Sprained Ankle Overview
Annually, an estimated 1 million people in the U.S. visit a doctor about an acute ankle injury, according to the American Academy of Family Practice. The ankle joint, which connects the foot with the lower leg, is injured often. An unnatural twisting motion can happen when the foot is planted awkwardly, when the ground is uneven, or when an unusual amount of force is applied to the joint. Ankle sprains are common sports injuries but can also happen during everyday activities such as walking or even getting out of bed.
The ankle joint is made up of three bones.
The tibia is the major bone of the lower leg, and it bears most of the body’s weight. Its bottom portion forms the medial malleolus, the inside bump of the ankle.
The fibula is the smaller of the two bones in the lower leg. Its lower end forms the lateral malleolus, the outer bump of the ankle.
The talus is the top bone of the foot.Tendons connect muscles to bones.
Several muscles control motion at the ankle. Each has a tendon connecting it to one or more of the bones of the foot.
Tendons can be stretched or torn when the joint is subjected to greater than normal stress.
Tendons also can be pulled off the bone. This type of injury is called an avulsion.
Ligaments provide connection between bones. Sprains are injuries to the ligaments.
The ankle has many bones that come together to form the joint, so it has many ligaments holding it together. Stress on these ligaments can cause them to stretch or tear.
The most commonly injured ligament is the anterior talofibular ligament that connects the front part of the fibula to the talus bone on the front-outer part of the ankle joint.
Ankle injuries can be painful and can make it difficult to carry out daily activities.
A sprained ankle is a very common injury. Approximately 25,000 people experience it each day. A sprained ankle can happen to athletes and non-athletes, children and adults. It can happen when you take part in sports and physical fitness activities. It can also happen when you simply step on an uneven surface, or step down at an angle.
The ligaments of the ankle hold the ankle bones and joint in position.They protect the ankle joint from abnormal movements-especially twisting, turning, and rolling of the foot.
A ligament is an elastic structure. Ligaments usually stretch within their limits, and then go back to their normal positions. When a ligament is forced to stretch beyond its normal range, a sprain occurs.
A severe sprain causes actual tearing of the elastic fibers.
How It Happens
Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions. A great force is transmitted upon landing. You can sprain your ankle if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range in an abnormal position.
Mechanism of Injury
If there is a severe in-turning or out-turning of the foot relative to the ankle, the forces cause the ligaments to stretch beyond their normal length. If the force is too strong, the ligaments can tear. You may lose your balance when your foot is placed unevenly on the ground. You may fall and be unable to stand on that foot. When excessive force is applied to the ankle’s soft tissue structures, you may even hear a “pop”. Pain and swelling result. The amount of force determines the grade of the sprain.
A mild sprain is a Grade 1.
A moderate sprain is a Grade 2.
A severe strain is a Grade 3 (see Table below).
Grade 1 sprain: Slight stretching and some damage to the fibers (fibrils) of the ligament.
Grade 2 sprain: Partial tearing of the ligament. If the ankle joint is examined and moved in certain ways, abnormal looseness (laxity) of the ankle joint occurs.
Grade 3 sprain: Complete tear of the ligament. If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs.
See your doctor to diagnose a sprained ankle. He or she may order X-rays to make sure you don’t have a broken bone in the ankle or foot.
A broken bone can have similar symptoms of pain and swelling.
The injured ligament may feel tender. If there is no broken bone, the doctor may be able to tell you the grade of your ankle sprain based upon the amount of swelling, pain and bruising.
The physical exam may be painful. The doctor may need to move your ankle in various ways to see which ligament has been hurt or torn.
If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. If this occurs, it is possible that the injury may also cause damage to the ankle joint surface itself.
The doctor may order an MRI (magnetic resonance imaging) scan if he or she suspects a very severe injury to the ligaments, injury to the joint surface, a small bone chip or other problem. The MRI can make sure the diagnosis is correct. The MRI may be ordered after the period of swelling and bruising resolves.
Nonsurgical Treatment Walking may be difficult because of the swelling and pain. You may need to use crutches if walking causes pain. Usually swelling and pain will last two days to three days. Depending upon the grade of injury, the doctor may tell you to use removable plastic devices such as castboots or air splints.
Most ankle sprains need only a period of protection to heal. The healing process takes about four weeks to six weeks. The doctor may tell you to incorporate motion early in the healing process to prevent stiffness. Motion may also aid in being able to sense position, location, orientation and movement of the ankle (proprioception). Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately. Even if an ankle has a chronic tear, it can still be highly functional because overlying tendons help with stability and motion.
For a Grade 1 sprain, use R.I.C.E (rest, ice, compression and elevation):
How To Care For Your Ankle Sprain
What is an ankle sprain?
The injury that occurs when your foot “rolls,” or turns in on itself, is called an ankle sprain. In this injury, the ligaments that hold the ankle and foot bones in place are stretched and weakened.
What should I do after an ankle sprain?
Many doctors recommend that you use the RICE treatment after a sprain:
- R = Rest.
Stay off the injured ankle to help it heal. This also helps prevent further injury. Your doctor might have you use crutches if walking is too painful. Stay off your feet most of the time until you can walk without pain.
- I = Ice.
Ice helps keep the swelling down. It also helps to reduce pain. Put an ice pack on the ankle for 15 minutes. Take the ice off for 10 minutes. Put ice back on for 10 minutes. Then use ice for 15 minutes at a time three times a day for two more days.
- C = Compression.
Compression (wrapping the ankle with a strip of elastic cloth) will help decrease swelling and support your ankle. You can use an elastic wrap from the drugstore, or get an air splint from your doctor. (Your doctor will show you how to use it.) Be careful not to wrap the ankle too tightly. That would slow the blood flow to your foot. Use the elastic bandage for 1 to 2 days.
- E = Elevation.
Keeping your foot raised helps decrease pain and swelling. When you elevate your ankle, try to keep it around the level of your heart. Lying on a couch with pillows under your foot is better than sitting in a chair with your foot on a footstool. Try to keep your foot elevated for 2 to 3 hours a day.
What can I take for pain?
Most doctors recommend anti-inflammatory medicines such as ibuprofen (brand names: Advil, Medipren, Motrin, Nuprin), naprosyn (brand name: Aleve) or ketoprofen (brand name: Orudis KT). You can also take acetaminophen (brand names: Tylenol, Datril, Panadol), although this medicine isn’t an anti-inflammatory.
After my ankle sprain heals, what can I do to strengthen my ankle?
It’s important for you to strengthen your ankle after a sprain. This helps prevent another injury. Use elastic tubing (available at drug stores and most sports equipment stores) and follow a few basic exercises, described below. Do 10 repetitions of each exercise (this is called a “set”); do three sets of each exercise, twice a day. For example, in the morning, you’ll do 40 repetitions (four exercises, 10 times each) three times. In the evening, you’ll do another 40 repetitions three times.
Exercises After an Ankle Sprain
Sit on a firm chair, or stand up. Loop one end of the tubing around the ball of the foot with the injured ankle. Hold the other end of the tubing in your hand. Put your heel on the floor. Stretch the tubing by pushing down with your foot, the way you push on the gas pedal of a car.
Sit on a firm chair, or stand up. Loop one end of the tubing around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by pulling up with your foot (lifting up your foot), using your ankle, as if you were trying to pull the table toward you. (This motion is the opposite of trying to “step on the gas.”)
Sit on a firm chair, or stand up. Loop one end of the tubing around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by moving your foot out to the side, away from the leg of the table.
Sit on a firm chair, or stand up. Loop one end of the tube around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by moving your foot in to the middle, toward your good ankle.
You can also do these exercises with your uninjured ankle, to keep it strong and less likely to sprain.
What can I do to help prevent another ankle sprain?
Wear Flat Shoes Instead Of High Heels.
When taking part in a sporting activity, wear a lace-up ankle support (brace) for added protection.
If you don’t like lace-up ankle braces, wear an elastic slip-on support. (It won’t be as protective as the lace-up ankle brace.)
Don’t Stop Doing The Ankle Exercises After Your Ankle Feels Better.
Keep Doing The Exercises Several Times A Week To Keep Your Ankles Strong.
Rest your ankle by not walking on it.
Ice should be immediately applied. It keeps the swelling down. It can be used for 20 minutes to 30 minutes, three or four times daily.
Combine ice with wrapping to decrease swelling, pain and dysfunction.
Compression dressings, bandages or ace-wraps immobilize and support the injured ankle.
Elevate your ankle above your heart level for 48 hours.
For a Grade 2 sprain, the RICE guidelines can also be used. Allow more time for healing to occur. The doctor may also use a device to immobilize or splint the ankle.
A Grade 3 sprain can be associated with permanent instability. Surgery is rarely needed. A short leg cast or a cast-brace may be used for two weeks to three weeks.
Rehabilitation is used to help to decrease pain and swelling and to prevent chronic ankle problems. Ultrasound and electrical stimulation may also be used as needed to help with pain and swelling. At first, rehabilitation exercises may involve active range of motion or controlled movements of the ankle joint without resistance. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Lower extremity exercises and endurance activities are added as tolerated. Proprioception training is very important, as poor propriception is a major cause of repeat sprain and an unstable ankle joint. Once you are pain-free, other exercises may be added, such as agility drills. The goal is to increase strength and range of motion as balance improves over time.
All ankle sprains recover through three phases:
Phase 1 includes resting, protecting the ankle and reducing the swelling (one week).
Phase 2 includes restoring range of motion, strength and flexibility (one week to two weeks).
Phase 3 includes gradually returning to activities that do not require turning or twisting the ankle and doing maintenance exercises. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities) such as tennis, basketball or football (weeks to months).
Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to control pain and inflammation.
If an ankle sprain is not recognized, and is not treated with the necessary attention and care, chronic problems of pain and instability may result.
Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for persistent instability after months of rehabilitation and non-surgical treatment.
Surgical options include:
A surgeon looks inside the joint to see if there are any loose fragments of bone or cartilage, or part of the ligament caught in the joint.
A surgeon repairs the torn ligament with stitches or suture, or uses other ligaments and/or tendons found in the foot and around the ankle to repair the damaged ligaments.