Syndesmosis Injury in Rugby Athletes
High ankle sprains, also known as syndesmotic ankle sprains, are a prevalent concern among athletes, particularly those engaged in high-impact sports like rugby. Unlike typical ankle sprains that involve damage to the ligaments on the outer side of the ankle, high ankle sprains affect the ligaments connecting the tibia and fibula bones above the ankle joint. This type of injury can be particularly debilitating for rugby players due to the unique demands of the sport.
In this post, we'll delve into the anatomy of high ankle sprains, the mechanisms of injury, and why rugby players may be especially susceptible. We'll also explore strategies for prevention, diagnosis, and rehabilitation to help rugby athletes mitigate the risk and recover effectively.
Anatomy and Mechanisms of High Ankle Sprains
The syndesmotic ligaments are strong fibrous bands that hold the tibia and fibula bones together at the ankle joint. When these ligaments are stretched or torn due to excessive force or twisting motions, a high ankle sprain occurs. Unlike typical ankle sprains, which often result from inversion (rolling outward) of the foot, high ankle sprains typically occur due to external rotation of the foot combined with dorsiflexion (lifting the foot upward). This is also the best way that practitioners can test for a syndesmosis injury. The practitioner will place the patient in this position and evoke a pain response from separating the tibia and fibula.
How we test for Syndesmosis
Why Rugby Players Are at Risk
Rugby is a physically demanding sport characterised by sudden changes in direction, high-velocity collisions, and intense physical contact. These factors increase the risk of high ankle sprains for several reasons:
Grass Surface: Rugby is typically played on natural grass fields, which can be uneven and prone to divots or holes. Uneven terrain can increase the risk of ankle injuries, including high ankle sprains.
Contact and Tackling: Rugby involves frequent tackling and physical contact between players. The force of impact during tackles can lead to excessive twisting or rotational forces on the ankle, predisposing players to high ankle sprains.
Sudden Direction Changes: Rugby players must frequently change direction while running at high speeds to evade opponents or position themselves strategically. These abrupt changes in direction increase the likelihood of ankle injuries, including high ankle sprains.
Scrum Engagement: In rugby scrums, players from opposing teams come together in a tightly bound formation, exerting immense pressure on their lower limbs. The sheer force and compression experienced during scrums can contribute to ankle injuries, including syndesmotic sprains.
Prevention and Management Strategies
Preventing high ankle sprains in rugby requires a comprehensive approach that includes:
Strength and Conditioning: Rugby players should engage in strength and conditioning programs focused on enhancing lower limb strength, proprioception, and balance to improve ankle stability and reduce injury risk.
Proper Technique: Coaches should emphasise proper tackling and movement techniques to minimise excessive stress on the ankles during gameplay.
Footwear and Equipment: Wearing appropriate footwear with ankle support and ensuring properly fitted protective gear can help reduce the risk of ankle injuries on the field.
Early Recognition and Treatment: Prompt recognition and appropriate management of high ankle sprains are crucial for optimal outcomes. Players should seek medical evaluation if they experience symptoms such as pain, swelling, or instability in the ankle joint.
Rehabilitation and Return to Play Strategies
Rehabilitation following a high ankle sprain is a crucial phase in the recovery process for rugby players. It involves a systematic approach aimed at restoring ankle function, strength, and stability while minimizing the risk of reinjury. Here are key components of the rehabilitation and return to play process:
Early Intervention: Prompt initiation of rehabilitation is essential to prevent complications and promote optimal healing. Immediately following injury, rest, ice, compression, and elevation (RICE) can help reduce pain and swelling.
Medical Evaluation: Rugby players with high ankle sprains should undergo a thorough medical evaluation by a qualified healthcare professional, such as a sports medicine physician or physical therapist. Diagnostic imaging, such as X-rays or MRI scans, may be necessary to assess the severity of the injury.
Immobilisation: In some cases, immobilization of the ankle joint may be necessary to facilitate healing of the syndesmotic ligaments. This may involve the use of a walking boot or ankle brace to restrict motion and provide support.
Progressive Rehabilitation: Rehabilitation programs should be individualised based on the severity of the injury, athlete's functional goals, and stage of healing. Initially, the focus is on reducing pain and inflammation while restoring range of motion and proprioception through gentle exercises and manual therapy techniques.
Strength and Stability Training: As pain subsides and healing progresses, emphasis is placed on strengthening the muscles surrounding the ankle joint, including the calf, peroneals, and intrinsic foot muscles. Exercises may include calf raises, ankle dorsiflexion/plantarflexion, and resistance band exercises to improve ankle stability.
Example of a basic strength exercise during early stage rehab
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Functional Rehabilitation: Rugby-specific movements and drills are gradually incorporated into the rehabilitation program to simulate the demands of gameplay. This may include agility drills, plyometric exercises, and sport-specific movements to enhance proprioception, balance, and neuromuscular control.
Later stage functional assessment/rehab
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Gradual Return to Play: Return to play decisions should be guided by objective measures of ankle function, such as strength, range of motion, and functional performance tests. Rugby players should progress through a structured return to play protocol under the supervision of a qualified healthcare professional to minimise the risk of re-injury.
Monitoring and Maintenance: Even after returning to play, ongoing monitoring and maintenance of ankle health are essential to prevent recurrent injuries. Rugby players should continue with targeted strength and conditioning exercises, proper warm-up and cool-down routines, and appropriate footwear and protective equipment to mitigate the risk of high ankle sprains.
Conclusion
High ankle sprains pose a significant risk to rugby players due to the physical demands and inherent nature of the sport. Understanding the mechanisms of injury, implementing preventive measures, and adopting evidence-based management strategies are essential steps in reducing the incidence and severity of high ankle sprains among rugby athletes. By prioritising ankle health and injury prevention, rugby players can enjoy the sport while minimising the risk of debilitating syndesmotic ankle injuries.