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Ankle sprains occur when the ligaments that support the ankle are stretched beyond their limit and they tear, or avulse. As you might imagine, this is a common injury for pickleball players.

Ligaments are strong fibrous connective tissues that attach bone to bone, and are named according to the bones for which they connect. They stabilize and maintain proper position in the foot and ankle. The vast majority of sprained ankles result when landing on the outside of the foot with the foot turning inward. This is known as an inversion sprain and it represents over 90% of all sprained ankles. With an inversion sprain the most commonly injured ligament is the anterior talofibular ligament (ATFL), which prevents forward displacement of the ankle.

With a more severe ankle sprain, the calcaneofibular ligament (CFL) may also be damaged. This is a much stronger ligament than the ATFL and is not as easily damaged. The posterior talofibular ligament (PTFL) is rarely injured unless there is a complete dislocation of the ankle. Rarely seen is an eversion sprain where the person lands on the inside of the foot injuring the inner or medial ligaments. Ankle sprains not only damage ligaments but they may also result in damage to other surrounding structures, including connective tissue, tendons, muscles and even bones. This is why a severe ankle sprain should be carefully assessed by a trained medical professional to determine the extent of the injury.

Ankle sprains are graded in increasing
severity from Grade 1 to Grade 3

Grade 1 Sprain
• The injured person can walk with some difficulty and pain.
• Mild tenderness, swelling, stiffness and pain are present.
• There is a mild stretching and microscopic tearing of ligaments.
• The ankle joint is still very stable.

Grade 2 Sprain
• There is considerable difficulty when walking, with severe pain.
• There is moderate and partial tearing of ligaments.
• Moderate pain, tenderness, swelling and bruising are present.
• Some looseness and instability is noted in the joint.

Grade 3 Sprain
• There is complete tearing or avulsion of the ligament.
• The ankle is totally unstable, and walking or weight bearing is impossible.
• There is a complete tear of the ATFL and a partial tear of the CFL.
• Surgical intervention is needed to reattach the torn ligament.

Treatment of Ankle Sprains
Immediately following the injury you must do everything possible to reduce swelling. The faster this
is done the quicker you will recover, and the injury will resolve faster. Ignoring the injury results in prolonged pain, swelling and a slower recovery. Perform the following RICE treatment and continue for the first 48 hours:

• Rest (Immobilization) – Do not play pickleball and avoid weight bearing on the affected side.
• Ice – Cool the area for 10-15 minutes using ice packs or cold water; this should be done many times a day, and avoid direct contact of ice pack with bare skin by using a towel.
• Compression – Apply a compressive bandage immediately to slow the bleeding and reduce swelling.
• Elevation – Elevate the foot and ankle above the heart to reduce swelling.

With more serious sprains, visiting a health care professional is recommended to rule out a fracture or serious damage requiring surgery. He/she can also determine if crutches or a cast or boot is needed.

Rehabilitation: It is very important to introduce motion into the joint by doing non-weight-bearing exercises such as circles and writing the alphabet with the foot, and moving a towel with your toes. Also light stretching of the calf, cycling on a stationary bike and swimming are helpful. After 2-5 days, or when the pain and swelling are down to a minimum, rehabilitation can begin in earnest. Begin putting weight and balancing on the ankle; when walking, try to maintain a normal gait pattern. Use rubber tubing or Thera Bands to strengthen the muscles around the ankle. After you can walk and stand without pain, continue to build up strength and flexibility. This can be accomplished with a balance or wobble board, increased walking, an elliptical machine and a slow return to pickleball.

Surgical treatment for ankle sprains is rare and used only when there is persistent ankle instability with
a failure to respond to conservative treatment and rehabilitation. Fortunately, with proper rehabilitation, most ankle sprains resolve favorably and the injured athlete is able to return to normal activities. Sometimes, damage to the ankle ligaments will result in a chronic ankle sprain with instability. Once you have had a sprained ankle, the ligaments in the ankle are unstable and weaker, making recurrence more likely. If instability persists, consider the use of an ankle brace to help stabilize the ankle and reduce the risk of future injury.

Prevention of ankle sprains involves maintaining good muscle strength, balance and flexibility. Proper warm-up prior to activity and exercise, along with paying attention and being careful while playing are important. The use of proper footwear for pickleball is critical; playing in running, basketball or hiking shoes is a recipe for disaster. Finally, when you are overly tired and fatigued, rest or stop playing before you get injured.

Alan Bragman is a chiropractor living in Atlanta, Georgia. He is an IPTPA-certified coach and a 4.5 level player. In addition, he is a former Cat 3 cyclist, nationally ranked table tennis player and inline speed skater. He was on the medical advisory board at Bicycling magazine for 10 years and has written for numerous other sports publications.

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