An ankle sprain is a very common injury and usually happens when the ankle is twisted or inverted (toes are turned in and ankle rolls over). The term “sprain” means injury to soft tissues—muscles, ligaments and tendons. It is usually ligaments that are ruptured or torn; in this case ligaments in the ankle. Ligaments connect bones or cartilage to other bones or cartilage. Ankle sprains are immediately and severely painful and disabling; they can develop into a chronic problem if not completely healed and the muscles around the ankle strengthened. If treated quickly and properly, ankle sprains can heal well, allowing a safe and early return to your activities.
There are factors that increase your risks for ankle sprains:
- Previous ankle injuries
- Weak or unbalanced muscles
- Shoes that are worn out or are not the right shoes for the activity you’re doing
- Being overweight
- Family tendency
Sprains happen most often when your foot lands on an uneven surface that causes the foot to turn as the ankle rolls out—called inversion. The stress on the ligaments can result in a stretching or tearing of the ligaments and the capsule on the outside of the ankle joint. At the time of the injury, you may feel a pop or snap in the ankle joint, have pain and trouble walking. Within a few hours the ankle can become bruised and swollen.
Basic Ankle Anatomy
A ligament is made up of multiple strands of rope-like bundles of tissue that are both stretchy (elastin) and strong (collagen). The ligaments support the ankle joint. A sprain is tearing of the ligaments. The tear can be a complete tear through all the strands of the ligament or a partial tear, where only part of the ligament strands are torn. This type injury weakens the ligament and the ankle. The amount of weakness depends on the degree of the tear. The lateral ligaments—those on the outside of the ankle—are the most commonly injured in a typical inversion injury of the ankle.
There are three ligaments that make up the lateral ligament complex:
- the anterior talofibular ligament – keeps the ankle from sliding forward
- the calcaneofibular ligament – keeps the ankle from rolling over on its side
- the posterior talofibular ligament
The very common inversion injury to the ankle usually injures the ligaments on the outside of the ankle—the anterior talofibular ligament and the calcaneofibular ligament. For a better understanding of your foot and ankle anatomy and function.
Symptoms of Ankle Sprain
At first the ankle is swollen, painful, and can bruise. The bruising, and the initial swelling, are caused by ruptured blood vessels when the soft tissues tear. Most of the initial swelling is bleeding into the surrounding tissues; this initial swelling then increases due to other fluids leaking out into the tissues as well over the next 24 hours.
Diagnosis of Ankle Sprain
The right diagnosis and early treatment are important in the care of ankle sprains. Ankle sprains are graded into three degrees of severity. The more severe the sprain, the longer the time to recover.
- First Degree Sprain: This injury is the most common and if taken care of early, the most minor. In this sprain, the ligaments of the ankle are stretched but not torn. There is little swelling and no instability in the ankle. With a first degree injury, you can expect to be back at sports within a few weeks.
- Second Degree Sprain: In this injury, the ankle ligaments are partially torn, and the ankle usually swells right away. A second-degree sprain may need 3-6 weeks of rest before you can return to full activity.
- Third Degree Sprain: This injury is a more serious tear of the ligaments although it rarely requires surgery. The ligament(s) in a third-degree ankle sprain can take 8-12 months to fully heal.
The diagnosis of an ankle sprain is usually made by looking at the ankle and taking x rays to rule out bone fractures. If your doctor thinks there is a complete rupture of the ligaments, he may order stress x-rays. Stress x-rays are taken while someone twists or “stresses” the ankle ligaments. You may need further diagnostic study with an MRI to determine the extent of the damage to the soft tissues.
Treatment for Ankle Sprain
Ankle sprains are the most common fitness or sports related injury. And, although they are common, if not properly treated they can turn into long-term pain, swelling, instability and limitations in your activity.
Treatment should begin immediately after the injury happens—even before you see a doctor. The sports medicine treatment of RICE therapy also applies to sprains. The goal of RICE therapy is to control pain, swelling and weight bearing. You should seek medical attention as soon as possible after anything more than a very minor ankle injury.
- REST: Get off your ankle. Elevation will help control the swelling and prevent further injury.
- ICE packs control swelling and help relieve the pain; mild pain relievers help relieve pain also. Apply ice for 15-20 minutes every 2-3 hours.
- Gentle COMPRESSION with an elastic wrap (Ace bandage) will control swelling
- ELEVATION above the level of your heart will help control the swelling and prevent further injury. Elevation helps drain the extra fluid (edema) back into the lymph system. Keep your ankle elevated as much as possible.
Treatment is divided into four stages. How fast you progress through stages depends on the amount of swelling and pain you have and if your ankle is stabilized with a brace or tape.
- Stage 1 (up to 72 hours) – to reduce swelling, ice your ankle up to an hour every 2 hours, compress with an elastic bandage and prop up your foot as often as possible so your ankle is above the level of your heart. Depending on the grade of your sprain, you may need a splint, tape or brace to immobilize your ankle. Your doctor may order antiinflammatories to relieve pain and reduction inflammation and swelling.
- Stage 2 (1st week) – you can walk on your ankle as soon as it’s comfortable for you. You can use crutches or a cane for partial support as you start walking. More support can be added by taping or using a brace. Use pain as your guide as to how much activity you can do. Unless you do range-of-motion exercises to maintain the full range-of-motion of your ankle, it will get stiff. An easy range-of-motion exercise at this stage is to prop your heel on the floor and use your big to to write the alphabet in the air with big letters.
- Stage 3 (After the second week) The crucial part of treatment now is to regain flexibility and strength in the muscles that support your ankle. Your doctor may give you an exercise rehab plan or recommend you see a physical therapist.
- Stage 4 (Varies by injury) You must regain the strength in your ankle before you return to your full daily activities or sports. Returning to these activities too soon can result in a re-injury and lead to a chronic problem. Test your readiness by standing on the toes of the injured ankle for 20 seconds and hop on your toes 10 times. When you can do this you’re ready to run. Start out jogging in a straight path. As you get stronger you can start adding large figure-8s and eventually cutting and zigzagging. You can return to your sport when you can zigzag without pain or instability. Protect you ankle for at least 6 months after your injury.
Crutches help with weight bearing. As treatment progresses, early weight bearing has been shown to be beneficial. Braces that can be worn to support the ankle but still allow weight bearing are a popular treatment method. The swelling may last for several months. You may also need to see a physical therapist to help you regain full function in your ankle. Pay attention to the shoes you wear. Wear shoes that stabilize you foot and minimize slipping. Your shoes should have strong, flat, even soles that are not too spongy or too thick.
In a few cases, the ligaments will not heal back as strong as before the injury. This results in an unstable ankle that has a tendency to give way or sprain again very easily. Ankle instability can lead to an ankle that is sore and painful, sometimes swollen, and unstable on uneven ground. If the ligaments in our ankle don’t heal well enough after a sprain there are several things that your doctor may recommend.
A physical therapy program can help strengthen the muscles around the ankle to help make your ankle more stable. Physical therapy is also needed to “retrain” the proprioceptive nerves around the ankle torn when the ligament was injured. Proprioceptive nerves tell our brains how to use our muscles to allow the joints to work as they should. An ankle brace can help control instability and keep the ankle from giving way.
Surgery to Repair Ligaments
If all these simple measures fail, surgery may be recommended to reconstruct the torn ligaments, particularly a complete tear of the deltoid. Surgery involves making an incision on the injured side of the ankle. A piece of the peroneus brevis tendon is taken and used as a graft to reconstruct the torn lateral ligaments. A drill hole is drilled in the fibula, near the attachment of the original ligament. A second drill hole is made near the where the ligaments attached to the talus. The tendon graft is then woven into these holes and attached to the bones to repair the ligament complex. After surgery, you will likely be in a cast or brace for 6 weeks to let the reconstructed tendon heal. After the cast is removed, physical therapy will begin to help you regain full use of your ankle.
Whether your ankle sprain required surgery or whether you’re recovering from surgical reconstruction of the ankle ligaments physical therapy will help speed healing of your ankle. The physical therapist will evaluate your foot and ankle on your first visit to therapy. This helps your therapist locate the sore tissues and develop an exercise treatment plan. Therapy is often used along with bracing. Rehab will focus on exercises to improve balance and coordination.
The outside ligaments of the ankle are hurt most often in an ankle sprain. This is because most ankle sprains are from an inward twist (an inversion injury). When this happens, the force from the twist may also compress the tissues on the medial, or inside, of the ankle. This can be a source of pain and inflammation on the inside area of the ankle. A grade of I, II, or III is usually given depending on whether you had a slight sprain (I), significant tearing and bleeding (II), or a complete rupture of the tendon (III).
Different treatment choices may be used to further limit pain and inflammation such as contrast baths with hot and cold applications, cold whirlpool, or electrical stimulation.
Early Healing Phase
Range-of-Motion Exercises: As healing starts, it is important to begin a series of range-of-motion (ROM) exercises. To start, you’ll work on bending and straightening your ankle and progress to diagonal motions.
Strength Progression: Next, you’ll begin a progression of strengthening exercises for the muscles around the ankle. Emphasis is on muscles that pull the foot up and out (evertors), up (dorsiflexors), and that raise the heel (plantarflexors). Isometrics may be used in the early stages of rehab. Isometrics are strengthening exercises that work the muscles while the joint doesn’t move. Isometrics can exercise the ankle at different angles, so you can stay away from positions of the ankle that are painful. These exercises reduce overall pain and swelling and also help the muscles remember how they’re supposed work.
Early resistance exercises: Some equipment is helpful in reducing the effects of gravity, allowing you to begin muscle strengthening exercises without pain. Therapeutic bands, pulleys, or isokinetic devices can apply progressive resistance to the muscles around the ankle.
Balance exercises: These exercises are very important after a ligament injury. Healthy ligaments tell our central nervous system the position of a joint. That’s partly why when we close our eyes we know precisely how and where our body is positioned. Once a ligament has been injured, these receptors are unable to receive and send that information to the brain which increases the likelihood of another injury. Balance exercises help restore our sense of position heightening the sensitivity in the receptors that are still intact and working. Balance exercises include standing and walking on uneven or very soft surfaces, balancing on one leg, mini trampoline balance, and progressive agility drills.
Progression of Treatment
More intensive exercises are added as the pain and irritation in your ankle heal. Progressive resistive exercises are exercises for the leg and ankle muscles in which the amount of weight being used is gradually increased. Closed-chain exercises are done by fixing the sore-side foot on the ground. This allows the muscles around the ankle to be exercised while easing stress on the ligaments. Examples include partial squat, weight shifting, step ups/downs, single leg balance, and lunges. These exercises are very good as they mimic many of the activities we do everyday. Advanced resistance exercises can heighten “motor” control in the ankle muscles. These exercises are done by moving a specific amount of weight but controlling the speed at which you move it. If you are trying to prepare you ankle to return to a specific sport or type of work, then higher level exercises, like agility drills, progressive running and cutting, plyometrics, and heavy resistance training can be done.
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