Introduction

Ankle sprains are the most common athletic injury (Garrick 1977). The risk of ankle injuries varies by sport; they make up 45% of all injuries in basketball, 31% in soccer, and 25% in volleyball (Garrick 1977). The vast majority of injuries incurred during basketball are to the lower extremity (Zelisko et al, 1982; Yde et al, 1990). In addition, ankles sprains are the most common injuries in basketball game (Henry et al, 1982; Chan el al, 1984). Henry et al (1982) showed that in a seven years experience of professionals basketball players, ankle injuries accounted for 18.2% of all injuries. Based on the literature review, ankle sprain is the most common athletic injury in the basketball game. The aim of this case study was to examine an ankle injury of a 21 year old, semiprofessional basketball player. Following this case study, the reader will be able to identify and evaluate: i) the mechanism of injury, ii) immediate first aid treatment, iii) diagnosis, iv) acute, sub-acute and chronic phase of treatment, v) long term aims and methods of rehabilitation, vi) pre-discharge and fitness test to assess readiness for return, and vii) preventing aspects.

The mechanism of injury

During a training session, players had to play a game of five against five. After a missed three points shot, four players jumped to take the rebound. During the landing phase one of the players landed on the opponents foot (appendix 1; figure 1). After the sudden unnatural landing impact, the athlete fell down holding his ankle and screaming from the extreme pain. The coach and the players that were watching the actual incident realized that the player sprained his ankle (foot exceeded the physiological range of motion -ROM-).  During the landing phase the athletes foot turned inward (ankle inversion). The extreme ankle movement was supination; combined motions of subtalar inversion, ankle plantar flexion, and foot internal rotation (appendix 1; figure 2).  This can put extreme tension on the ligaments (the fibrous band of connective tissue that joins the end of one bone with another) and a simple stretch or tear of the ligaments may occur. 

Immediate first aid treatment

First aid treatment marks the beginning of the rehabilitation process. Correct management at this stage can reduce the severity of the injured part of the body. After the unlucky incident, one the players who was watching the training session run to the injured player and gently placed a plastic bag of ice on the athletes injured ankle. Additionally, the coach lightly wrapped a bandage around the injured area, taking care not to pull it too tight. Moreover, the injured athlete stayed in a position that he could elevate the foot higher than the waist, targeting blood flow reduction, hence swelling and pain reduction. The final suggestion to the athlete was to stay rest for a few minutes. That moment the coach surprising turned and faced the team players, and said: If an injury or accident like this does occur try to remember the word RICE. 

The magnitude of swelling and the unbearable pain that the athlete suffered from put the coach into further consideration about his athlete condition. The next step was to transfer the injured player to an Orthopaedist for diagnosis and immediate treatment.

Diagnosis

Orthopaedist is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves. Orthopaedist was satisfied with the treatment that the coach and the athletes teammates applied on the injured ankle after the incident. He said that ice can control inflammation; edema, muscle spasm and pain, and can help prevent further tissue damage at the site of the injury. He then faced the injured player and asked him some simple questions, such as:

i)        How did it happen (inversion, eversion, dorsiflexion, etc), and where does it hurt?

ii)       Did the intensity of pain make you stop playing (ruptured ligament, fracture)?

iii)     Were you able to bear any weight right away (fracture severity of injury)?

iv)     Have you injured this or the other ankle before (to identify recurrent sprain, fractures, normal contralateral ankle)?

Orthopaedist in order to identify any type of fracture in the injured ankle carried out a number of X-rays. After the X-rays procedure, Orthopaedist performed a physical examination on the uninjured and injured ankle. Orthopaedist first examined the athlete's uninjured ankle. By doing that, Orthopaedist obtained a useful reference point, and furthermore reduced the anxiety for the examination of the injured ankle. He asked the athlete to move the joint through all directions, and then Orthopaedist moved the ankle through the six ranges of motion: dorsiflexion, plantar flexion, and inversion and eversion in plantar flexion and dorsiflexion. Orthopaedist finished the examination performing a number of special tests in order to evaluate the stability of the joint (appendix 2; figures 1, 2, 3, 4, 5). Orthopaedists diagnosis was that the athlete was lucky since there was no any skeletal damage (appendix 3; fig 1), but the damage on the lateral ankle ligaments was severe (second degree ankle sprain). Based on the Orthopaedist diagnosis, there was a rupture on the anterior talofibular ligament, and a partial tearing on the anterior tibiofibular ligament (appendix 3; figure 2).

Acute, sub-acute and chronic phases of treatment

Weeks 1-2

The severity of the injury compelled the orthopedist to use plaster in order to immobilise the sprained ankle. The athlete kept his ankle immobilized for a two weeks time. During that period athlete stayed rest with his leg elevated in order to reduce blood flow to the injured ankle, and therefore further swelling. Medication was given in order to produce either an analgesic or an anti-inflammatory effect. Paracetanol tablets were used for pain relief, and non-steroidal anti-inflammatory drugs were used in order to reduce the vast swelling. Medication lasted exactly two weeks time. After the end of the first rehabilitation week, athlete started to perform arms exercises. Targeting fitness level maintenance and keeping his lower limb inactive, athlete performed a number of arms exercises on an arms cycle ergometer.

At the end of the two weeks period, the athlete went back to the orthopedist.  The plaster was removed, and a second physical examination took place (appendix 2; figures 1, 2, 3, 4, 5). After the two weeks time, swelling and pain had been significantly reduced. Orthopaedist was satisfied with the pain and swelling reduction. However some signs of swelling and edema were still on the injured ankle. Additionally, joint mobility and strength had significantly reduced, since the joint was immobilised for a two weeks period.

Week 3

At this stage, rehabilitation priorities were the disappearance of the last signs of swelling and edema, as well as, the restoration of the joints mobility. Physiotherapy was used to annihilate the last signs of swelling and edema, and to restore joints mobility. Aiming the increase of the local tissue temperature, physiotherapist used thermotherapy techniques (ultrasounds, Short-wave diathermy and microwaves). Thermotherapy techniques used in order to generate vasodilatation. Vasodilatation induced increase in local tissue metabolism (increase the removal rate of metabolic wastes; increase the delivery of oxygen, phagocytes and enzymes). Additionally, before and after the physiotherapy sessions, athlete performed a number of self-stretching exercises targeting the restoration of the injured joint mobility (appendix 4; fig 1, 2). Throughout this rehabilitation stage, athlete was kept wearing a protective ankle brace (appendix 4; fig 3), since the laxity of the injured ankle ligaments did the joint unstable and susceptible to a new unwanted reinjury. Physiotherapy sessions performed twice a day and lasted for one-week period. Moreover, athlete continued to perform arms exercises on an arms cycle ergometer in order to maintain aerobic fitness level.

Week 4

At the end of the physiotherapy treatment, swelling and edema signs were negligible.  Additionally, joints range of motion had significantly improved. Gaining a significant improvement on the ankle range of motion, rehabilitation programme concentrated on the muscle and ligaments strengthening.  Athlete continued to perform self-stretching exercises, but an additional set of exercises was introduced. Athlete started to perform a number of simple exercises in order to strength the weak muscles and ligaments of the injured ankle joint (appendix 5a; fig 1, 2, 3). Moreover, targeting the regaining of the ankle control and balance maintenance (proprioception), athlete performed a set of balance exercises (appendix 5b; fig 4, 5). At the same time, athlete started to perform jog sessions on a treadmill ergometer to strength his ankle joint as well as to improve his aerobic power. By using a treadmill ergometer, athlete could control the speed and inclination to the level that no pain occurred on the injured ankle joint. When ankle joint started to regain strength and coordination athlete performed ankle exercises on an isokinetic dynamometer. Through Isokinetic dynamometry, exercise can be concentrated on the muscles and ligaments that need further strengthening. Isokinetic dynamometry reduced the time needed for ankle muscle and ligaments strengthening. Resting and non-active period influenced negative not only the ankle muscles and ligaments but also group of muscles from lower and upper body. Athlete, using weights, started to perform a variety of exercises in order to regain legs, arms, and trunk muscles strengthening. During all rehabilitation periods, and after the end of each training session, athlete placed a plastic bag of ice on his injured ankle in order to relax the injured part of his body. Throughout the forth week of rehabilitation programme, athletes improvement was significant. Athlete improved:  i) ankle strength, joint range of motion, and balance /coordination ii) aerobic power and iii) lower body and upper body strength. Also, there was no sings of pain and swelling on the injured ankle.

Table 1: Tabular representation of the acute, sub-acute and chronic phases of treatment, and their aims.

Table 1

Ø      At the end of the four weeks rehabilitation program, coach and physiotherapist requested from the athlete to perform a number of exercises in order to evaluate readiness for return to the training routine.    

Pre-discharge and fitness test to assess readiness for return

At the end of the four weeks rehabilitation program, physiotherapist examined the athletes injured ankle. Physiotherapists diagnosis was that the injured area had regained normal strength, flexibility, and range of motion when compared to the uninjured ankle joint.  At that point, physiotherapist decided that the athlete had to perform a number of functional exercises. That type of testing exercises should be always commenced when the athlete is pain-free, has full range of motion, adequate muscle strength and proprioception. After a good warm up and stretching exercises, athlete executed sets of jumping, twisting, hopping, and sprinting exercises. Based on the athletes reactions on the specific exercises, coach and physiotherapists evaluated if the athlete was ready to return to normal training sessions. After the completion of the functional exercises, physiotherapist and the coach were satisfied with the athletes reactions, since no pain occurred on the injured ankle. Additional, athletes psychological condition demonstrated his willingness and enthusiasm to return to the teams training sessions. Physiotherapist knowing that return to sport is permitted when functional exercises can be performed without pain during or after activity, allowed to the athlete to start training with his teammates.

Preventative aspects

To prevent future sprained ankle, athlete had pay attention to his bodys warning signs. He should slow down when he felt pain or fatigue, and stayed in shape with good muscle balance, flexibility and strength in his soft tissues. Additionally, before any kind of activity a good warm up was required, and a good warm down was essential. Moreover, athlete, should use protective taping or bracing for all his future sporting activities. Taping or bracing will limit the abnormal or excessive movements of a sprained joint while also will provide support to the muscles that the sprain had compromised. Athlete, in order to prevent his ankle from future injury, had the opportunity to choose between bracing (appendix 4; fig 3) and taping (appendix 6) techniques. Athletes final decision was to use Brace (appendix 4; fig 3), since it was easier to fit and to adjust, and provided lack of skin irritation. Additionally, brace was less expensive compared to taping over a lengthy period.      

Long term aims of rehabilitation

It is essential for the athlete to follow precisely, and successfully complete the rehabilitation program, since it makes it less likely that he will hurt the same ankle again. If he does not complete the rehabilitation program, he might suffer chronic pain, instability and arthritis in his injured ankle joint. Moreover, if his ankle is still hurts, it could be means that the sprained ligament(s) has not healed properly, or that some other type of injury may also occur. Through proper rehabilitation procedure, athlete can achieve: i) rehabilitation time reduction, ii) avoidance of chronic pain, instability and arthritis, and iii) psychological boost for faster fitness regaining.         

Conclusion

The injured athlete was fortunate, since every step of the rehabilitation procedure was supervised by experts (physiotherapist, Orthopaedist). Moreover, coachs experience and consciousness helped the athlete to rapidly overcome the unwanted ankle injury. The severity of the injured ankle kept the athlete out of any competitive athletic activity for several weeks. Athletes willingness and persistence on the rehabilitation program recompensed his efforts. Athlete, following step by step the four weeks rehabilitation program achieved a remarkable result. At the end of the forth week, athlete started to participate to the teams training sessions, and the fifth week athlete joint his teammates on a basketball league game. He achieved to overcome his injury, and helped his team on the remaining championship games.