An ankle sprain is one of the most common sports injuries and is also the most frequently re-injured. Treament includes reducing symptoms of pain and swelling followed by mobility, strengthening, proprioception and sport specific exercises.
- Symptoms & diagnosis
- Causes & anatomy
- Complications & avulsion sprain
Sprained ankle symptoms & diagnosis
You often know instantly if you have sprained your ankle. The foot turns inwards under the weight of the body causing Instant pain around the ankle joint, specifically on the outside of the ankle where the damaged ligaments are located.
Swelling or bruising can appear immediately or may sometimes take up to 48 hours to develop, depending on the structures damaged and the severity of the sprain. Ankle sprains are graded 1, 2 or 3.
How bad is my ankle sprain?
Grade 1 is a mild injury with some pain but little or no swelling. The ankle may feel stiff and the athlete may be some difficulty in walking or running. However, they will most likely be able to finish the training session or game. In grade 1 sprains, the ligaments are usually stretched rather than completely torn and recover relatively quickly, usually somewhere between 2 and 4 weeks.
Grade 2 sprains cause moderate to severe pain. The athlete will be unable to continue running and will probably find it very difficult to walk. Minor bruising and swelling may occur either immediately, or over the following 48 hours. The ankle will feel stiff and may feel unstable as a result of torn ligament
Grade 3 is a complete, or near complete tear of the ligament. There will be immediate, severe ankle pain and the ankle will feel very unstable and weak. Swelling occurs immediately, with bruising often developing over the following 48 hours. Grade three sprains should be assessed in a hospital and often require an x-ray to rule out fractures. Severe ankle sprains (grade 3) can take up to 3 months to recover.
Sprained ankle assessment
A professional therapist or Doctor will use a range of techniques to help assess a sprained ankle. These will include range of motion, palpation (feeling), resisted muscle tests and specific assessment tests. Special tests to assess damage to ankle ligaments include:
- “Anterior drawer test” will be used to assess the ATFL ligament
- “Talar Tilt” test will be used to test the CFL ligament
- External rotation and squeeze tests will be used to assess the high ankle ligaments (syndesmosis complex)
Ankle sprain causes & anatomy
The ankle is supported by a number of ligaments which connect bone to bone. The main ligaments involved in a sprained ankle are the tibiofibular and the calcaneofibular ligaments on the outside of the ankle. Muscles on the inside and outside of the leg attach to the bones via tendons, also provide support and stability to the joint.
Inversion sprains vs eversion sprains
An inversion sprain is most common. The ankle rolls outwards as the sole of the foot turns inwards stretching or tearing the supporting ligaments on the outside of the ankle. An eversion sprain is less common and usually occurs in conjuntion with a fracture to the end of the fibula bone. As a result the ankle rolls inwards flattening the foot and stretching ligaments on the inside of the ankle. Mild sprains may only damage one of the ligaments whereas a more severe sprain can damage two or three.
What causes a sprained ankle?
Poor proprioception is a leading cause of sprains, especially recurrent ankle sprains. Proprioception is the body's awareness and ability to judge the position of body parts. If you have ever started to turn your ankle over and reacted automatically to stop it then this is proprioception at work. Poor proprioception means the muscles would be less able to detect when the joint is at risk of injury and less able to correct the position of the ankle when needed, which can result in a sprain. Previous injury and inappropriate footwear are also likely to increase the risk of a sprained ankle.
Ankle avulsion fracture & complications
An ankle avulsion fracture occurs when a tendon or ligament comes away from the bone often pulling a small piece of bone with it. The symptoms are similar to an ankle sprain, but unlike a sprain, an avulsion fracture pulls a piece of bone off when the ligament tears. An x-ray can determine which ankle injury you have and so how best to treat it.
Sprained ankle treatment
Ankle sprain treatment involves immediate first aid to reduce pain and swelling, rest to allow healing, followed by a rehabilitation program to restore full mobility, strength, and proprioception or coordination to prevent re-injury.
Apply the PRICE principles (protection, rest, ice, compression and elevation) as soon as possible after injury. It is important to rest the ankle to prevent further damage. Apply ice wrapped in a wet tea towel to prevent ice burns, or better still a cold therapy and compression wrap will reduce pain, inflammation, and swelling. Cold therapy can be applied for 10 mins every hour initially, reducing the frequency as symptoms improve. Elevating the ankle can also help reduce swelling by allowing tissue fluids to drain away.
Wear an ankle brace or support to protect the injured ligaments and provide compression. Initially, a simple elastic compression sleeve or support is ideal, whilst later in the rehabilitation process, a stronger brace with additional lateral support at the side may help protect the ligaments.
When pain allows, a full rehabilitation program of mobilizing, strengthening and finally functional or sports specific exercises should be performed. Read more on our step-by-step ankle sprain rehabilitation program that takes you from the initial injury through to full fitness.
What can a professional therapist do?
A professional therapist can accurately diagnose your injury and give advice on treatment and rehabilitation. They can advise on what exercises to do to repair the ankle and rehabilitate it. They may use electrotherapy such as ultrasound to help relieve pain, relax the muscles and reduce swelling.
Sports massage (play video) can be effective in treating a sprained ankle in a number of ways. Initially, light massage around the ankle, calf and shin muscles can be used to help reduce swelling from around 3 days after injury. As the pain subsides, deeper techniques can be incorporated to help loosen the calf and shin muscles and improve range of motion.
After the acute phase, cross friction massage directly to the ligament can help in preventing scar tissue formation. This type of deep massage can be commenced from around 7 days after injury, or as pain allows.
Cross friction massage should be applied with the ligament in the stretched position. Direct pressure with a single finger to the tendon is applied (but within the limits of pain) backward and forwards across the tendon - not along its length.
Taping is another treatment that can be used to both protect the injured ankle but also improve confidence following such an injury. Tape can help support the damaged structures in the ankle and activate the surrounding muscles, both for recovery and for when you return to sport. A professional therapist can apply the tape correctly, or you can try applying the tape at home by following the methods shown in our videos.
An expert will also be able to advise on rehabilitation exercises. Because they can assess the injury and where the damage has been done, they can recommend the best and most effective exercises for you to do. These exercises also involve strengthening the ankle and looking at any weaknesses that may have contributed to the injury. Performing these can help prevent any further injury in the future.
Sports Physiotherapist Neal Reynolds (play video) talks about how to treat a sprained ankle and top tips for ankle rehabilitation.
One of our top tips is:
“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.”
Read more on rehabilitation of ankle sprains.
Exercises for a sprained ankle
Mobility, strengthening and proprioceptive exercises are important in the rehabilitation of ankle sprains (download PDF record sheet).
Mobility and stretching exercises
Mobility exercises for the ankle can start very early in the rehabilitation process from day 2 in mild to moderate sprains. As a sprain can make the joint stiff, performing mobility exercises and stretches will help increase the range of movement. Sideways movements should be avoided early on so as not to put any stress at all on the injured ligaments. Later, when pain allows, exercises with lateral movements involving sideways motion can be done.
Active plantar flexion and dorsiflexion would be a good mobility exercise, to begin with as it does not involve any sideways movements. It keeps the ankle mobile and also keeps the calf and shin muscles active.
These are also important to help prevent any further injuries. They can be started as soon as the pain has lessened, although exercises that involve sideways movements should be avoided in the early stages.
Once pain allows, isometric eversion and inversion exercises help to control the "rolling" action of the ankle. This is especially helpful in preventing future injuries. A therapist or a friend can provide resistance, or you could use a wall.
Proprioceptive and functional exercises
One of the most important parts of ankle injury rehabilitation and in preventing re-injuries is proprioception. It is essential that proprioception exercises are performed to fire up the muscles around the ankle joint to prevent injuries from reoccurring. These can range from standing on one leg (which can be increased in difficulty by closing your eyes and standing on an unstable surface) to hopping (when pain allows).
As you increase the intensity, you can perform exercises with a more sports specific focus. For example, doing lunges, step backs and jumps will help build up strength and the muscles until you are able to train fully. The intensity of the exercises should be increased slowly, it is important not to rush the process.
Read more and watch videos on ankle rehabilitation exercises.
In addition to the ligament damage in ankle sprains, there may also be associated with damage to tendons, the joint capsules, the bones, the cartilages, the nerves or other soft tissues. 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.