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Sprained Ankle

Sprained ankleThe ankle sprain is the most common sports injury and is also the most frequently re-injured. In the majority of cases the ankle rolls inwards (inversion) under the weight of the rest of the body, resulting in damage to the ligaments on the outside of the ankle.

Here you will find everything you need to know about diagnosing, treating and rehabilitating a sprained ankle to ensure an effective and efficient recovery. We also recommended a number of products for treating ankle sprains including ice packs with compression and ankle supports.

Symptoms

Pain is usually felt around the ankle joint itself although more specifically on the outside of the ankle where the damaged ligaments are located. Swelling or bruising may present immediately or may not develop until later on over the next 48 hours (depending on the types of structures damaged and the severity of the sprain) but in milder cases this may never appear at all. Occasionally, pain may also be felt on the inside of the ankle where the bones have been pressed together (kissing contusion) or where soft tissues are pinched (impingement) between the bones.

How bad is my sprained ankle?

Sprains are graded 1, 2 or 3 depending on their severity and a professional therapist will be able to tell you which grade of injury you have sustained after carrying out a full ankle assessment. This will include a number of movement, muscle and ligament tests in order determine which structures have been injured and how badly.

Grade 1 injuries result in mild symptoms with some pain and little or no swelling. There may be a feeling of joint “stiffness” with some degree of difficulty in walking or running however more often than not, the athlete is able to play on and finish the training session or game. In these type of injuries, the ligaments are usually stretched rather than completely torn and the ankle should feel better relatively quickly. Recovery time for mild (grade 1) ankle sprains is usually somewhere between 2 and 4 weeks.

Grade 2 injuries results in symptoms of moderate to severe pain with severe difficulty on walking. The athlete is unlikely to be able to play on and will often limp heavily. Minor bruising and swelling may present immediately but can take several hours (up to 48) to develop. The ankle will feel very stiff but may also feel unstable resulting from a number of torn ligament fibres (this can be tested more accurately by a professional therapist). Recovery time for a moderate sprained ankle (grade 2) takes between is 4 and 8 weeks.

Grade 3 injuries result in almost complete tears or total ruptures of the ligament(s). There will be severe pain immediately and the ankle may feel very unstable and weak. Swelling usually develops immediately and bruising often develops over the next 48 hours. These injuries need to be assessed in a hospital and often require and x-ray to ensure no bones have been broken. Severe ankle sprains (grade 3) can take up to 3 months to recover.

Read more on ankle sprain assessment and diagnosis

Possible complications

In addition to the ligament damage in ankle sprains, there may also be associated damage to tendons, the joint capsules, the bones, the cartilages, the nerves or other soft tissues. As mentioned before, severely sprained ankles result in complete or almost complete ruptures of the ligaments and may be associated with dislocations and fractures of the ankle bones.

Types of bone/joint injuries in ankle sprains

  • An avulsion fracture occurs when an overstretched ligament pulls a small piece of bone away with it. This is not always obvious initially but should be suspected if the injury fails to heal and the ankle remains tender to touch after a number of weeks.
  • Osteochondral lesions are tears of the cartilage that lines the bony surfaces of the ankle joints and often occurs in moderate to severe injuries. If missed or not treated this may lead to osteoarthritis developing later on and therefore in severe cases this may require surgery to fix.
  • Ankle Fractures may also occur as a result of severe ankle sprains. These can occur in both INVERSION and EVERSION injuries and diagnosis is only confirmed using x-rays.

In view of the above, moderate (grade 2) and severe (grade 3) ankle injuries should always be assessed by a doctor to decide if an x-ray is required, especially if a fracture is suspected. However, it should be noted that X-rays are not required for all sprained ankles (especially minor injuries) as fractures are rare.

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Self Help (Home) Treatment

Cold ankle wrapTreatment for sprained ankles can take place at home however for a quicker and more effective recovery we recommend seeing a professional therapist. Home treatment starts by applying a cold therapy and compression wrap (the PRICE principles) to reduce pain, reduce inflammation and promote healing.

This is then followed by mobilising exercises to regain movement and then strengthening the muscles to help support the ankle. Balance exercises (or “Proprioception” as it is known) are vital to ensure the ankle heals effectively and minimises the risk of re-injury.

Immediate treatment for a sprained ankle should involve P.R.I.C.E. (Protection, Rest, Ice, Compression, Elevation) and should be applied as soon as possible.

The PRICE principles are the “gold” standard treatment for treating acute sports injuries. The acronym stands for Protection, Rest, Ice, Compression and Elevation and should be applied as early as possible and continued for at least the first 24-72 hours.

Protection of the damaged tissue is vital to prevent further damage and enable the healing process to start efficiently and effectively.

Rest - In the early stages, rest is one of the most important components of the P.R.I.C.E principle but is often neglected or ignored.

Ice therapy, also known as cryotherapy, is one of the most widely known and used treatment modalities for acute sports injuries. Ice should only be applied for 15 minutes maximum and should always be wrapped in a cold towel to prevent ice burn.

Compression - Applying compression to an injured area minimises the amount of swelling that forms after an injury in two ways and should be applied for the first 24 to 72 hours from the onset of injury.

Elevation of the injured limb is the final principle of PRICE but is equally as important as the other 4.

Read more on PRICE and how to apply

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Ankle Taping

Ankle tapingAnother very important treatment for ankle sprains is taping / strapping. Our resident expert Neal Reynolds demonstrates how to tape an ankle - play ankle taping techniques video.

Taping plays an important role in the treatment of sprained ankles both in the early stages and in the later rehabilitation stages. During the first few days, compression bandages (link to neoprene ankle support) and ankle taping can be combined with the aim of reducing swelling and providing protection and support to the injured structures. During the rehabilitation stages taping is useful to support the injured structures in addition to “firing” up the muscles around the ankle (proprioception). Finally, taping of ankles can be useful in those that are recurrently injured by providing additional support whilst playing sport.

Read more on ankle taping.

Home Exercises

There are a number of exercises that can be performed in the comfort of your own home and will aid the recovery process. They are divided into movement, strengthening and functional exercises to address all the important aspects of ankle sprain rehabilitation.

Download our ankle exercises weekly record sheet (pdf)

Movement Exercises

Active mobility exercises for anklesOnce the swelling, pain and stiffness has settled down it is important to start to move the ankle and start to walk normally. This can start as early as day 3 for grade 1 injuries and as early as day 7 for grade 2 injuries (as long as there is no associated fracture), however pain should always be the indicator for whether they can start and progress. It is very important to walk as normally as possible to ensure “bad” habits do not develop.

Lateral or sideways movements should be avoided in the early stages to allow the ligaments to heal but can be started when walking and up and down movements of the ankle are pain free.

Read more on mobility exercises for sprained ankles

Strengthening Exercises

Isometric ankle exercise with partnerRegaining strength of the muscles around the ankle is very important and will help to support the healing ligaments. The calf and shin muscles are important in supporting the ankle joint and there are also muscles on the inside and the outside of the ankle joint that stop the foot rolling excessively inwards and outwards.

Isometric inversion and eversion is an early stage ankle strengthening exercise which can be done as soon as pain allows. It strengthens the muscles which help to control the 'rolling' action at the ankle. Isometric means there is no movement at the joint throughout the exercise.

Read more on strengthening exercises for sprained ankles

Proprioception / Balance

One of the most important rehabilitation strategies in treating and preventing re-injuries of ankle sprains is PROPRIOCEPTION. It is essential that proprioception or balance/coordination exercises are performed to “fire” up the muscles around the ankle joint complex to prevent re-injuries from occurring. There are a number of pieces of equipment that can be used in proprioception exercises, such as wobble boards and balance pads, but do not panic – there are also a number of exercises that can be done without any equipment and can be done at home. Simply standing on one leg with your eyes closed is a great way of regaining ankle proprioception. Play balance exercise video.

Read more on proprioception exercises for ankle sprains

Functional Exercises

The final component of ankle rehabilitation is performing functional exercises that are more dynamic and replicate actions within sport. They include lunges, calf raises, hopping and jumping and finish with sport specific drills. This stage is very important to ensure the ankle is ready to go back to playing sport.

Read more about functional exercises for sprained ankles

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Ankle Rehabilitation Program

Here at sportsinjuryclinc.net we have compiled a step-by-step ankle sprain rehabilitation program that takes you from the initial injury through to full fitness. After the initial acute stage has passed (which lasts at about 24 to 48 hours but could be longer with a severe sprain), rehabilitation exercises can begin but only if pain and swelling allows. The program is based around three phases starting with reducing pain and inflammation followed by restoring normal ankle and mobility and finally building up strength and proprioception (or coordination of the ankle joint). If at any time the ankle pain or swelling increases whilst following the program, then stop the exercises immediately and go back to an easier level of exercise.

Read more about our ankle rehabilitation program

Professional Treatment

For the most effective treatment and rehabilitation program we recommend you see a professional therapist. He/she will be able to accurately diagnose the injury and effectively treat the ankle to speed up the healing time and design a program to strengthen the ankle and design functional drills to effectively rehabilitate it.

A doctor or medical professional may prescribe anti-inflammatory medication e.g. ibuprofen which is beneficial in the first few days after the injury. Do not take ibuprofen if you have asthma and always speak to a pharmacist or doctor before taking medications. There is some evidence that anti-inflammatories can impair healing so do not take them for more than a few days at the beginning of the injury. Also, taking medication can sometimes "mask" any pain and may therefore be detrimental to the healing process.

Electrotherapy such as ultrasound may be applied. This transmits high frequency sound waves into the tissues, which in the early stages can help with pain relief and to reduce swelling. In the later stages of rehabilitation, the ultrasound waves cause a micro massaging effect which can help stimulate blood flow into the muscle.

Sports massage may be beneficial for treating a sprained ankle, particularly in the later stages or injuries that seem to take ages to recover from. We have interviewed a soft tissue expert to demonstrate some simple self-help cross friction massage techniques that may be used to help align scar tissue on the ligaments for effective healing.

Play video on sports massage for ankle sprains

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Expert Interview

We have interviewed our resident expert Neal Reynolds about how to treat a sprained ankle and top tips for ankle rehabilitation. The video is split into three sections to include all the phases of the treatment and rehabilitation process. In the first section he discusses the early stages of the injury and treatment and ankle exercises that can be performed at this stage. The second section looks at mid to late stages of rehabilitation and the final section focuses on preventing ankle injuries in the future.

Play expert interview on sprained ankles

In detail

The “ankle” is made up of 3 separate joints and involves 4 different bones – the talotibial (talus and tibia bones) joint, the tibiofibular joint (tibia and fibula bones) and the subtalar joint (talus and calcaneus bones).

Sprained ankle showing ligaments

The most common joint to be injured is the tibiotalar joint and it is supported by a number of ligaments to prevent excessive movement. There are 3 ligaments on the outside of the joint (anterior talofibular, posterior talofibular and calcaneal fibular) and these form the lateral ligament complex and are most commonly injured in ankle sprains. There is also a ligament complex on the inside (medial aspect) of the joint and this is called the deltoid ligament (tibionavicular, tibiospring, and deep posterior tibiotalar ligaments).

Finally, there is a ligament complex above the ankle joint connecting the tibia and fibula bones and this is called the syndesmotic complex (anterior tibiofibular ligament, posterior tibiofibular ligament and the interosseus membrane). Considering the amount of force that is transmitted through the ankle during walking and running, these ligament complexes are vital in providing stability to the ankle. In addition to these ligaments, there are a number of muscles that also support the ankle and can be injured in an ankle sprain.

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How Ankle Sprains Occur?

Ankle sprains usually occur during a sudden incident involving twisting or rolling of the ankle and can as a result of both contact (tackles) and non-contact situations. The most common structures that are damaged in ankle sprains are the lateral ligaments however tendons, muscles, nerves and bones can also be injured.

The most common mechanism for ankle injuries is INVERSION leading to a lateral ligament sprain where the ankle rolls under so the sole of the foot faces inwards. This causes damage to the ligaments and soft tissues on the outside of the ankle.

The ankle can also be sprained from excessive EVERSION where the ankle turns outwards and will sometimes coincide with a fracture of the fibula bone in the lower leg, although this is much less common. This is a less frequent injury than inversion injuries and is therefore often misdiagnosed and also takes considerably longer to heal.

The main ligaments that are involved in INVERSION sprains are the anterior talofibular ligament (ATFL) which connects the talus bone in the foot to the tibia (shin) bone and the calcaneofibular ligament (CFL) which connects the calcaneus or heel bone to the fibula bone. Mild ankle inversion sprains often cause damage to only one of the ligaments whereas moderate to severe injuries usually damage two or three of the ligaments.

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Top Tip from the Expert

People often say they have “weak” ankles but in most cases they have ankles that are in fact “poor proprioceptively” and not weak at all. Proprioception is by far the most effective treatment for treating and is the secret to preventing re-injuries in ankle injuries.

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