Sprained Ankle

What is a sprained ankle?

A sprained ankle occurs following a sudden sideways or twisting movement of the foot. An ankle sprain can occur during athletic events or during everyday activities. All it takes is an awkward step or an uneven surface to cause an ankle sprain--that is why sprained ankles are among the most common orthopedic injuries. Orthopedic doctors see patients for ankle sprains very often, and it is the most common foot and ankle injury.

Because of the position of the bones around the ankle, the inversion injury is far more common. This injury causes damage to the lateral ligaments on the outside of the ankle.

The most commonly injured ligament is the Anterior Talo Fibular (ATF) ligament which, as the name suggests, joins the fibular and talus bones together. If the force to the ankle is more severe, the Calcaneo Fibular ligament (between the Calcaneus and Fibula) is also damaged. The Posterior Talo Fibular (PTF) ligament is very rarely damaged in comparison to the other two ligaments.

In the case of an eversion injury the damage occurs on the medial (inside) of the ankle. The ligament on the inside of the ankle is called the Deltoid ligament and is very strong. It is so strong in fact that the bone on the inside of the ankle can be pulled off, in what is called an avulsion fracture, before the ligament is damaged.

As well as damage to the ligaments, the capsule which surrounds the ankle joint is also damaged. The damage causes bleeding within the tissues and the ankle begins to swell up and can be extremely painful.

Ankle sprains can be classified as follows:

• First degree, where only a few ligament fibres are damaged
• Second degree sprain refers to more extensive damage to the ligament with associated swelling
• Third degree sprain refers to a complete rupture of the ligament with swelling and a possible joint dislocation

In the more severe injuries there may be associated bone injury and it is wise to get an x-ray to determine whether there is a fracture.

Sprained Ankle Symptoms

With a first degree sprain there is pain when turning the foot in or out and also pain when the damaged area is touched. With a second degree sprain the pain is more severe, there is swelling all around the area and it is painful to walk. With a third degree sprain the pain is excruciating and walking is impossible. There is gross swelling and there may be deformity if the ankle is dislocated.

Causes

The most common type of ankle sprain is when your foot turns inwards, overstretching the ligaments on the outside of your ankle. This is called an inversion sprain.

Half of all ankle sprains happen during sport. They are especially common in sports that involve running and jumping, landing from a jump, fast changes in direction or lots of stop-starts (such as football, basketball and volleyball).

Other common causes of ankle sprains include:

• walking on an irregular surface
• your foot slipping off the edge of a kerb
• twisting your ankle while climbing stairs
• losing your balance wearing high-heels

You are more likely to sprain your ankle if it has happened before.

Diagnosis

You may not need to see your GP or visit the accident and emergency department at a hospital. It depends on how severe your symptoms are.

If you do seek medical treatment, your doctor will examine your ankle to assess how bad the sprain is. He or she will ask about your symptoms and how the injury happened, which will help establish which ligaments are involved. You will also be asked to try and walk.

Your doctor may recommend an X-ray if he or she suspects that a bone has been damaged and needs specific treatment.

Treatment

Treatment depends on how serious the injury is.

All soft tissue injuries should receive the same immediate first aid treatment. Treatment follows the RICE procedure, which stands for the following.

• Rest the injury initially, then re-introduce movement so you don't lose too much muscle strength.
• Ice packs or a bag of frozen peas wrapped in a towel should be applied to your ankle to reduce swelling and bruising. You could also immerse your ankle in ice. You should not apply ice directly to your skin as it can give you an "ice burn" - place a cloth between the ice and skin.
• Compress your ankle by bandaging it to support the injury and help decrease swelling.
• Elevate your ankle by resting your foot above the level of your heart and keep it supported.

Further treatment will vary according to how badly you have sprained your ankle.

Applying heat - eg warm baths or a hot water bottle - may be soothing. They encourage blood flow, the opposite effect of ice, so these treatments should not be used during the first two days while swelling is developing.

Your GP may refer you to a physiotherapist who can advise you on exercises and may use massage, heat, ultrasound or other treatments. A sports medicine specialist may help you if you play professional or competitive sports.

Over-the-counter painkillers can help reduce pain. Some may help reduce swelling. Painkilling creams or gels don't work any better than tablets. Ask your pharmacist for advice and always read the patient information leaflet that comes with the medicine.

Surgery can repair torn ankle ligaments, but there isn't enough evidence to say whether this is better than keeping you ankle in a cast, or wearing a support brace. Your doctor may recommend surgery for torn ankle ligaments that aren't getting better.

Recovering from a sprained ankle

The swelling and discomfort should begin to subside after a few days. At this point, you should begin to move your ankle. Compression bandages should normally be taken off after two days because they limit movement. Instead you can use a support or taping that doesn't restrict movement too much.

Initial exercises can include rotating the foot and moving it up and down. Take care not to cause more pain while you are moving your foot. Try to increase the range of movement each day.

Sprained Ankle Injury Prevention

Ankle instability is characterised by ankle weakness and giving way, even though the ankle ligaments are intact and the joint is mechanically stable. It is due to an impairment of proprioception, which leads to a lack of balance and ankle joint position sense. Proprioception is the mechanism by which nerve receptors in skin, muscle, ligament and joint tissue relay information to the brain about body position sense, where this information is quickly processed and movement strategies are formulated and executed using nerve signals to muscles. This mechanism can help you 'catch yourself' when you are about to turn your ankle.

In the unstable ankle these receptors may have been damaged directly during an ankle sprain. This impaired proprioceptive ability may, therefore, lead to a delay in protective muscle activity and the resultant loss of postural awareness and stability around a joint. This may explain why recurrent ankle sprains are so common.

The Wobble Board together with Ankle Braces are commonly used in the rehabilitation of ankle instability. Wobble Boards are designed to assist the re-education of the proprioceptive system by improving sensory receptor function. Previous research has also shown that wobble board training improves single leg stance ability and balance; while other studies have suggested that patients with ankle instability who underwent wobble board training experienced significantly fewer recurrent sprains during a follow-up period than those who did not follow the training programme.

Taping and Bracing the ankle can also help to reduce recurrent ankle injury. Previous research has shown the injury incidence in students with taped ankles was 4.9 ankle sprains per 1000 participant games, compared with 2.6 ankle sprains per 1000 participant games in students wearing ankle braces. This compared with 32.8 ankle sprains per 1000 participant games in subjects that had no taping or bracing.