stressing a joint. […] Most ankle sprains involve injuries to the three ligaments on the outside of your ankle. Ligaments are tough bands of tissue that stabilize joints and help prevent excessive movement. An ankle sprain occurs when you roll, twist or turn your ankle in an awkward way. This can stretch or tear the ligaments that help hold your ankle bones together.
#2 Ankle Sprain | UConn Musculoskeletal Institute
https://health.uconn.edu/msi/clinical-services/orthopaedic-surgery/foot-ankle-and-podiatry/ankle-sprain/
A sprained ankle is a very common injury. Approximately 25,000 people experience it each day. A sprained ankle can happen to athletes and non-athletes, children and adults. It can happen when you take part in sports and physical fitness activities. It can also happen when you simply step on an uneven surface, or step down at an angle. […] A ligament is an elastic structure. Ligaments usually stretch within their limits, and then go back to their normal positions. When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers. […] Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions. A great force is transmitted upon landing. You can sprain your ankle if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range in an abnormal position.
#3 Understanding acute ankle ligamentous sprain injury in sports | BMC Sports Science, Medicine and Rehabilitation | Full Text
https://bmcsportsscimedrehabil.biomedcentral.com/articles/10.1186/1758-2555-1-14
This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. […] The aetiology of most ankle sprain injuries is incorrect foot positioning at landing a medially-deviated vertical ground reaction force causes an explosive supination or inversion moment at the subtalar joint in a short time (about 50 ms). Another aetiology is the delayed reaction time of the peroneal muscles at the lateral aspect of the ankle (6090 ms).
#4 Ankle Sprain | UConn Musculoskeletal Institute
https://health.uconn.edu/msi/clinical-services/orthopaedic-surgery/foot-ankle-and-podiatry/ankle-sprain/
A sprained ankle is a very common injury. Approximately 25,000 people experience it each day. A sprained ankle can happen to athletes and non-athletes, children and adults. It can happen when you take part in sports and physical fitness activities. It can also happen when you simply step on an uneven surface, or step down at an angle. […] A ligament is an elastic structure. Ligaments usually stretch within their limits, and then go back to their normal positions. When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers. […] Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions. A great force is transmitted upon landing. You can sprain your ankle if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range in an abnormal position.
#5 Ankle Sprain | UConn Musculoskeletal Institute
https://health.uconn.edu/msi/clinical-services/orthopaedic-surgery/foot-ankle-and-podiatry/ankle-sprain/
A sprained ankle is a very common injury. Approximately 25,000 people experience it each day. A sprained ankle can happen to athletes and non-athletes, children and adults. It can happen when you take part in sports and physical fitness activities. It can also happen when you simply step on an uneven surface, or step down at an angle. […] A ligament is an elastic structure. Ligaments usually stretch within their limits, and then go back to their normal positions. When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers. […] Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions. A great force is transmitted upon landing. You can sprain your ankle if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range in an abnormal position.
#6 Sprain – Wikipedia
https://en.wikipedia.org/wiki/Sprain
A sprain is a soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers made of collagen that connect two or more bones to form a joint and are important for joint stability and proprioception, which is the body’s sense of limb position and movement. […] Acute sprains typically occur when the joint is abruptly forced beyond its functional range of motion, often in the setting of trauma or sports injuries. The most common cause of sprains in general is repetitive movements (overuse). […] Ligaments are collagen fibers that connect bones together, providing passive stabilization to a joint. These fibers can be found in various organizational patterns (parallel, oblique, spiral, etc.) depending on the function of the joint involved. Ligaments can be extra-capsular (located outside the joint capsule), capsular (continuation of the joint capsule), or intra-articular (located within a joint capsule). The location has important implications for healing as blood flow to intra-articular ligaments is diminished compared to extra-capsular or capsular ligaments.
#7 Sprain – Wikipedia
https://en.wikipedia.org/wiki/Sprain
Collagen fibers have about a 4% elastic zone where fibers stretch out with increased load on the joint. However, exceeding this elastic limit causes a rupture of fibers, leading to a sprain. It is important to recognize that ligaments adapt to training by increasing the cross-sectional area of fibers. When a ligament is immobilized, the ligament has been shown to rapidly weaken. Normal daily activity is important for maintaining about 80-90% of the mechanical properties of a ligament.
#8 Sprain – Wikipedia
https://en.wikipedia.org/wiki/Sprain
A sprain is a soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers made of collagen that connect two or more bones to form a joint and are important for joint stability and proprioception, which is the body’s sense of limb position and movement. […] Acute sprains typically occur when the joint is abruptly forced beyond its functional range of motion, often in the setting of trauma or sports injuries. The most common cause of sprains in general is repetitive movements (overuse). […] Ligaments are collagen fibers that connect bones together, providing passive stabilization to a joint. These fibers can be found in various organizational patterns (parallel, oblique, spiral, etc.) depending on the function of the joint involved. Ligaments can be extra-capsular (located outside the joint capsule), capsular (continuation of the joint capsule), or intra-articular (located within a joint capsule). The location has important implications for healing as blood flow to intra-articular ligaments is diminished compared to extra-capsular or capsular ligaments.
#9 Ankle sprain research – Dr Daniel Fong Sport Injury Laboratory
https://danielfong.org/ankle-sprain-research/
Ankle ligamentous sprain is the most common sport-related injury. […] Repeated ankle sprains, without adequate treatment, may lead to ankle instability or even osteoarthritis. […] Since 2014, I have been working on a series of studies on the injury mechanism of ankle sprain. […] There are two major aetiologies which cause an ankle inversion sprain injury. Firstly, an incorrect landing posture with a slightly inverted or supinated ankle joint would cause a ground reaction force acting on the lateral foot edge to point medially and not pass through the ankle joint centre, thus creating a vigorous inward twisting torque, subsequent excessive inversion, and finally high ligament strains which tear the lateral ligaments. […] Secondly, the reaction of the peroneal muscles, which function to resist ankle inversion, is too slow (60-90ms) to catch up to accommodate the sudden explosive inversion which happened within 50ms after a foot strike.
#10 Ankle sprain research – Dr Daniel Fong Sport Injury Laboratory
https://danielfong.org/ankle-sprain-research/
Ankle ligamentous sprain is the most common sport-related injury. […] Repeated ankle sprains, without adequate treatment, may lead to ankle instability or even osteoarthritis. […] Since 2014, I have been working on a series of studies on the injury mechanism of ankle sprain. […] There are two major aetiologies which cause an ankle inversion sprain injury. Firstly, an incorrect landing posture with a slightly inverted or supinated ankle joint would cause a ground reaction force acting on the lateral foot edge to point medially and not pass through the ankle joint centre, thus creating a vigorous inward twisting torque, subsequent excessive inversion, and finally high ligament strains which tear the lateral ligaments. […] Secondly, the reaction of the peroneal muscles, which function to resist ankle inversion, is too slow (60-90ms) to catch up to accommodate the sudden explosive inversion which happened within 50ms after a foot strike.
#11 Ankle sprain research – Dr Daniel Fong Sport Injury Laboratory
https://danielfong.org/ankle-sprain-research/
The stability of a joint depends on both the contraction of the muscles and the contribution from the ligaments, therefore, when the muscles are inactive, the joint stability would rely mainly on the ligaments. […] Since the ligaments possess viscoelastic property, a sudden explosive stretch would tear them. […] There are many ways to further study the injury mechanism, and the most direct one is to study the real injury incidents. […] The data suggested that the peak inversion has reached 48 degrees, and such a range of inversion is often regarded as normal from the literature. […] Moreover, a dorsiflexed instead of plantarflexed ankle orientation was observed, and this was not in agreement with the supination mechanism clinically suggested. […] The peak inversion velocity reached 638 deg/s, and this was the first time such a value was reported.
#12 Acute Ankle Sprain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK459212/
Acute ankle sprains are commonly seen in both primary care practices and emergency departments and can result in significant short-term morbidity, recurrent injuries, and functional instability. […] Appropriate treatment can limit the impact of long-term detrimental effect such as chronic recurrent ankle instability, arthritic progression, and long-term disability. […] Ankle sprains most commonly involve injury to the anterior talofibular ligament (ATFL) and/or the calcaneofibular ligament (CFL). Ankle sprains vary depending on the mechanism of injury (high- versus low-energy injuries), position of the foot, and rotational force on the joint and stabilizing ligamentous structures. […] The most common ankle injury occurs with inversion of the ankle which stresses the lateral ligament complex. The three ligaments that compose the lateral complex are the anterior talofibular (ATFL), the calcaneofibular (CFL), and posterior talofibular (PTFL) and they tend to be injured in this order with the anterior talofibular ligament being injured most commonly.
#13 Ankle Sprain | PM&R KnowledgeNow
https://now.aapmr.org/ankle-sprain/
Lateral ligament sprains are most common (85% of sprains) and occur from subtalar supination/inversion, talocrural plantarflexion, and tibial external rotation. As the foot rotates, the anterior talofibular ligament (ATFL) is injured first, then the calcaneofibular ligament (CFL) and posterior talofibular ligaments (PTFL) tend to tear in that sequence, depending on severity of the injury. […] The ATFL generally consists of two bands that are separated by branches of the perforating peroneal artery. The ATFL is intracapsular, has the lowest failure resistance, and is the most important ligament in talofibular stability. It is under maximal stress with the ankle in plantarflexion. The CFL is extracapsular, thicker, and stronger than the ATFL, and the next to tear in a plantarflexion/inversion injury. The PTFL is the strongest of the three ligaments and least likely to fail because it is only taut in extremes of dorsiflexion. […] The most common mechanism of injury is a high energy forced external rotation with the foot in dorsiflexion. This injury may coexist with either medial or lateral ankle sprains, with medial ankle sprains being more common.
#14 Management of Ankle Sprains | AAFP
https://www.aafp.org/pubs/afp/issues/2001/0101/p93.html
The most common mechanism of injury in ankle sprains is a combination of plantar flexion and inversion. The lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular and posterior talofibular ligaments, are most often damaged. The anterior talofibular ligament is the most easily injured. Concomitant injury to this ligament and the calcaneofibular ligament can result in appreciable instability.5 The posterior talofibular ligament is the strongest of the lateral complex and is rarely injured in an inversion sprain.5,7 […] The mechanism of injury is excessive eversion and dorsiflexion. […] Injury to the tibiofibular syndesmosis ligaments, which bind together the distal ends of the tibia and fibula, is commonly referred to as a high ankle sprain. Although this injury accounts for only about 10 percent of ankle sprains, it represents a more disabling problem and requires different treatment than common ankle sprains.14 The mechanism of injury is excessive dorsiflexion and eversion of the ankle joint with internal rotation of the tibia.
#15 Ankle Sprain | PM&R KnowledgeNow
https://now.aapmr.org/ankle-sprain/
Lateral ligament sprains are most common (85% of sprains) and occur from subtalar supination/inversion, talocrural plantarflexion, and tibial external rotation. As the foot rotates, the anterior talofibular ligament (ATFL) is injured first, then the calcaneofibular ligament (CFL) and posterior talofibular ligaments (PTFL) tend to tear in that sequence, depending on severity of the injury. […] The ATFL generally consists of two bands that are separated by branches of the perforating peroneal artery. The ATFL is intracapsular, has the lowest failure resistance, and is the most important ligament in talofibular stability. It is under maximal stress with the ankle in plantarflexion. The CFL is extracapsular, thicker, and stronger than the ATFL, and the next to tear in a plantarflexion/inversion injury. The PTFL is the strongest of the three ligaments and least likely to fail because it is only taut in extremes of dorsiflexion. […] The most common mechanism of injury is a high energy forced external rotation with the foot in dorsiflexion. This injury may coexist with either medial or lateral ankle sprains, with medial ankle sprains being more common.
#16 Ankle Sprain | Quincy, MA | Furnace Brook Physical Therapy
https://furnacebrookpt.com/physical-therapy/ankle-sprains/
In an ankle sprain, there is damage to one or more of the ligaments caused by overstretching. […] Ankle sprains can be medial or lateral in nature, depending on the direction the ankle rolls during injury, or can be classified as high ankle sprain. […] In a medial ankle sprain, an eversion (arch of foot rolling inward) mechanism causes damage to ligaments on the inside of ankle including the deltoid ligament. […] In a high ankle sprain, an external rotation (toes facing out) mechanism causes damage to the tibiofemoral ligaments. […] In the most common, lateral ankle sprain, an inversion (rolling onto outside of foot) and plantar flexion (pointing toes) mechanism causes damage to the ligaments on the outside of the ankle including the ATFL (anterior talofibular ligament), CFL (calcaneofibular ligament), and/or PTFL (posterior talofibular ligament). […] Lateral ankle sprains can be classified into Grades I, II, or III based upon the severity of the sprain and which structures are involved. […] If an ankle sprain goes untreated, it can lead to further injury to the joint including chronic instability.
#17 Musculoskeletal Injuries
https://www.utmb.edu/pedi_ed/CoreV2/Musculoskeletal/Musculoskeletal3.html
A sprain is an injury to a ligament which is a band of short, fibrous connective tissue that connects between two bones or bone to cartilage to stabilize a joint together with other ligaments. […] […] Caused from inversion of the plantar-flexed foot. […] […] Caused by forced eversion to the deltoid ligament, consisting of anterior tibiotalar ligament, posterior tibiotalar ligament, tibionavicular ligament, and tibiocalcaneal ligament. […] […] Occurs with forced dorsiflexion and eversion (e.g. a child jumps from a height, slides into a base, or decelerates while skiing). […] […] The syndesmosis is the membrane between the distal tibia and fibula. […] […] The test identifies a syndesmotic sprain. It is a positive test when there is pain anterior and proximal to the ankle joint upon squeezing the tibia against the fibula at mid-calf. […]
#18 Management of Ankle Sprains | AAFP
https://www.aafp.org/pubs/afp/issues/2001/0101/p93.html
The most common mechanism of injury in ankle sprains is a combination of plantar flexion and inversion. The lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular and posterior talofibular ligaments, are most often damaged. The anterior talofibular ligament is the most easily injured. Concomitant injury to this ligament and the calcaneofibular ligament can result in appreciable instability.5 The posterior talofibular ligament is the strongest of the lateral complex and is rarely injured in an inversion sprain.5,7 […] The mechanism of injury is excessive eversion and dorsiflexion. […] Injury to the tibiofibular syndesmosis ligaments, which bind together the distal ends of the tibia and fibula, is commonly referred to as a high ankle sprain. Although this injury accounts for only about 10 percent of ankle sprains, it represents a more disabling problem and requires different treatment than common ankle sprains.14 The mechanism of injury is excessive dorsiflexion and eversion of the ankle joint with internal rotation of the tibia.
#19 How To Rehab a High Ankle Sprain | [P]rehab
https://theprehabguys.com/high-ankle-sprain/
High ankle sprains: Mechanism of Injury and Risk Factors […] Forced External Rotation: Twisting outwards of the ankle is the most common mechanism of injury for a high ankle sprain. What happens during this external rotation motion coupled with a high amount of force is that the talus (ankle bone) causes a separation of the distal tibia and fibula. […] Forced Ankle Dorsiflexion: There also is a less frequent mechanism of injury for high ankle sprains in which there is a hyperdorsiflexion moment at the ankle. Dorsiflexion of the ankle is when your toes are drawn back towards your shin in the open chain, or when your knee is moving past your toes in the closed chain. Similar to the external rotation mechanism of injury, an excessive amount of dorsiflexion causes the widest portion of the talus to excessively rotate within the ankle mortise. An analogy to conceptualize the separation of the distal tibia and fibula bones is a splitting maul that forces firewood to split apart.
#20 How To Rehab a High Ankle Sprain | [P]rehab
https://theprehabguys.com/high-ankle-sprain/
High ankle sprains: Mechanism of Injury and Risk Factors […] Forced External Rotation: Twisting outwards of the ankle is the most common mechanism of injury for a high ankle sprain. What happens during this external rotation motion coupled with a high amount of force is that the talus (ankle bone) causes a separation of the distal tibia and fibula. […] Forced Ankle Dorsiflexion: There also is a less frequent mechanism of injury for high ankle sprains in which there is a hyperdorsiflexion moment at the ankle. Dorsiflexion of the ankle is when your toes are drawn back towards your shin in the open chain, or when your knee is moving past your toes in the closed chain. Similar to the external rotation mechanism of injury, an excessive amount of dorsiflexion causes the widest portion of the talus to excessively rotate within the ankle mortise. An analogy to conceptualize the separation of the distal tibia and fibula bones is a splitting maul that forces firewood to split apart.
#21 Overview of Sprains and Other Soft-Tissue Injuries – Injuries; Poisoning – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/injuries-poisoning/sprains-and-other-soft-tissue-injuries/overview-of-sprains-and-other-soft-tissue-injuries
Tears in ligaments or muscles may be graded as 1st degree: Minimal (fibers are stretched but intact, or only a few fibers are torn) […] 2nd degree: Partial (some to almost all fibers are torn) […] 3rd degree: Complete (all fibers are torn). […] Tendon tears can be partial or complete. With complete tears, the motion produced by the detached muscle is usually lost. Partial tears can result from a single traumatic event (eg, penetrating trauma) or repeated stress (chronically, causing tendinopathy). Motion is often intact, but partial tears may progress to complete tears, particularly when significant or repetitive force is applied. […] Many partial tears in ligaments, tendons, or muscles heal spontaneously. Complete tears often require surgery to restore anatomy and function. Prognosis and treatment vary greatly depending on the location and severity of the injury.
#22 Ankle Sprain | UConn Musculoskeletal Institute
https://health.uconn.edu/msi/clinical-services/orthopaedic-surgery/foot-ankle-and-podiatry/ankle-sprain/
If there is a severe in-turning or out-turning of the foot relative to the ankle, the forces cause the ligaments to stretch beyond their normal length. If the force is too strong, the ligaments can tear. You may lose your balance when your foot is placed unevenly on the ground. You may fall and be unable to stand on that foot. When excessive force is applied to the ankle’s soft tissue structures, you may even hear a „pop.” Pain and swelling result. […] The amount of force determines the grade of the sprain. A mild sprain is a Grade 1. A moderate sprain is a Grade 2. A severe strain is a Grade 3. […] A Grade 1 Sprain: Slight stretching and some damage to the fibers (fibrils) of the ligament. […] A Grade 2 Sprain: Partial tearing of the ligament. If the ankle joint is examined and moved in certain ways, abnormal looseness (laxity) of the ankle joint occurs.
#23 Ankle Sprain | UConn Musculoskeletal Institute
https://health.uconn.edu/msi/clinical-services/orthopaedic-surgery/foot-ankle-and-podiatry/ankle-sprain/
A Grade 3 Sprain: Complete tear of the ligament. If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs. […] If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. If this occurs, it is possible that the injury may also have caused damage to the ankle joint surface itself. […] The amount of pain depends on the amount of stretching and tearing of the ligament. Instability occurs when there has been complete tearing of the ligament or a complete dislocation of the ankle joint. […] A Grade 3 sprain can be associated with permanent instability. […] Possible complications of ankle sprains and treatment include abnormal proprioception. There may be imbalance and muscle weakness that causes a re-injury. If this happens over and over again, a chronic situation may persist with instability, a sense of the ankle giving way (gross laxity) and chronic pain. […] Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to non-surgical treatment, and for persistent instability after months of rehabilitation and non-surgical treatment.
#24 Sprains, Strains & Other Soft-Tissue Injuries – OrthoInfo – AAOS
https://orthoinfo.aaos.org/en/diseases–conditions/sprains-strains-and-other-soft-tissue-injuries/
Sprains, strains, and contusions, as well as tendinitis and bursitis, are common soft-tissue injuries. […] A sprain is a stretch and/or tear of a ligament, a strong band of connective tissue that connects the end of one bone with another. […] The areas of the body that are most vulnerable to sprains are the ankles, knees, and wrists. […] A sprained ankle can occur when your foot turns inward, placing extreme tension on the ligaments of your outer ankle. […] Sprains are classified by severity: Grade 1 sprain (mild): Slight stretching and some damage to the fibers of the ligament. […] Grade 2 sprain (moderate): Partial tearing of the ligament. […] Grade 3 sprain (severe): Complete tear of the ligament. […] While the intensity varies, pain, bruising, swelling, and inflammation are common to all three categories of sprains. […] Treatment for sprains begins with the RICE protocol and physical therapy. […] The most severe sprains may require surgery to repair torn ligaments.
#25 :: JKOA :: The Journal of the Korean Orthopaedic Association
https://www.jkoa.org/DOIx.php?id=10.4055/jkoa.2014.49.1.1
Ankle sprain is one of the most common musculoskeletal injuries, nearly half of all ankle sprains occur during athletic activity. […] The stability of the ankle joint is maintained by both bony structure and ligamentous complex. The anterior talofibular ligament is the primary restraint of internal rotation and adduction of the talus with the ankle joint unloaded, while both bony mortise structure and calcaneofibular ligament restrict adduction of the talus with the ankle joint loaded. Plantar flexion and inversion is the most common mechanism of ankle sprains, which lead to injury of the anterior talofibular ligament followed by calcaneofibular ligament. […] Ligament injuries are classified according to three grades based on the extent of rupture and the severity of clinical features. Associated injuries with lateral ankle sprain include peroneus tendon rupture, osteochondral fracture, deltoid ligament injury, syndesmosis injury, and nerve traction injuries.
#26 :: JKOA :: The Journal of the Korean Orthopaedic Association
https://www.jkoa.org/DOIx.php?id=10.4055/jkoa.2014.49.1.1
Ankle sprain is one of the most common musculoskeletal injuries, nearly half of all ankle sprains occur during athletic activity. […] The stability of the ankle joint is maintained by both bony structure and ligamentous complex. The anterior talofibular ligament is the primary restraint of internal rotation and adduction of the talus with the ankle joint unloaded, while both bony mortise structure and calcaneofibular ligament restrict adduction of the talus with the ankle joint loaded. Plantar flexion and inversion is the most common mechanism of ankle sprains, which lead to injury of the anterior talofibular ligament followed by calcaneofibular ligament. […] Ligament injuries are classified according to three grades based on the extent of rupture and the severity of clinical features. Associated injuries with lateral ankle sprain include peroneus tendon rupture, osteochondral fracture, deltoid ligament injury, syndesmosis injury, and nerve traction injuries.
#27 Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability
https://pmc.ncbi.nlm.nih.gov/articles/PMC164367/
Two theories of the cause of CAI have traditionally been postulated: mechanical instability and functional instability. […] Mechanical instability of the ankle complex occurs as a result of anatomic changes after initial ankle sprain, which lead to insufficiencies that predispose the ankle to further episodes of instability. […] Pathologic laxity can result in joint instability when the ankle is put in vulnerable positions during functional activities, resulting in subsequent injury to joint structures. […] Mechanical instability may also occur due to insufficiencies caused by synovial hypertrophy and impingement or the development of degenerative joint lesions. […] Injury to the lateral ligaments of the ankle results in adverse changes to the neuromuscular system that provides dynamic support to the ankle.
#28 Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability
https://pmc.ncbi.nlm.nih.gov/articles/PMC164367/
Objective: To describe the functional anatomy of the ankle complex as it relates to lateral ankle instability and to describe the pathomechanics and pathophysiology of acute lateral ankle sprains and chronic ankle instability. […] Lateral ankle sprains typically occur when the rearfoot undergoes excessive supination on an externally rotated lower leg. […] Chronic ankle instability may be due to mechanical instability, functional instability, or most likely, a combination of these 2 phenomena. […] Mechanical instability may be due to specific insufficiencies such as pathologic laxity, arthrokinematic changes, synovial irritation, or degenerative changes. […] Functional instability is caused by insufficiencies in proprioception and neuromuscular control. […] The mechanism of recurrent ankle injury is not thought to be different than that of initial acute ankle sprains; however, adverse changes that occur after primary injury are believed to predispose individuals to recurrent sprains.
#29 Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability
https://pmc.ncbi.nlm.nih.gov/articles/PMC164367/
Objective: To describe the functional anatomy of the ankle complex as it relates to lateral ankle instability and to describe the pathomechanics and pathophysiology of acute lateral ankle sprains and chronic ankle instability. […] Lateral ankle sprains typically occur when the rearfoot undergoes excessive supination on an externally rotated lower leg. […] Chronic ankle instability may be due to mechanical instability, functional instability, or most likely, a combination of these 2 phenomena. […] Mechanical instability may be due to specific insufficiencies such as pathologic laxity, arthrokinematic changes, synovial irritation, or degenerative changes. […] Functional instability is caused by insufficiencies in proprioception and neuromuscular control. […] The mechanism of recurrent ankle injury is not thought to be different than that of initial acute ankle sprains; however, adverse changes that occur after primary injury are believed to predispose individuals to recurrent sprains.
#30 Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability
https://pmc.ncbi.nlm.nih.gov/articles/PMC164367/
Two theories of the cause of CAI have traditionally been postulated: mechanical instability and functional instability. […] Mechanical instability of the ankle complex occurs as a result of anatomic changes after initial ankle sprain, which lead to insufficiencies that predispose the ankle to further episodes of instability. […] Pathologic laxity can result in joint instability when the ankle is put in vulnerable positions during functional activities, resulting in subsequent injury to joint structures. […] Mechanical instability may also occur due to insufficiencies caused by synovial hypertrophy and impingement or the development of degenerative joint lesions. […] Injury to the lateral ligaments of the ankle results in adverse changes to the neuromuscular system that provides dynamic support to the ankle.
#31 Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability
https://pmc.ncbi.nlm.nih.gov/articles/PMC164367/
Objective: To describe the functional anatomy of the ankle complex as it relates to lateral ankle instability and to describe the pathomechanics and pathophysiology of acute lateral ankle sprains and chronic ankle instability. […] Lateral ankle sprains typically occur when the rearfoot undergoes excessive supination on an externally rotated lower leg. […] Chronic ankle instability may be due to mechanical instability, functional instability, or most likely, a combination of these 2 phenomena. […] Mechanical instability may be due to specific insufficiencies such as pathologic laxity, arthrokinematic changes, synovial irritation, or degenerative changes. […] Functional instability is caused by insufficiencies in proprioception and neuromuscular control. […] The mechanism of recurrent ankle injury is not thought to be different than that of initial acute ankle sprains; however, adverse changes that occur after primary injury are believed to predispose individuals to recurrent sprains.
#32 Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability
https://pmc.ncbi.nlm.nih.gov/articles/PMC164367/
The individual symptoms of functional ankle instability do not occur in isolation but are likely all components of a complex pathoetiologic paradigm. […] The interactions between mechanical insufficiency and functional insufficiency and the relationships between the specific insufficiencies have not been clearly elucidated.
#33 Intrinsic and Extrinsic Risk Factors for Lateral Ankle Sprain: A Literature Review
https://scholars.direct/Articles/sports-medicine/aspm-3-026.php
Ankle injuries are very common, specially sprained ankles. Fong, et al. reported that ankle sprain was the major ankle injury in 33 of 43 sports. In high impact, contact and pivoting activities, as well as in jumping and landing, a high proportion of the injuries will affect the lower limb, namely the ankle joint. Ankle sprain can injure the medial ligaments, lateral ligaments, or the syndesmotic tibio-fibular joint. Respectively, these injuries are referred as medial, lateral or high ankle sprains. Lateral ankle sprains are more common, and athlete’s are at a significantly higher risk of sustaining one. This review will focus primarily on lateral ankle sprains, which from now on, will be referred only as ankle sprains. Very often, an exaggerated supination and inversion of the foot, with external rotation of the tibia leads to this injury. This mechanism generates tension that stretches the ligaments beyond their tensile strength, leading to damage. Classically, this damage is divided in three grades and the patient usually has pain with weight bearing, ecchymosis and swelling, progressively increasing with the grade. Most of the times, the treatment for a sprained ankle is conservative, rarely including surgery. Even though ankle sprains tend to be considered „easy to treat”, sometimes a bad outcome may be present. According to the severity of the tear, the patient might have different grades of short-and long-term disabilities. As mentioned above, ankle sprain treatment is usually conservative. Nonetheless, considering the high incidence of this injury, and the negative impact that it might have on personal, professional and leisure activity, it’s easy to understand why medical teams make a huge effort trying to prevent it. A thorough understanding of the risk factors behind ankle sprain is mandatory to create proper education and prevention programs, either in non-professional and professional sports activities. This literature review intends to summarize and condense the available scientific evidence up to the date. Williams proposed a classification for injuries’ mechanism, which we adapted, dividing risk factors into intrinsic (one’s characteristics) and extrinsic (external causative agent). The mechanism that usually leads to an ankle sprain is an exaggerated inversion and supination of the foot. Thus, it is logical to expect that the stronger the concentric function of the muscles that antagonize this exaggerated motion is, the less likely it will be to have an ankle sprain. Additionally, the stronger the eccentric contraction of supinators and invertors is, the fewer injuries will occur. This information proposes a relation between ankle-complex muscles and ankle sprains. In fact, even proximal muscles might play a role in this injury. However, prospective studies that measure muscle strength of all the ankle-complex muscles should be developed, in order establish independent and clear risk factors. Previous ankle sprain as a risk factor for re-injury might be one of the risk factors with more scientific evidence supporting it. Proprioception is a complex process which is coordinated by afferent and efferent impulses, working as feedback loops. It implies a fine tune between nervous and musculoskeletal systems, allowing one to be aware of his own joint position (joint position sense) and joint movement (kinesthesia). This neuromuscular feedback mechanism might be interrupted with injury and abnormalities, but surgical intervention and rehabilitation might restore it. Proprioceptive rehabilitation training includes exercises that challenge the ability of the targeted joint to detect and react to afferent input regarding joint position, for example, balance exercises. As this type of exercises and neuromuscular control are implied in proprioception, it’s logical that different authors have explored the effectiveness of improving these diverse components in injury prevention, namely in the ankle joint. Most professionals working with athletes would rather prevent an injury than treat one. However, solid scientific evidence is needed to build structured and efficient prevention programs. Unfortunately, despite the high incidence of ankle sprain, the literature hasn’t reached a consensus when it comes to define clear risk factors for this injury. Similarly to others, our review found previous ankle sprain as a risk factor for a new injury, and external ankle support (bracing/taping) as a preventive measure for a new or recurrent sprained ankle. Moreover, our review suggests that ankle sprains might be related to specific ankle-complex muscle strength, and even with proximal muscle strength. It also appears that balance and proprioceptive training might reduce the incidence of this injury. Athletes practicing indoor and court team sports also have a higher risk of sustaining a sprained ankle. Even though the next topics were less unanimous, it appears that younger female athletes, with a high BMI, might have an increased risk for ankle sprain. Shoe type and player position might also be a risk factor in specific sports. We didn’t find any correlation between muscle reaction time nor anatomic foot type and ankle sprains.
#34 Acute Ankle Sprains
https://chiro.org/Graphics_Box_LINKS/FULL/Acute_Ankle_Sprains.html
Ankle sprains are a common cause of lost playing time and disability among athletes. […] Sprains are most likely to occur when the ankle is injured in a position in which the bony architecture conveys little stability. […] Differentiating the injury mechanism can help determine whether to order radiographs or to seek more specialized treatment or surgery. […] The high number of recurrent sprains and the frequency of long-term complications from instability and arthritis suggest that the current management protocols may not be optimal. […] Impaired proprioception is associated with functional instability and recurrent sprains. […] Lateral ligament sprains are the most common injuries caused by acute ankle trauma. […] Interosseous membrane sprains can occur when a dorsiflexed ankle (ie, locked talus) is rotated.
#35 Acute Ankle Sprains
https://chiro.org/Graphics_Box_LINKS/FULL/Acute_Ankle_Sprains.html
Disruption of the interosseous membrane, also known as a high ankle sprain, can interfere with the integrity of the ankle mortise and cause chronic joint instability. […] Proprioceptive deficits may be increased by prolonged non-weight bearing or immobilization and may lead to further injury if not corrected. […] No preventive strategy effectively eliminates all sprains. However, preventive measures and proper rehabilitation of injuries may reduce the frequency and severity of ankle injuries.
#36 Acute, Chronic and Recurrent Ankle Sprains | Kingsley Physio | More than your local Physio
https://kingsleyphysio.com/common-conditions/acute-chronic-recurrent-ankle-sprains/
Once an ankle has suffered an inversion sprain there are several factors which make recurring injuries more likely: The intrinsic stability (or instability) of the ankle joint how stable (or loose) are the joints of the foot and ankle now that some of the support structures have been damaged? […] To reduce the risk of reoccurrence, all of these factors need to be addressed by your physiotherapist. […] Proprioception can be thought of as the ability to sense the position or movement of a joint. […] These stretch receptors also detect when a joint is being overstretched and may be vulnerable to damage. […] Consequently, damaged joints can be more susceptible to reinjury as they are less able to sense (and correct) the joint position when a joint is forced beyond its normal range of movement.
#37 Acute Ankle Sprain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK459212/
The mechanism may also lead to complete tendon disruptions and fractures of the ankle and foot in the highest energy scenarios. […] The most common mechanism of high ankle injuries is external rotation and/or ankle dorsiflexion. […] Given the amount of force required to injure this ligamentous complex, these injuries are distinctly uncommon in the general population and tend to occur primarily in competitive athletes. […] While most ankle sprains are successfully managed with nonoperative modalities, recurrent instability and associated defects can be seen in up to 25-40% of patients. Recognition of these possible concomitant injuries and the appropriate referral to an orthopedic/sports medicine specialist is mandatory to mitigate the risks of long-term detrimental outcomes.
#38 How and Why Does Inversion Ankle Sprain Affect Athletes
https://certifiedfoot.com/inversion-ankle-sprains-athelete/
Not to mention that repeated inversion ankle sprain injuries can put undue pressure within the joint itself and cause a compression or shearing injury on the surface of the cartilage â this is known as an osteochondral defect. If this is left untreated, it can eventually form what resembles a crater within the ankle joint. […] However, bear in mind that in individuals with functional injury, these clinical maneuvers may not necessarily be abnormal. This is because they are sensory receptors specifically affiliated with tendons, known as Golgi tendon organs that are very sensitive to both tension and pressure. […] This explains why once a person has had one ankle sprain, and if they are not properly rehabilitated they are likely to undergo these injuries over and over again. […] Once an individual has initially protected, iced, compressed, elevated, and supported an injury, there are further options including: ankle bracing, taping, custom orthotics, nutritional supplements, shockwave therapy, amniotic fluid injections. The last resort is surgical reconstruction of the damaged tissue. […] Crucial to reestablishing this neuromuscular feedback mechanism, is working together with physical therapy for proprioception and neuromuscular reeducation. This is done in an attempt to help to regain some of the somatosensory feedback mechanisms that were previously injured.
#39 Overview of Sprains and Other Soft-Tissue Injuries – Injuries; Poisoning – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/injuries-poisoning/sprains-and-other-soft-tissue-injuries/overview-of-sprains-and-other-soft-tissue-injuries
Serious complications of sprains, strains, and tendon injuries are unusual but may cause permanent limb dysfunction. […] Various ligament injuries, particularly 3rd-degree sprains, can lead to joint instability. Instability can be disabling and increases the risk of osteoarthritis. […] Stiffness is more likely if a joint needs prolonged immobilization. The knee, elbow, and shoulder are particularly prone to posttraumatic stiffness, especially in older people. […] Injuries that result in joint instability predispose to repeated joint stresses that can damage joint cartilage and result in osteoarthritis. […] Many 3rd-degree sprains and tendon tears require surgical repair.
#40 Ankle Injuries and Sprains (Assessment, Symptoms, and Treatment)
https://patient.info/doctor/ankle-injuries-pro
Ankle sprains and injuries are common in primary care, AE and sports medicine. Most are inversion and plantar flexion injuries that lead to damage to the lateral ligaments. […] Between 50% and 70% of people who sustain a lateral ankle sprain will develop chronic ankle instability, which is characterised by lingering pain, instability, injury recurrence, and persistent functional disability. […] Ankle sprains are classified from grade I to grade III depending on their severity: Grade I injuries – the ligament is stretched, with microscopic (but not macroscopic) tearing. Swelling is mild, with little or no functional loss and no joint instability. The patient bears weight at least partially. Grade II injuries – the ligament is stretched with partial tearing. Swelling is moderate-to-severe, with ecchymosis. There is moderate functional loss and mild-to-moderate joint instability. Patients usually have difficulty bearing weight. Grade III injuries – the ligament is completely ruptured. Swelling is immediate and severe, with ecchymosis. The patient usually cannot bear weight (or not without severe pain). There is moderate-to-severe instability of the joint.
#41 Different Types of Ankle Sprains and Implications for Recovery | POGO Physio Gold Coast
https://www.pogophysio.com.au/blog/different-types-of-ankle-sprains-and-implications-for-recovery/
A Lateral ankle sprain is the most common musculoskeletal injury in a physically active population (1). A lateral ankle injury also known as an inversion sprain occurs when the foot plants and the ankle rolls outwards causing injury to numerous tissues of the foot and ankle. […] Lateral ankle sprains are the most common musculoskeletal injury and typically occur with forced plantar flexion and inversion of the foot. The different injuries that occur from this common mechanism differ depending upon the degree of plantar flexion, the speed of sprain, twisting or rotation forces and if the sprain occurs with a fall from height or impact. […] Individuals who suffer an ankle sprain are more likely to reinjure the same ankle (1- 4) which can result in disability and can lead to chronic pain or instability in 2050% of these cases (5).
#42 Ankle Sprain | UConn Musculoskeletal Institute
https://health.uconn.edu/msi/clinical-services/orthopaedic-surgery/foot-ankle-and-podiatry/ankle-sprain/
A Grade 3 Sprain: Complete tear of the ligament. If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs. […] If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. If this occurs, it is possible that the injury may also have caused damage to the ankle joint surface itself. […] The amount of pain depends on the amount of stretching and tearing of the ligament. Instability occurs when there has been complete tearing of the ligament or a complete dislocation of the ankle joint. […] A Grade 3 sprain can be associated with permanent instability. […] Possible complications of ankle sprains and treatment include abnormal proprioception. There may be imbalance and muscle weakness that causes a re-injury. If this happens over and over again, a chronic situation may persist with instability, a sense of the ankle giving way (gross laxity) and chronic pain. […] Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to non-surgical treatment, and for persistent instability after months of rehabilitation and non-surgical treatment.
#43 How and Why Does Inversion Ankle Sprain Affect Athletes
https://certifiedfoot.com/inversion-ankle-sprains-athelete/
Not to mention that repeated inversion ankle sprain injuries can put undue pressure within the joint itself and cause a compression or shearing injury on the surface of the cartilage â this is known as an osteochondral defect. If this is left untreated, it can eventually form what resembles a crater within the ankle joint. […] However, bear in mind that in individuals with functional injury, these clinical maneuvers may not necessarily be abnormal. This is because they are sensory receptors specifically affiliated with tendons, known as Golgi tendon organs that are very sensitive to both tension and pressure. […] This explains why once a person has had one ankle sprain, and if they are not properly rehabilitated they are likely to undergo these injuries over and over again. […] Once an individual has initially protected, iced, compressed, elevated, and supported an injury, there are further options including: ankle bracing, taping, custom orthotics, nutritional supplements, shockwave therapy, amniotic fluid injections. The last resort is surgical reconstruction of the damaged tissue. […] Crucial to reestablishing this neuromuscular feedback mechanism, is working together with physical therapy for proprioception and neuromuscular reeducation. This is done in an attempt to help to regain some of the somatosensory feedback mechanisms that were previously injured.
#44 How and Why Does Inversion Ankle Sprain Affect Athletes
https://certifiedfoot.com/inversion-ankle-sprains-athelete/
Not to mention that repeated inversion ankle sprain injuries can put undue pressure within the joint itself and cause a compression or shearing injury on the surface of the cartilage â this is known as an osteochondral defect. If this is left untreated, it can eventually form what resembles a crater within the ankle joint. […] However, bear in mind that in individuals with functional injury, these clinical maneuvers may not necessarily be abnormal. This is because they are sensory receptors specifically affiliated with tendons, known as Golgi tendon organs that are very sensitive to both tension and pressure. […] This explains why once a person has had one ankle sprain, and if they are not properly rehabilitated they are likely to undergo these injuries over and over again. […] Once an individual has initially protected, iced, compressed, elevated, and supported an injury, there are further options including: ankle bracing, taping, custom orthotics, nutritional supplements, shockwave therapy, amniotic fluid injections. The last resort is surgical reconstruction of the damaged tissue. […] Crucial to reestablishing this neuromuscular feedback mechanism, is working together with physical therapy for proprioception and neuromuscular reeducation. This is done in an attempt to help to regain some of the somatosensory feedback mechanisms that were previously injured.
#45 Cervical Sprain and Strain: Practice Essentials, Pathophysiology, Epidemiology
https://emedicine.medscape.com/article/306176-overview
Cervical strain is produced by an overload injury to the muscle-tendon unit because of excessive forces on the cervical spine. The cause is thought to be the elongation and tearing of muscles or ligaments. Secondary edema, hemorrhage, and inflammation may occur. […] A major advance in the understanding of chronic pain following whiplash injury over the past two decades has been the discovery that central sensitization plays an important role in symptom perpetuation. […] Many cervical muscles do not terminate in tendons but attach directly to the periosteum. Muscles respond to injury by contracting, with surrounding muscles recruited in an attempt to splint the injured muscle. Myofascial pain syndrome, which is thought to be the resultant clinical picture, may be a secondary tissue response to disc or facet-joint injury.
#46 Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability
https://pmc.ncbi.nlm.nih.gov/articles/PMC164367/
Objective: To describe the functional anatomy of the ankle complex as it relates to lateral ankle instability and to describe the pathomechanics and pathophysiology of acute lateral ankle sprains and chronic ankle instability. […] Lateral ankle sprains typically occur when the rearfoot undergoes excessive supination on an externally rotated lower leg. […] Chronic ankle instability may be due to mechanical instability, functional instability, or most likely, a combination of these 2 phenomena. […] Mechanical instability may be due to specific insufficiencies such as pathologic laxity, arthrokinematic changes, synovial irritation, or degenerative changes. […] Functional instability is caused by insufficiencies in proprioception and neuromuscular control. […] The mechanism of recurrent ankle injury is not thought to be different than that of initial acute ankle sprains; however, adverse changes that occur after primary injury are believed to predispose individuals to recurrent sprains.
#47 Acute Ankle Sprain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK459212/
Acute ankle sprains are commonly seen in both primary care practices and emergency departments and can result in significant short-term morbidity, recurrent injuries, and functional instability. […] Appropriate treatment can limit the impact of long-term detrimental effect such as chronic recurrent ankle instability, arthritic progression, and long-term disability. […] Ankle sprains most commonly involve injury to the anterior talofibular ligament (ATFL) and/or the calcaneofibular ligament (CFL). Ankle sprains vary depending on the mechanism of injury (high- versus low-energy injuries), position of the foot, and rotational force on the joint and stabilizing ligamentous structures. […] The most common ankle injury occurs with inversion of the ankle which stresses the lateral ligament complex. The three ligaments that compose the lateral complex are the anterior talofibular (ATFL), the calcaneofibular (CFL), and posterior talofibular (PTFL) and they tend to be injured in this order with the anterior talofibular ligament being injured most commonly.
#48 Acute Ankle Sprain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK459212/
The mechanism may also lead to complete tendon disruptions and fractures of the ankle and foot in the highest energy scenarios. […] The most common mechanism of high ankle injuries is external rotation and/or ankle dorsiflexion. […] Given the amount of force required to injure this ligamentous complex, these injuries are distinctly uncommon in the general population and tend to occur primarily in competitive athletes. […] While most ankle sprains are successfully managed with nonoperative modalities, recurrent instability and associated defects can be seen in up to 25-40% of patients. Recognition of these possible concomitant injuries and the appropriate referral to an orthopedic/sports medicine specialist is mandatory to mitigate the risks of long-term detrimental outcomes.