A sprained ankle is an extremely common form of foot pain and most people manage it on their own without ever consulting a medically related person. Most people recover completely but an important number develop chronic issues that lead to on-going problems or limitations.
Severe sprains are difficult to distinguish from a broken ankle, so medical advice should be sought in cases where the pain is severe and the person is unable to weight bear on the foot.
Ankle Anatomy
The ankle is a hinged joint held within a mortise (a clamp on both sides) of the tibia and the fibula. It mostly moves up and down but other foot joints allow the whole complex to move side to side so the foot can cope with uneven surfaces.
Strong ankle ligaments hold the tibia and the fibula to the foot bones, preventing the ankle from going into unsuitable positions.
What Is A Sprained Ankle?
An sprained ankle occurs when one or more of the ankle ligaments are stressed beyond their strength and develop minor tears, major tears or complete rupture.
The commonest injury (around 85% of ankle sprains) is an inversion sprain where the foot turns inwards suddenly, leading to damage to the ligaments on the outside of the foot. The most commonly injured ligament is called the anterior talofibular ligament (ATFL).
Much less commonly the deltoid ligament on the inside of the ankle is damaged or even the joint between the tibia and fibula above the ankle. The latter may need surgical repair.
Recurrent ankle sprains may contribute to long term ankle problems of pain, swelling and instability.
Levels of Severity for A Sprained Ankle
Ankle sprains are classified into three categories to allow more accurate diagnosis and treatment for their severity.
- Grade 1. The ligament has been stretched and there is microscopic tissue tearing, little swelling, a stable joint and ability to bear weight normally
- Grade 2. The ligament stretch results in a partial tear of the ligament tissue, swelling, bruising, some joint instability and some difficulty bearing weight on the foot
- Grade 3. The ligament has been fully ruptured. Severe swelling, bruising, joint instability and inability to put weight on the foot without severe pain.
Who Gets A Sprained Ankle?
Anyone can get an ankle sprain but they are most common in sports, and may make up to 30% of the workload in sports injury clinics. Basketball, soccer and volleyball are all high risk sports, and the higher the level of athletic performance the higher the risk of an ankle sprain. Women may be at higher risk than men for the same sports.
Symptoms Of A Sprained Ankle
- Immediate pain on the outside of the ankle, from mild to severe
- Swelling – a swollen ankle may persist for some time
- Bruising may occur
- Tenderness over the likely ligament damage areas
- Limited ability to weight bear
If a patient has very severe pain and is unable to weight bear, then a rupture of a ligament or an ankle fracture should be suspected and medical advice sought immediately.
Sprained Ankle Treatment
The treatment depends entirely on the severity of the injury, varying from a few painkillers to weeks in plaster of Paris.
Physiotherapists routinely assess and manage ligament sprains such as ankle and knee injuries. The PRICE system of managing acute injuries is the guiding system.
- Protection. This may consist merely of reducing weight bearing for a while and taking care to avoid uneven surfaces. For more severe sprains, stirrup type braces are favoured as they prevent side to side movement but allow forward and back movement. This allows scar tissue to form naturally under typical weight bearing stresses.
- Rest. A degree of rest is appropriate to make sure that the person does not increase pain and swelling further. The physio will encourage patients to do as big movements of the ankle (with the splint off) as they can without significant pain. Too much rest or immobilisation can lead to loss of muscle power and loss of movement.
- Ice. Ice is used to reduce swelling, pain and any muscle spasm. Pain reduction is very important to allow the return of normal function as soon as possible.
- Compression. The application of a compression bandage to the ankle as soon as possible helps to limit the degree of swelling in the damaged tissues. This may be the most important early therapeutic intervention.
- Elevation. Keeping the ankle above the level of the heart will improve venous return from the lower leg and prevent pooling of swelling and circulation at the lowest point.
Sprained Ankle Rehabilitation
Each time a ligament is injured it needs rehabilitation of some sort, even if that is not formally done. Full healing and the restoration of normal strength and movement can be compromised if the ligament’s healing process is not managed well. This can lead to chronic pain or repeated ankle sprains.
Once the initial period of protection and the reduction of swelling and pain have been completed, the next stage is the restore the range of movement of the ankle and foot joints and the strength of the calf and foot muscles.
The physiotherapist will teach you range of motion exercises for the ankle and the mid-foot joints, as restoration of full movement is essential for full foot function. You will then progress onto strengthening exercises in standing and joint position retraining (proprioception exercises) to help your balance and coordination.
Static standing on one leg is progressed to throwing a ball against a wall whilst staying stable. Further joint position work (proprioception) can be performed on the wobble board to restore the normal awareness of where the ankle joint is.
Standing on one leg with eyes closed is a good test of how good the ankle is. It should be as good on the injured as the uninjured leg. Balance training may reduce the chance of future ankle sprains.
Once you have no pain, full movement and reasonable strength and joint position sense, the physio will progress you onto straight-line activities such as jogging and figure-of-eight circuits. This will be progressed again to sporting specific activities where a sudden change of direction at speed (cutting) is required.
Following a logical sequence of rehabilitation under guidance from a physiotherapist is important for a good long-term outcome. Without this it is possible your ankle might have some instability and pain that could lead to you suffering from repeated ankle sprains.
Athletes should have a formal examination from their physio or medical supervisor before returning to sport or other vigorous activity.
Surgery for Ankle Sprains
Surgery for grade 1, 2 and 3 ankle sprains has not been found to be useful, although it may be appropriate in individual cases. However, surgery may be indicated to treat a severe sprain of the tibiofibular ligaments that hold the ankle mortise together.
References:
- NHS Encyclopaedia – Sprains and Strains – http://www.nhsdirect.wales.nhs.uk/encyclopaedia/s/article/sprainsandstrains/
- Sprained ankle. OrthoInfo. American Academy of Orthopaedic Surgeons AAOS. http://orthoinfo.aaos.org/topic.cfm?topic=a00150?
- British Journal of Sports Medicine – Sprained Ankle Management – http://bjsm.bmj.com/content/36/2/83.full
Last Review Date: 14-03-2018
Next Review Date: 14-03-2020
