What is a sprained ankle?A div sprained ankle or twisted ankle as it is sometimes known, is a common cause of ankle pain. A sprain is stretching and or tearing of ligaments (you sprain a ligament and strain a muscle). The most common is an inversion sprain (or lateral ligament sprain) where the ankle turns over so the sole of the foot faces inwards, damaging the ligaments on the outside of the ankle.
How does an ankle sprain occur?A sprained ankle usually occurs when a person lands from jumping or running on to an uneven surface. For example, sprained ankles are often seen when basketball players come down from a jump and land on another player’s foot. Ankle sprains also occur with more routine daily activities such as stepping off a curb or slipping on ice.
Types Of Ankle SprainThere are two broad categories of ankle sprain:
Inversion Ankle Sprains
The most common type of ankle sprain occurs when the foot is inverted, falling inward. When this type of ankle sprain happens, the outer, or lateral, ligaments are stretched too far. There are three ligaments that attach to the outer side of the ankle. About 90% of ankle sprains are inversion injuries. Pain is always on the outside of the ankle, and there is usually no pain on the inside of the ankle joint.
Eversion Ankle Sprains
The other type of sprained ankle is called an eversion injury, where the foot is twisted outwards. When this occurs, the inner ligament, called the deltoid ligament, is stretched too far. Patients will have pain on the inner side of the ankle
What are the symptoms of an ankle sprain?Common symptoms associated with an ankle sprain are pain with swelling and bruising. The degree of symptoms tends to correlate well with the extent of the damage to these ligaments.
Grades of Severity for Sprained Ankles :Sprained ankles, as with all ligaments sprains, are divided into grades 1-3, depending on their severity:
Grade 1 sprain:
- Some stretching or perhaps minor tearing of the lateral ankle ligaments.
- Little or no joint instability.
- Mild pain.
- There may be mild swelling around the bone on the outside of the ankle.
- Some joint stiffness or difficulty walking or running.
- Moderate tearing of the ligament fibres.
- Some instability of the joint.
- Moderate to severe pain and difficulty walking.
- Swelling and stiffness in the ankle joint.
- Minor bruising may be evident.
- Total rupture of a ligament.
- Gross instability of the joint.
- Severe pain initially followed later by no pain.
- Severe swelling.
- Usually extensive bruising.
Treatment of a Sprained AnkleTreatment of a sprained ankle can be separated into immediate first aid and longer term rehabilitation and strengthening.
Immediate First Aid for a sprained ankle:
Aim to reduce the swelling by RICE (Rest, Ice, Compression, Elevation) as soon as possible.
- R is for rest. It is important to rest the injury to reduce pain and prevent further damage. Uce crutches it necessary. Many therapists advocate partial weight bearing as soon as pain will allow. This is thought to accelerate rehabilitation.
- I is for ICE or cold therapy. Applying ice and compression can ease the pain, reduce swelling, reduce bleeding (initially) and encourage blood flow (when used later). Apply an ice pack or similar immediately following injury for 15 minutes. Repeat this every 2 hours.
- C is for compression - This reduces bleeding and helps reduce swelling. A Lousiana wrap bandaging technique is excellent for providing support and compression to a recently injured ankle.
- E is for Elevation - Uses gravity to reduce bleeding and swelling by allowing fluids to flow away from the site of injury. So put your feet up and get someone else to wait on you!
A wobble balance board is an important part of rehabilitation of ankle sprains.
What can a Sports Injury Specialist do about it?
- A sports injury specialist will undertake a thorough assessment of the injury so time is not wasted treating the wrong condition.
- A doctor may prescribe anti-inflammatory medication (e.g. ibuprofen) to help with pain and swelling.
- Reduce swelling by compression devices or taping techniques.
- Use ultrasound and laser treatment to reduce pain and inflammation and promote healing.
- Use cross friction massage to promote healing and reduce scar tissue development.
- Prescribe a full ankle rehabilitation programme to strengthen the joint and help prevent future ankle sprains.
Aims of assessment
- To assess the degree of instability.
- Grade of ligament damage.
- Identify any reduction in range of motion or reduced strength.
- Identify any other additional or associated injuries such as an avulsion fracture where a piece of bone at the end of a ligament has come away from the main bone itself.
As with any sports injury the therapist will usually follow a set procedure to diagnose an injury. The following is one example:
- Read medical records if available or X-rays. Previous treatment should be taken into account when diagnosing an injury, even one as simple as an ankle sprain.
- Listening - asking a number of questions to build up a picture of what might have happened. For example:
- How did it happen?
- Was there any pain at the time?
- Was the pain sudden onset or gradual?
- Was there any swelling and was it sudden onset or gradual? - a sudden swelling often indicates a bleeding into the joint rather than a gradual increase in synovial fluid within the joint.
- Did you hear any noises? - this could indicate ligaments tearing or bones breaking!
- Did you apply any emergency procedures such as RICE?
- Is there anything you do which makes it worse / better?
- Is this the first time you have injures the ankle in this way or is it recurrent?
- Observe the patient as they stand and when lying or sitting on a couch with the legs out in front. They will look for any abnormal position, deformity and of course swelling.
- The patient moves the foot from plantar flexion to dorsi flexion.
- Looking for reduction in normal range of movement and any pain in performing these movements.
- Then repeat moving from eversion to inversion.
- The therapist moves the ankle and foot from plantar flexion to dorsi flexion and then inversion to eversion looking again at range of movement, comparing one foot with the other and and painful movements.
- The athlete remains relaxed and does not resist or actively move the foot or ankle. Any pain at the extreme range of inversion may indicate ligament damage as it is the ligament that is being stressed.
- The anterior drawer test is a special test which assesses the integrity of the ankle ligaments, particularly the anterior talo fibula ligament and the calcaneo fibula ligament.
- The therapist gently resists the athlete as they try to move the ankle from inversion to eversion .
- Pain when performing this test may be an indication of tendon damage or inflammation (possibly peroneal tendons) as it is the tendons connecting muscle to bone that are stressed when performing this test.
- These can only be performed if pain allows. A badly injured ankle will not be capable of performing these tests.
- The lunge test involves the athlete leaning forwards over one knee keeping the heel of the front foot in contact with the ground.
- It measures dorsi flexion in comparison to the uninjured ankle.
- Other tests include one leg standing balance (eyes closed) test and hopping tests.
- Note - hopping on a recently injured ankle is definitely to be avoided but this test may be of benefit much later in the rehabilitation process.
- Finally the therapist will touch or feel certain points of the ankle to identify any specific painful areas.
- The following are usual points to palpate: distal fibula (bottom of the fibula bone), lateral malleolus (bony bit on the outside of the ankle - peroneal tendon dislocation / inflammation), lateral ligaments (most likely to be painful), talus (bone at the top of the ankle which the tibia or shin bone sits on), peroneal tendon, base of 5th metatarsal (where the peroneus brevis attaches to) and medial ankle ligaments.
Does it need an X-Ray?
- If the sprain is severe and the athlete has trouble weight bearing an X-Ray may be beneficial in identifying possible fractures.
- However, an experienced sports medicine professional should be capable of palpating to identify if the pain is worse on the bone (lateral or medial malleolus) or on the ligament itself.
The therapist should then record any significant signs or symptoms and test results for future reference and as a record of what was found.
RehabilitationThe following guide is intended for information purposes only. We recommend seeking professional advice before attempting any rehabilitation.
Aims of rehabilitation
The aims of rehabilitation of an ankle sprain can be broken down into separate phases:
- Decrease initial pain and swelling.
- Improve mobility and flexibility.
- Improve the strength of the joint.
- Re-establish neural control and co-ordination.
- Return to full fitness.
Decreasing pain and swelling
This should start as soon as possible after you have injured the ankle. This phase can last from 2 days to 2 weeks (or more) depending on how bad the injury is.
- Protection of the ankle from further injury by resting, non-weight bearing and using an ankle support or taping technique.
- A useful support at this stage is the aircast gel type ankle support which prevents most sideways movement but still allows limited use of the ankle. The cold gel can also be beneficial by compressing and reducing swelling . This support is useful in the early stages but is not practical in the later stages of rehabilitation.
- The Louisiana wrap strapping technique using cohesive bandage can also be beneficial in applying compression and support and is quick and easy to apply.
- The Open basketweave taping technique also accomplishes early medial and lateral protection while allowing plantar flexion and dorsi flexion.
- Rest - this is essential. Use crutches with partial weight bearing to get about with if necessary for the first few days. A healing ligament needs a certain amount of stress to heal properly but overdoing it early on in the rehabilitation process can prevent healing. Full weight bearing should be introduced as soon as pain allows.
- Isometric exercises of ankle dorsiflexion (pulling the foot upwards) and plantarflexion (pointing the foot away) can be performed early on so long as they are not too painful. Avoid inversion and eversion (turning tha ankle) though as this will stress the injured ligaments.
- Ice - use cold therapy throughout the rehabilitation process. Apply ice for 15 minutes every hour initially for the first day then reduce this to 4 to 5 times a day from then on. In the acute stage ice will constrict blood vessels and further bleeding. Longer term benefits include reduction of pain and muscle spasm.
- Ice should not be used for longer than 15 minutes as prolonged cooling has the reverse effect of increasing blood flow. Long periods of cooling can also cause nerve palsy. Ice should be used for as long as it is beneficial. As soon as the rehabilitation process plateaus the therapist may decide to alternate hot and cold to progress further.
- Compression - use a tubi-grip bandage or taping. Even better are products that specifically apply compression at the same time as cooling . The Open Basketweave taping technique also contributes to compression and helps to control swelling or 'edema'.
- Elevation - put your feet up and read all about your injury! Elevating the leg will help swelling drain away from the site of the injury. Elevate the leg while icing and for 10 minutes after.
Phase 2 - Rehabilitation phase
The rehabilitation phase begins when swelling starts to decrease and pain lessens. This means the ligaments have reached the point in the healing process where they are not in danger of being re-injured from mild stress. Improve mobility and flexibility
- For the first 2 to 7 days after injury you can start to move the ankle straight up and down but do not turn it in or out. This will help increase mobility and start to strengthen it up. Do as much as pain will allow. Try 2 sets of 40 reps whilst the ankle is iced and elevated and build up on that.
- Manual joint mobilization can be carried out by a sports injury professional in the anteriorposterior direction (forwards and backwards).
- Seated wobble board exercises may be beneficial for an ankle that has reduced mobility. Initially plantar flexion / dorsi flexion and then progress to inversion / eversion as pain allows.
- As swelling and pain lessen you can start to invert and evert the ankle (move the soles of you feet inwards and upwards and the outwards and upwards). This will start to put more stress on the damaged structures so be careful not to do too much. See mobility exercises.
- Stretching the achilles tendon several times a day is important. There are a number of methods which can be used for stretching the calf and achilles, including using a slant board.
Strengthening the ankle joint
- Again as the ankle improves you can start to do strengthening exercises where you pull the foot and toes up and hold for 10 sec's and then push down and hold for 10 sec's This can also be done for inversion and eversion as pain allows. Try 3 sets of 10 reps twice a day and build on that.
- If you see no further improvement with ice alone then start to alternate it with heat. Apply a warm pack (or hot water bottle - ensuring something is covering the skin to prevent burns) for 5 minutes, followed by a cold pack for 5 minutes. Repeat this again so that the whole process last 20 minutes.
- Strapping and taping may still be beneficial here to provide compression and support the ankle as you return to full weight bearing.
- You should be able to maintain fitness by swimming or cycling as pain allows.
Re-establish co-ordination and proprioception
- Proprioception exercises are thought to be important in avoiding recurrent ankle sprains. The neuromuscular control you have over your muscles will have been damaged when you injured the ankle as these small sensors are located in ligaments and tendons. Balance type exercises can be used to improve this function and help avoid future ankle injuries. An ankle wobble board can be used, intially in a sitting position, followed by standing on both legs and progressing to single leg balancing. Wobble board exercises
- If you don't have a wobble board, simply balancing on one leg can be effective. Once you can manage this, you can challenge your balance by moving your arms, twisting your body and bending the knee. For a real challenge, try to balance with your eyes closed!
Return to full fitness / functional training
- In order to start the functional rehabilitation phase (activity and sports specific training) it is important the athlete has full range of motion and 80 to 90% of pre-injury strength. When you can comfortably do all of the above then you are ready to start phase 3 and begin your return to activity
- Cardiovascular exercise is important and should begin as soon as possible after injury depending on what pain will allow. It is important that the athlete maintain some kind of CV exercise not just for the physical benefits but for psychological well being as well. Stationary cycling, hand cycle ergometer, running in water and swimming are all possibilities depending on severity of injury and what pain will allow.
- Running may begin as soon as walking is pain free. Ankle taping can be very beneficial when starting running training particularly during early sessions until confidence, proprioception and strength has returned. A laced ankle brace can also provide support and is less expensive in the long run, particularly if laxity in the ligaments means a support needs to be worn permanently.
- Running should begin on a clear flat surface such as a running track. Grass or bumpy surfaces will increase the risk of re-injury. Jog the straights and walk the curves.
- Speed should be gradually increased over time to a sprint.
- Sports specific drills using cones can be introduced. Changing direction, running in a figure of 8 pattern and zig zagging between cones.
Prevention of ankle sprainsIt is estimated that 30 to 40% of all ankle inversion sprains end in re-injury. To avoid being one of the 30 to 40% it is important not to stop the rehabilitation process but continue with it until full fitness is regained and beyond. It is a common complaint that once an athlete goes over on the ankle they become prone to doing the same thing again. If the original sprain is a bad one and joint laxity has resulted then it may be for certain sports where fast changes of direction are required that strapping of the ankle or wearing a brace is necessary to prevent re-injury. If the sprain does not result in joint laxity then a recurrence may be avoided by the following:
- Re-establish proprioception. This involves lots of balancing exercises on one leg. Essential to avoid re-injury. If you start to turn the ankle over then you will find you automatically right it without even thinking about it. If the proprioception is damaged then you lose this ability.
- Strengthening the ankle. This will provide a far more stable joint. Also, if the ankle does start to turn and the proprioceptors work properly, the ankle starts to right itself, the muscles need to be strong enough to pull the ankle back in a split second.