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A Physical Therapist’s Analysis of Tyler Saladino’s Ankle Injury

As much as we love providing relevant and informative content, we hate to see another Brewers player go down. A few games ago, Tyler Saladino was placed on the 10-day disabled list with a left ankle sprain. Saladino suffered the injury when he turned his ankle on second base on a force play. Unfortunately, ankle injuries are a very common sports injury.

 

Causes of Ankle Sprains

Ankle sprains can happen to anyone, because our ankles support our entire body weight. Our body weight is what makes our ankles vulnerable to strains and instability.  Playing sports, running, jumping or even walking on an uneven surface can cause a sudden force to come across the ankle. This unexpected force is what causes many people to  lose their balance and twist their ankles.  If the ankle turns far enough, the ligaments that hold the bones together can overstretch (sprain) or even tear. A major sprain or several minor sprains over time can lead to permanent ankle instability.

 

 

 

 

 

 

Symptoms

You may lose your balance and fall if your foot is placed at a poor angle when hitting the ground.  Some individuals may hear a “pop” noise when the injury takes place.  Most people  have difficulty putting weight on their foot and walking.  Pain is usually the first symptom of a sprained ankle followed by swelling and stiffness. After a few hours, bruising typically develops.

 

Diagnosis

Your physical therapist or doctor can diagnose a sprained ankle by conducting a physical examination and asking you what caused the injury.  Then, they will move your ankle in various positions to determine which ligament was injured.  An x-ray may be used to make sure that you do not have a broken bone in your ankle or foot.  In severe cases, a Magnetic Resonance Imaging (MRI) scan may be ordered to view the ankle structures in more detail, especially if after a few weeks your symptoms are not improving.

Ankle sprains are categorized by the amount of injury to the ligaments.  A grade 1 sprain has minimal impairment.  In other words, the ligament has sustained slight stretching and about 10% damage to the fibers.  When the ankle joint is lax or looser than normal, the ankle sprain is categorized as a grade 2 sprain. Grade 2 sprains are when there is partial tearing of the ligament due to about 50% damage to the fibers. Lastly,  a grade 3 sprain is when a complete tear of the ligament occurs and the ankle joint is completely unstable. Despite the complete tear of the ligament, you may actually have less pain with a grade 3 ankle sprain if you tear the sensory nerve. Regardless, your ankle will become very swollen and bruised.

 

Treatment

The majority of ankle sprains heal without surgery (grade 1 and 2).  Because of this, it is imperative that you seek evaluation and treatment from a physical therapist or doctor to see if you have fractured of one of the bones that make up the ankle joint. If the ligament is stronger then the bone, you can also have an avulsion fracture.

The treatment of an ankle sprain depends on its grade.  Grade 1 sprains are treated with the RICE method – Rest, Ice, Compression, and Elevation.  You should always initially rest your ankle.  Crutches can be used to help you walk.  Applying ice packs with your foot elevated above your heart can help keep the swelling down and reduce pain.  You should apply ice immediately after spraining your ankle. Your doctor may recommend over-the-counter or prescription pain medication.  Compression bandages, such as elastic wraps, are helpful to immobilize and support the ankle for the first 72 hours (3 days).

Care for grade 2 sprains includes applying the RICE method of treatment and in most cases an ankle air cast, soft splint or walking boot for positioning and stability.  As healing takes place, your doctor will refer you to physical therapy to gradually increase your activities and improve healing.  You may be recommend to wear an ankle brace for stability for a longer period of time as your healing continues, but an ankle brace should never be a permanent solution.

For a grade 3  sprains, your doctor may recommend a short leg cast or a walking boot brace.  The cast is typically worn for two or three weeks and followed by physical therapy.  Your physical therapist will initially help you move and stretch your foot.  Movement can be helpful to improve circulation, reduce swelling, improve range of motion and function.  As you progress in physical therapy, you will participate in exercises to strengthen your muscles and improve your balance and proprioception (awareness of where your foot is in space).  Physical therapy is also helpful in decreasing pain and swelling, and normalizing your functional range of motion, movement, coordination, endurance, and strength.  Your physical therapist will instruct you on how to walk normally again so that you can eventually return to higher level activities. You may need to wear a customized insert called an orthotic for your shoe to help you maintain proper ankle positioning and prevent future ankle sprains.

 

Surgery

Ankle sprains rarely require surgery; however, it is an option when non-surgical treatments and rehabilitation fail.  Every ankle sprain is evaluated on an individual basis.  Your physician will discuss surgical options and help you determine the most appropriate choice for you.

One type of surgery, Ligament Tightening, is performed to tighten the overstretched ligaments.  This usually involves the Anterior Talofibular Ligament (ATFL) and the Calcaneofibular Ligament (CFL).  The surgeon will make an opening over the ligaments and separate the ATFL and the CFL in half.  The ends of these two ligaments are surgically attached to the Fibula.  The surgeon will further reinforce the ligaments by also attaching the top edge of the Ankle Retinaculum.  The Ankle Retinaculum is a large band of connective tissue located at the front of the ankle.

If the ligaments are severely damaged or not appropriate for a Ligament Tightening procedure, the surgeon may perform a Tendon Graft.  For this procedure, the surgeon will use a portion of a nearby tendon for a tendon graft.  The tendon from the Peroneus Brevis muscle in the foot is most commonly used.  The tendon graft is surgically attached to the Fibula and the Talus, near the attachment sites of the original tendon.

In cases of chronic pain, an Arthroscopic Surgery may be performed to remove bone fragments, scar tissue, and damaged cartilage.  Arthroscopic surgery uses a small camera, called an arthroscope, to guide the surgery.  Only small incisions need to be made and the joint does not have to be opened up fully.  This can shorten the recovery time.

 

Recovery

The grade of the ankle injury and the surgical or non-surgical methods used determine the rate of recovery.

Grade 1 sprains should only experience slight range of motion limits. The healing and recovery process is approximately six weeks. (No Surgery Indicated, just physical therapy).

Grade 2 sprains experience moderate impairment and pain. The healing and recovery process may take a few months. (No Surgery Indicated, just physical therapy).

Grade 3 sprains have severe impairment but minimal pain due to there being no nerve intact. The healing and recovery process may take several months.  In most cases, a physical therapy rehabilitation program will help restore strength, mobility, and range of motion. If there is still excessive laxity and dysfunction, surgery is indicated.

Recovery from surgery differs and depends on the extent of the ankle injury and the type of surgery that was performed.  Your physician will let you know what to expect.  Individuals usually wear a cast for up to two months following surgery.  Your doctor will instruct you to carefully increase the amount of weight that you put on your foot.  Rehabilitation following surgery is a slow process.  Individuals typically participate in physical therapy for two to three months.  Physical therapy helps to strengthen the ankle muscles and increase movement.  Success rates are high for all ankle surgical procedures.  The majority of individuals achieve an excellent recovery in about six months.

 

Prevention

Individuals that experience one ankle sprain are at an increased risk to experience another.  Because of this, it may be helpful to strengthen the muscles around the ankle, maintain good flexibility, improve your balance and wear shoes that provide extra ankle support and stability.  Shoes with low and/or flared heels often feel steadier.

 

We are confident that Tyler Saladino is in goods with the Brewers athletic training, physical therapists, and doctors they have on staff. As long as he follows the doctor’s orders, he will be back on the field in no time! Go Brewers!

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