Sprained Ankle Management

Lateral Ankle Sprain

Ankle sprains remain the most common lower extremity injury in all of sports.  From the minor “tweak” of the ankle to the high ankle sprain, the range of symptoms and the limitations vary greatly.  The challenging factor with ankle sprains remains the ongoing vulnerability of the ankle joint for years after a sprain because of the resulting ligament instability so common after a significant injury.

The term “sprain” refers to an injury that involves damaging a ligament.  Ligaments connect bones to bones while tendons connect muscles to bones.  Ligaments are common stabilizers of joints, often embedded within a capsules surrounding most of the joints in the body.  The ligaments in a normal ankle provide static stability to the bones of the lower legs and hindfoot.

A ligament sprain can be as simple as a minor stretch or as complex as a complete disruption or tearing of the ligament fibers that give stability to a joint.

Lateral Ankle Sprain

With a lateral ankle sprain, commonly called an inversion sprain, occurs, a majority of the ligament damage takes place along the lateral or outside of the ankle joint.  These ligaments include the following ligaments:

1.  Anterior Talofibular Ligament (ATF) – located in front of the outer distal Fibula (shin) bone.

2.  Calcaneofibular Ligament – Connects the fibula (shin) to the heel bone

3.  Posterior Talofibular Ligament (PTF) – located behind the outer distal Fibula (shin) bone.

High Ankle Sprain

Often we read about elite athletes with an ankle sprain that forces the athlete to be out of competition for 2-6 weeks.  Immediately, questions arise as to why anyone would miss so much time with “just an ankle sprain”?  In most cases, the reason is that the athlete has suffered a high ankle sprain.  The high ankle sprain is one of the most frustrating and difficult injuries for an athlete to recover from during a season.  This injury is even more difficult to overcome when the athlete is involved in what I refer to as a “stop and go sport” where rapid changing of direction is required.

With a high ankle sprain or interosseous ankle sprain, most of the damage is found in the anterior ankle and distal shin area.  These structures include the following:

  1. Interosseous Membrane – located between the two bones of the distal shin.
  2. Anterior Distal Tibiofibula Ligament – located at the front of the distal two bones of the shin just above the ankle joint.

Additional damage to the surrounding bone, tendon, capsule and joint surfaces can result from any ankle sprain.  A serious ankle sprain can result in complete ruptures of the lateral and anterior ankle ligamentous structures including the capsule.  Ankle joint dislocations and fracture often occur.  I suffered such an injury while in college resulting in two surgeries and four months of rehabilitation.

Signs and Symptoms of a Lateral Ankle Sprain

The signs and symptoms for a lateral ankle sprain will vary based upon the grade or significance of the ligament damage.  Sprained ankles are graded from 1 to 3 based upon their laxity or the ligament looseness.

Grade 1 Lateral Ankle Sprain:

  • Minor stretching of the lateral ankle ligaments.
  • Minimal joint instability with a firm end-feel or tautness of the ligaments when stressed.
  • Mild pain.
  • Minimal swelling around the bone on the outside of the ankle.
  • Mild joint stiffness with walking or running.

Grade 2 Lateral Ankle Sprain:

  • Moderate stretching and tearing of the lateral ankle ligaments.
  • Moderate joint instability with a firm end-feel or tautness of the ligaments when stressed.
  • Moderate to severe pain and difficulty walking.
  • Moderate swelling on the outside, front and back of the ankle.
  • Significant stiffness of the ankle and mid-foot.
  • Moderate bruising of the lateral ankle and mid-foot.

Grade 3 Lateral Ankle Sprain:

  • Complete tearing of the lateral ankle ligaments.
  • Significant joint instability with a soft end-feel or tautness of the ligaments when stressed.
  • Significant pain.
  • Significant swelling throughout the outside, front and back of the ankle and mid-foot.
  • Significant bruising of the lateral ankle and mid-foot.

Treating a Lateral Ankle Sprain

  • Rest the distal leg with Ice, Compression and Elevation (RICE).
  • Ice is a valuable tool for a fast recovery.  Ice bags on the outside and inside of the ankle joint for 15 minutes is a good way to reduce the swelling and pain.  The best way to aggressively ice the entire ankle/foot/distal shin area is to place the ankle into an ice bucket for 10 minutes.  A rubber glove or insulated sock covering only the toes will significantly help make the ice bucket more tolerable.
  • Depending upon the grade of the sprain, limitations in the weight bearing status may be necessary.  The use of a walking boot and/or crutches will prove to be helpful to allow for a daily reduction of the symptoms while still performing normal activities of daily living. (ADL’s)
  • Easy range of motion (ROM) with elevation can be started in a painfree range.  This motion should only be in the upward (dorsi flexion) and downward (plantar flexion) directions to avoid stretching any damaged ligaments located on the outer ankle joint.
  • Compression when weight bearing and with activities is very helpful to control swelling and pain in the ankle joint and surrounding tissue.  Compression with rest will be helpful for acute sprains.
  • Massage to the arch, ankle joint, Achilles and calf will help reduce the swelling and enhance blood flow the injured tissue.
  • Bike riding with compression can be started early.
  • Manually resisted strengthening exercises can be started when the swelling is reduced by 50%.  Starting with resisted upward (dorsi flexion) and outward (eversion) movements while avoiding inward (inversion) stretches.  Typically this inversion motion was the mechanism of injury resulting in ligament damage to the outside of the ankle.
  • Slant board can be initiated when stretching of the calf and posterior ankle joint is comfortable.  Include calf strengthening heel raises when tolerable.
  • Balance activities are great drills for the final stages of treatment to prepare you to return to your sport.
  • Sports specific activities can be started when strength is at least 75% and the swelling is not significantly increasing with activities.
  • Having your ankle joint taped by a certified athletic trainer is the smart way to minimize your chances of re-injuring your ankle.

Questions a Pro Athlete Would Ask

A smart professional athlete with an ankle sprain who wants to safely return to his/her sport will ask his sports medicine specialist the following questions:

  1. What grade is my ankle sprain?
  2. Do I need an x-ray to rule-out a fracture?
  3. What do I need to accomplish with my rehab to be able to safely return to my sport?
  4. Do you recommend that I have my ankle joints taped or braced when I return to my sport?

Sports Medicine Tips for a Sprained Ankle

Avoid the Bum Ankle – Trust me: a chronically loose ankle can ruin your confidence and your game.  So many have a “bum ankle” that rolls over just walking across the yard or stepping off a curb.  Treat your ankle sprain right now will keep your ligaments tight and keep you from becoming a “bum” down the road.

Flexible Calves and Achilles Are Key – If your calves and Achilles remain loose, your ankle will have great range of motion and function normally.

Compression is Your Friend – Wearing compression on the ankle joint and distal calves will help maintain the congruity of the lower leg long after the sprain has healed.

Back to Basics – Other then Michael Jordon, none of us where born with sneakers on our feet.  Get out of those hard shoes and spend more time barefoot.  It will strengthen your arches, foot muscles and ankle ligaments.