Feb62011

Sprained Ankle Management

Year over year, ankle sprains are the most common lower extremity injury in all of sports.  From a minor “tweak” to a high ankle sprain, the range of symptoms and corresponding limitations vary greatly.  Ankle sprains are challenging due to the ankle joint’s inherent vulnerability years after the sprain and ligament instability that is common after a significant injury.

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

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 provide joint stability.

Lateral Ankle Sprain

When a lateral ankle sprain, commonly referred to as an inversion sprain, occurs, the majority of the ligament damage occurs along the lateral or outside part of the ankle joint.  This includes 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

We often read about elite athletes who have an ankle sprain that sidelines them for 2-6 weeks.  This sparks immediate questions about why anyone would miss so much time with “just” a sprain (rather a more serious-sounding injury, like a break).  In most cases, this athlete has suffered a high ankle sprain, one of the most frustrating and difficult injuries to overcome.  Recovery is even more difficult when the athlete plays (what I refer to as) a “stop-and-go sport” that involves quick changes in direction.

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

1. Interosseous Membrane – located between the two distal shin bones

2. Anterior Distal Tibiofibular Ligament – located at the front of the two distal shin bones, just above the ankle joint

Ankle sprains cause damage to surrounding bones, tendons, capsules and joint surfaces, but the most serious ones can lead to a rupture of lateral and anterior ankle ligamentous structures, including the capsule.  Ankle joint dislocations and fractures can also occur, which I personally suffered as a collegiate athlete and had to endure two surgeries and four months of rehabilitation.

Signs and Symptoms of a Lateral Ankle Sprain

The signs and symptoms of a lateral ankle sprain vary based upon the grade or significance of the ligament damage.  Sprained ankles are graded from one to three depending on their laxity, or looseness of the ligaments.

Grade 1 Lateral Ankle Sprain:

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

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 swelling on the outside, front and back of the ankle
  • Moderate bruising of the lateral ankle and mid-foot
  • Moderate-to-severe pain and difficulty walking
  • Significant stiffness of the 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).
  • Leverage the power of ice as a valuable tool for a fast recovery.  Placing ice bags on the outside and inside of the ankle joint for 15 minutes each day is a good way to reduce pain and swelling.  The best way to aggressively treat the entire ankle/foot/distal shin area is to immerse it in an ice bucket for 10 minutes.  Placing a rubber glove or insulated sock over only the toes will make this significantly more tolerable.
  • Depending on the grade of the sprain, adhere to weight-bearing limitations.  Utilize a walking boot and/or crutches to help gradually reduce symptoms while still allowing for normal activities of daily living (ADLs).
  • Gradually perform range-of-motion (ROM) activities with elevation.  Use only upward (dorsi flexion) and downward (plantar flexion) directions to avoid stretching any damaged ligaments located on the outer ankle joint.
  • Use compression to control swelling and pain in the ankle joint and surrounding tissue when performing weight-bearing activities.  Mixing compression with rest is also helpful for acute sprains.
  • Massage the arch, ankle joint, Achilles and calf to help reduce swelling and enhance blood flow to the injured tissue.
  • Ride a bike using compression, which can be started early on.
  • When the swelling is 50% improved, perform strengthening exercises with manual resistance.  Start with upward (dorsi flexion) and outward (eversion) movements while avoiding inward (inversion) stretches, as inversion motion is the typical injury mechanism that causes ligament damage in the outer ankle.
  • Use a slant board to aid in stretching the calf and posterior ankle joint as it becomes more comfortable.  Include calf-strengthening heel raises when tolerable.
  • As you prepare for your return to sport, perform balance activities, which are great exercises during the final stages of treatment. 
  • Begin sport-specific activities when back to 75% strength and if swelling does not significantly increase with activity.
  • Call on a certified athletic trainer to tape your ankle joint, a smart way to minimize the chance of re-injury.

Questions a Pro Athlete Would Ask

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

1. Is my ankle sprain classified as Grade 1, 2 or 3?

2. Is an X-ray required to rule out a fracture?

3. What do I need to accomplish in rehab to safely return to my sport?

4. Should I have my ankle joints taped or braced when I return to my sport?

Sports Medicine Tips for a Sprained Ankle

Avoid a Bum Ankle – Trust me: A chronically loose ankle can ruin your confidence and your game.  Without proper treatment, ankle sprains can result in a “bum ankle” that rolls over while performing simple actions such as walking across the yard or stepping off a curb.  Prioritize treatment to tighten affected ligaments and prevent becoming a “bum” down the road.

Flexible Calves and Achilles Are Key – Partnered with loose calves and Achilles, your ankle will enjoy great range of motion and function normally.

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

Get Back to Basics – Other than Michael Jordon, none of us were born with sneakers on our feet.  Bust out of those tight shoes and spend more time barefoot to strengthen your arches, foot muscles and ankle ligaments.