Introduction
Lateral ankle ligament injuries are common in most sports, particularly in football. The most recent studies put the incidence of such an injury in a range of 10-17% of all injuries (1,2,3) in elite soccer. The majority of these injuries are managed conservatively with a graduated rehabilitation program before returning to play. This often involves the use of an immobilization boot, brace, or strapping with the progressive increase in load-bearing demanded throughout the specific rehabilitation stages. Recovery time for ankle sprains varies between 7 –34 days; post-surgery in more severe cases this figure is reported as 77-105 days (4)
Case Report
The subject is a 21-year-old professional footballer Bobby Burns who is presently contracted to a professional English soccer team in EFL 2 for the 2020-2021 season. He primarily plays as a left-sided full-back or midfielder and has represented his country at U-18, U-19, and U-21 level. His injury occurred in a pre-season friendly match when he came on as a substitute. Two minutes after entering the field of play, his left foot was trapped in a collision with an opponent, and his fixed foot ‘rolled’ over into a plantar flexed/inverted position. He tried to play on but 5 minutes after the injury he was substituted to prevent further damage.
On initial examination, he complained of moderate pain over the anterolateral aspect of the ankle, with an effusion over the anterior/inferior lateral malleolus. He had tenderness on direct palpation of the anterior talofibular ligament (ATFL) with mild to moderate instability on stress testing. All other ankle structures appeared normal. He was treated with ice, compression, and elevation using a Cryo-cuff with ankle attachment (Picture 1) and immobilized in an immobilization walking boot (Picture 2).
His injury was re-assessed daily but no further stress testing of the ATFL was performed until day 5 to allow the acute symptoms to subside and repair tissue to start to form. Each day his symptoms subsided and after re-examination on day 5, the medical team was happy that the player had an isolated Grade2 tear of the ATFL. An MR (Magnetic Resonance) scan was considered but after daily discussion with the player/medical team, this was decided to be unnecessary as physically and psychologically the player was improving daily without this additional intervention.
Intervention and Outcome
In order to assist his rehabilitation after coming out of the immobilisation boot, the player was offered the use of semi-rigid Empowerband ankle support (Picture 3) which is worn over the boot unlike most other ankle braces or supports and which has been designed specifically for football.
The player himself was very keen to use this and wore it throughout the proliferation and re-modelling phase of his rehabilitation, post immobilization boot. Exercise therapy combined with progressive weight bearing is an essential stage in the functional treatment of acute lateral ligamentous sprain [11] and the use of the Empowerband support at all stages gave physiological and psychological assistance as well as sports specificity to his recovery. Early active range of motion exercises were subsequently followed by strengthening exercises, proprioceptive training, and functional exercises. It has been shown that external ankle support does not impede speed, agility, and kicking accuracy in football players (7). Sports specific activities in the final phase progressively simulated the physical demands of football, many similar to the drills accessible on the Empowerband web site https://www.empowerband.com
The player returned to full training 23 days post-injury and was back in the first-team squad as a substitute 9 days later after a full week of training with the first-team squad, where he continued to wear the Empowerband ankle support.
The other common option after coming out of the immobilisation boot is to tape the ankle, twice daily for rehabilitation and training sessions. Although a recent study reported no differences in outcome 6 months after treatment with tape, semi-rigid brace, or lace-up brace [9], a significant number of studies report superior results from protection with a brace [8, 10]. There is a consensus that external ankle braces can reduce the re-occurrence by approximately 70% (5) but it is unclear whether external braces are more effective than strapping as there are advantages and disadvantages for both. Taping can produce skin lesions and loses 50% of its effectiveness 15 minutes after application with intense exercise (6). However, some athletes do not like braces as they may not sit correctly in football boots and can be initially expensive. However, they are reusable, re-adjustable, and need minimal expertise to apply. At present-day prices, the cost of the tape materials would be approximately £4 per strapping at a cost of more than £250 for his 32-day rehabilitation/return to training post-injury. This works out at a cost of 6 times more expensive than the Empowerband brace. It would also have necessitated application by a sports medicine professional twice a day.
Conclusion
Rehabilitation of an ATFL injury is a common case for many sports medical professionals. For a successful return to sport, it is important that each stage of the recovery is only progressed after successful clinical outcomes have been achieved. To try and fast track the recovery process can often lead to the re-occurrence of this type of injury, so any product which can assist and supplement the skills of the sports physiotherapist while helping the player both physically and mentally can only be an adjunct. In this process, the use of the Empowerband ankle support helped achieve the aforementioned goals throughout the rehabilitation program, albeit as demonstrated in this single case study. Further similar reports using a larger number of players is necessary to totally assess the use of this particular ankle brace
The most critical risk factor for an ankle sprain is the history of a previous ankle sprain due to a reduced mechanical stability and reduced proprioceptive ability. There is evidence that neuromuscular training, especially balance training (e.g. wobble board), is useful in the pre-
prevention of recurrent ankle sprains. This type of therapy can also be effectively performed at home [44]. It is controversial if neuromuscular training is beneficial in healthy ankles in preventing the first presentation of a sprain [28]. There is a consensus that an external ankle brace reduces the risk of recurrent ankle injury in previously injured athletes [40] by approximately 70% [59]. These results were reproduced in football players [7,60]. It is unclear whether an external brace is more effective than taping [48], since both have their advantages and disadvantages. The taping technique can lead to skin lesions and loses 40–50% of its effectiveness after 15 min of intensified exercise [61]. However, some athletes tend to dislike braces because they do not fit well in the usual football shoes. Braces are re-usable and re-adjustable, and minimal expertise is required for correct installation. Contrary to popular belief, external ankle support does not impede speed, agility, and kicking accuracy in football
References