As physios, ankle sprains are one of the most common sporting injuries we see. The more severe ankle sprains are generally treated with the appropriate level of diligence. However, we often see the milder sprains left untreated and not given the respect they deserve; possibly leading to a high recurrence rate. Because of repeated untreated ankle sprains, ankle instability, chronic ankle pain, swelling become an all too common presentation. So, in today’s blog, we will look at the ankle’s structure, how its ligaments provide it support, what happens when an injury occurs, how best to manage the injury and include tips on how to prevent them from reoccurring.
The what and the how…
No doubt you know what ligaments are, or have heard of them – they are strong, fibrous tissues that connect bones to other bones. The ligaments in the ankle help to keep the bones in proper position and stabilise the joint. An ankle sprain occurs when your ankle ligaments are overstretched. They vary in severity, from a mild sprain (the twisted or rolled ankle) through to severe: complete ligament ruptures, avulsions, and fractures.
Ankle sprains more commonly occur in sports requiring jumping, turning, and twisting movements such as basketball, netball, and football. Participants in sports with explosive changes of direction such as hockey, football and tennis are also particularly vulnerable to ankle sprains.
Lateral ankle ligaments
The outside (lateral side) of the ankle is stabilised by three smaller ligaments: the anterior talofibular (at the front), the calcaneofibular (at the side) and the posterior talofibular (at the back). Sprains to any of these ligaments are called inversion sprains. This is where the foot twists inwards. These types of sprains account for more than 80% of all ankle sprains. Inversion ankle sprains can occur simply by rolling your ankle on some unstable ground, awkwardly planting your foot when running, landing unbalanced from a jump or landing on an opponent’s foot after jumping.
The most commonly injured ligament is the anterior talofibular ligament (ATFL). Injury to thie ATFL can cause swelling and pain on the outside of the ankle. If the force is more severe, the calcaneofibular ligament is also likely to be damaged. The posterior talofibular ligament is less likely to be sprained. A complete tear of all ligaments may result in a dislocation of the ankle joint and an accompanying fracture!
Medial ankle ligaments
On the inside of the ankle (medial side), the joint is stabilised by a thick, strong ligament called the deltoid ligament. Sprains to the deltoid ligament are called eversion sprains. This is where the foot twists outward. These types of sprains account for less than 20% of all ankle sprains. These are less likely to occur but when they do, are often more severe and have a longer recovery time.
Image credit (http://sma.org.au)
Have you sprained your ankle? These are the key questions…
Image credit (http://orthoinfo.aaos.org)
Do I need an X-Ray?
X-Rays aren’t routinely required for ankle sprains and are one of the most over-prescribed investigation. After an examination from your physio or GP, an X-Ray may be ordered if you have boney tenderness in specific locations around your ankle, or if you are unable to weight bear through your foot. The X-Ray is taken because damage to a bone can cause similar symptoms (pain and swelling) to an ankle sprain. The management of an ankle fracture however, is different from a sprain and may require a surgical review.
A MRI can be taken if you are suspected of having a severe ankle sprain, if damage to your ankle joint cartilage or if a small bone chip is suspected.
How bad is my ankle sprain?
Grades of ankle sprains
After your assessment, your physio can determine the grade of your sprain to help develop a treatment plan. Sprains are graded based on how much damage has occurred to the ligaments.
Grade 1 Sprain (Mild)
- Slight stretching and microscopic tearing of the ligament fibres
- Mild tenderness and swelling around the ankle
- Mild pain with weight bearing
- Slight loss of balance
Grade 2 Sprain (Moderate)
- Partial tearing of the ligament
- Moderate tenderness and swelling around the ankle
- Moderate loss of ankle range of movement
- Poor balance
- Pain with weight bearing
Grade 3 Sprain (Severe)
- Complete tear of the ligament
- Significant tenderness and swelling around the ankle
- Gross instability of the joint
- Possible pain with weight bearing
- Very poor balance
I’ve sprained my ankle. What now?
The good news is almost all ankle sprains can be treated without surgery. Even a complete ligament tear can heal without surgical repair if it is immobilised appropriately. Firstly, you need to follow the RICE protocol as soon as possible after your injury for first 48-72 hours:
- REST your ankle by not walking on it or using crutches
- ICE should be immediately applied to keep the swelling down. It can be used for 20 to 30 minutes, three or four times daily. Do not apply ice directly to your skin
- COMPRESSION dressings, bandages or tape will immobilise and support your injured ankle
- ELEVATE your ankle above the level of your heart as often as possible during the first 48 hours
After RICE, your physio will take you through a three-phase treatment program:
Phase 1: Resting, protecting the ankle and reducing the swelling. Your physio might tape your ankle, fit a brace or boot, perform oedema massage, apply therapeutic ultrasound and commence you on a rehab program.
Phase 2: Restoring range of motion, strength and flexibility. Your physio might perform ankle mobilisations, frictions and other massage techniques, apply ultrasound and progress your rehab program.
Phase 3: Gradual return to sport. Your physio will progress your rehab program and include sport-specific training drills to perform. You may still require massage and mobilisations, as your ankle returns to full strength. Your physio will also advise on whether taping and bracing is still required, and if so, for how long.
Recovery may take just 1 to 2 weeks for minor sprains, 3 to 4 weeks for moderate sprains or up to 6 to 12 weeks for more severe injuries.
To prevent reoccurrence, as always, prevention is the key!
The best way to prevent ankle sprains is to:
- not return to sport until you have been cleared to play by your physiotherapist
- maintain good muscle strength, balance (proprioception) and flexibility
- warm up thoroughly before exercise and physical activity
- be cautious when walking, running, or working on uneven surfaces
- wear shoes that are made for your activity
- tape or use an ankle brace if you have a history of ankle sprains
Hopefully today’s blog has provided you with some helpful knowledge in the diagnosis and management of ankle sprains. Most of the time, the sooner you see your physiotherapist for an assessment and commence treatment, the quicker your recovery time can be!
The information in today’s blog is general in nature and should not be used as a substitute for an in person consultation from your health care practitioner.