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Ankle Sprain

An ankle sprain is a very common injury and usually happens with a twisting injury of the ankle (most commonly, the ankle rolls inwards). The term “sprain” typically refers to injury to a ligament. Ligaments typically connect bones to other bones. Depending on the severity of the sprain, the ligament can be stretched, partially torn, or completely torn.

While specific treatment largely depends on the severity of the sprain, if treated quickly and properly, ankle sprains can heal well, allowing a safe and early return to your activities. If more severe sprains are not appropriately treated, they can become a chronic problem if they are not allowed to completely heal.

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 inwards—called ankle 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 an immediate pop or snap in the ankle joint. Immediately following this, you may have pain and experience difficulty with walking. Within a few hours, the ankle can become bruised and swollen.

Basic Ankle Anatomy

A ligament is made up of fibrous tissue that is strong yet flexible. In the ankle, the ligaments provide added stability to the joint.  As discussed previously, a sprain is an injury to the ligaments. The lateral ligament complex—the ligaments that are on the lateral ankle (or outer part of the ankle)—are most commonly injured in a typical inversion injury of the ankle.

There are three main ligaments that make up the lateral ligament complex:

  • the anterior talofibular ligament (ATFL) – keeps the ankle from sliding forward
  • the calcaneofibular ligament (CFL) – keeps the ankle from rolling inwards
  • the posterior talofibular ligament (PTFL)

Please reference the following link for a better understanding of your foot and ankle anatomy and function.

Symptoms of Ankle Sprain

During the initial injury, you may feel an associated pop or snap within the ankle joint. Immediately following this, your ankle may become painful and you may find it difficult to put weight on the ankle. Within a few hours, the ankle can become bruised and swollen. The latter is caused by ruptured blood vessels when the soft tissues tear.  Swelling may continue to worsen over the next 1-2 days.

Diagnosis of Ankle Sprain

Early diagnosis and treatment are important in the care of ankle sprains.  The diagnosis of an ankle sprain begins with your doctor asking you questions about how the injury occurred and any symptoms that you are having. Your doctor will perform an examination of your ankle to give him/her clues regarding your injury. Additionally, plain X-rays may be ordered to make sure that there is no associated bony injury.

Ankle sprains are subcategorized into three grades of severity. The more severe the sprain, the longer it takes for the ligaments to recover.

  • Grade I Sprain: In this injury type, ligaments of the ankle are mildly stretched. This is the most common injury type. There is little swelling and no instability in the ankle. With this degree of injury you can expect to be back to normal activities within a week or two.
  • Grade II Sprain: Here, the ligaments are significantly stretched and may even be partially torn, and as such, the ankle usually swells right away. A grade II sprain may require a few weeks of bracing and physical therapy before you can return to full activity.
  • Grade III Sprain: This is a more severe injury. The ligaments are torn. That being said, surgery is rarely required and a few weeks of bracing and physical therapy may be all that it takes for you to get back to normal activity.

Although uncommon, if you have persistent pain past 2-3 months, a MRI may be ordered to further evaluate the health of the ankle and to determine if there are any additional associated injuries.

Treatment for Ankle Sprain

Ankle sprains are the most common fitness or sports related injury. If not properly treated they can turn into long-term pain, swelling, instability and limitations in your long-term ability to participate in normal activities.

Treatment should begin immediately after the injury happens—even before you see a doctor. RICE therapy definitely applies to the treatment of ankle sprains. The goal of RICE therapy is to control pain, swelling and to limit weight bearing. See a doctor for your ankle injury as soon as you can.

  1. REST: In the first few days following an injury, let your ankle rest.
  2. ICE packs control swelling and help with pain control. Apply ice for 15-20 minutes every 2-3 hours.
  3. Gentle COMPRESSION with an elastic wrap (Ace bandage) will help to control swelling
  4. ELEVATION of your ankle above the level of your heart will help to control decrease swelling.

Treatment cant be divided into 4 stages. How fast you progress through stages depends on you and the severity of the initial injury.

  1. 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.
  2. 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.
  3. 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.
  4. 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.

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.

Ankle Instability

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 that were 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. The use of an ankle brace can also help to stabilize the ankle.

 Surgery to Repair Ligaments

Ankle Brace After Severe Ankle Injury

Flexible Ankle Brace After Severe Ankle Injury

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 and reconstruction of the torn ligaments with synthetic material or your own tendon, transferred from elsewhere.  After surgery, you will likely be in a cast or brace for 6 weeks to let the reconstructed ankle heal. After the cast is removed, physical therapy will begin to help you regain full use of your ankle.

Rehabilitation Exercises

Whether or not surgery is performed, well-timed physical therapy is perhaps the single most important treatment of ankle sprains and has been shown to speed healing of your ankle. Therapy is often used along with bracing. Rehab will focus on exercises to improve balance and coordination.

Many of the following exercises and technical considerations will be implemented in your therapy regimen:

Muscles in the foot

Muscles in the foot

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.

Comments

  1. Foot and leg very cold after second sprain within two months, now foot and leg below knee very cold

  2. My ankles were sprained as I was running down the stairs and it hurt a lot. Someone tried to massage and turn the ankle the other way immidiatley so it would heal faster but only could do little beacause it
    swelling began to subside and peopke told me to not put ice on my ankle because the blood might clot. It has been almost two months and the pain is almost gone but when it gets hot my other ankle shows vessels but the sprained ankle does not. What should I do.

  3. mri after 9 months of chronic pain reveals partial to full thickness tear in the tibiofibular tendon. without my boot every step has trepedation. feel like ill never surf again. pain unbearable and has changed who i am. do i need surgery. do i need opiates.

  4. Roll my ankles 19 day ago and start walk on it just how long it take before I start run agai.

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