Ankle Sprains

The ankle is the area connecting the foot to the lower leg. We have tendons and muscles to provide movement, and ligaments around the ankle to provide stability, along with nerves which supply the power and sensation to the ankle and foot.

Ankle sprains are common, and generally occur when you land or plant the foot awkwardly and roll on to the outside of the foot (inversion). You can sprain the ankle rolling the other way, on to the side of the big toe (eversion) but this is less common.

A sprain is defined as, “one or more of the ligaments of the ankle are partially or completely torn.” (Physiopedia, 2019). This occurs due to them being suddenly forced or stretched in to inversion or eversion e.g. with a fall or trip in sports or going over uneven ground.

Picture from Physiopedia (2019).

Ligaments are strong connective tissues which act to restrict joint range of movement and provide stability to the joint (Woon, C; Moore, D, 2018). Tendons are tissues which connect muscle to bone, and are structured to transmit large mechanical forces (Physiopedia, 2019).

There are three main ligaments on the outside (lateral aspect) of the ankle. The anterior talofibular ligament (ATFL), Calcaneufibular ligament (CFL), and Posterior Talofibular ligament (PTFL).

Do I need an X-Ray?

The Ottawa rules for x-raying ankle injuries (From Stiell, 2019):

An ankle X-ray is required if:

• Unable to weight bear immediately after injury, and in the emergency department for 4 steps, or
• Bony tenderness at the posterior aspect or tip of lateral malleolus (6cm), or
• Bony tenderness at the posterior edge or tip of the medial malleolus (6cm)

A foot x-ray is required if:

• There is bony tenderness at the base of the fifth metatarsal, or
• Bony tenderness at the navicular, or
• Inability to weight bear immediately after the injury or in the emergency department for four steps

Please see our YouTube video for more information on the bony palpation landmarks, and when to attend the Emergency Department following an ankle sprain:

https://www.youtube.com/watch?v=WLkDNC0fsy8

How long does it take to get better?

There is no fixed timescale for this, as it depends on a variety of factors, such as the severity of the sprain and a history of previous sprains. Usually, it can take between 2 and 6 weeks for the initial pain and swelling to reduce. It can take 3-6 months for the strengthening and balance re-education.

What can I do?

• If you are unable to weight bear, have significant swelling and difficulty mobilising, go to the Emergency Department for an assessment and advice
• Mobilise the ankle – point your toes to and away from you 10 times, then in circles, a few times daily to stop the ankle getting stiff
• Elevate the leg and ice the swelling. Wrap ice in a damp towel and apply to the ankle (as long as no sensation loss) for 10-15 minutes, with your leg elevated on some pillows (above heart level). This can help reduce the swelling with the mobility exercise above
• Speak to a pharmacist or GP about pain relief if you feel if would be appropriate
• If you have sprained your ankle, it is worth seeing a Physiotherapist, as with this injury it can affect the strength of the muscles, integrity of the ligaments and sensory nerve fibres (Physiopedia, 2019)
• If you have sprained your ankle in the past, your risk can be higher for repeating this injury (Physiopedia, 2019), so again, Physiotherapy can help you build up strength, balance and proprioception

What would Physiotherapy do?

In Physiotherapy, we would carry out the ankle rehabilitation in stages:

• Exclude bony injury, reduce swelling and gradually return to normal walking pattern (gait)
• If we were concerned about the severity of the sprain, we may organise x-rays to check the bones of the ankle and foot, and an ultrasound to see the injury to the ligaments and soft tissues around the ankle and foot
• Improve balance, proprioception and strength
• Return to sport rehabilitation
• If there were ongoing problems we would refer you to one of the Sports Medicine Doctors for further assessment

Management – advice for Health Professionals

The British Journal of Sports Medicine developed an updated guideline for the treatment of ankle sprains in 2019. You can read the guideline here on the British Journal of Sports Medicine Website (reference at end of article). The main summary has included risk factors and treatment options. Some of the recommendations are (Veerburg et al, 2019):

• Use the Ottawa ankle rules to exclude a fracture
• No evidence for Rest, Ice, Compression, Elevation (RICE) for reducing symptoms alone
• Limited dorsiflexion, reduced peroneal reaction time, reduced balance, lower BMI, reduced cardiorespiratory endurance, wearing high heels, increased height and females have a higher risk of having a lateral ankle sprain
• Start exercise therapy as soon as possible to prevent recurrent sprain
• Manual mobilisation can be helpful when used with exercise therapy
• Functional treatment preferred over surgery, but should be assessed on an individual basis
• No strong evidence for electrotherapy or acupuncture
• NSAIDs (nonsteroidal anti-inflammatories) may be used for acute lateral ankle sprain for reducing pain and swelling, but caution due to complications with NSAID usage, and may suppress or delay the natural healing process

References:

Vuurberg, G; V; Hoorntje, A; Wink, L; van der Doelen, B; van den Bekerom, M; Dekker, R; van Dijk, N; Krips, R; Loogman, M; Ridderikhof, M; Smithuis, F; Stufkens, S; Verhagen, E; Bie, R; Kerkhoff, G. 2019. Diagnosis, Treatment and Prevention of Ankle Sprains: Update of an Evidence-Based Clinical Guideline. [online]. British Journal of Sports Medicine. [Accessed 3^rd July 2019]. Available from: http://www.bjsm.bmj.com

Physiopedia. 2019. Ankle Sprain. [online]. [Accessed 26^th June 2019]. Available from: http://www.physio-pedia.com

Physiopedia. 2019. Tendon Anatomy. [online]. [Accessed 26^th June 2019]. Available from: http://www.physio-pedia.com

Stiell, I. 2019. The Ottawa Ankle Rules. [online]. [Accessed 3^rd July 2019]. Available from: http://www.theottawarules.ca

Woon, C; Moore, D. 2018. Ligaments. [online]. [Accessed 26^th June 2019]. Available from: http://www.orthobullets.com