Ankle sprains

Ankle sprains are a very common injury to the ligaments around the ankle joint. A sprained ankle can happen to anyone who walks or runs.

An ankle sprain is an injury to one or more ligaments usually on the outside of the ankle joint. Ligaments are bands of elastic tissue that connect one bone to another. The ligaments of the ankle joint hold the tibia, fibula, calcaneus and talus bones in position. The ligaments protect the ankle joint from abnormal movements-especially twisting, turning, and rolling of the foot. Ligaments usually stretch within their limits, and then go back to their normal positions. A sprain occurs when a ligament is forced to stretch beyond its normal range. A severe sprain causes actual tearing of the elastic ligament fibers.

How does an ankle sprain occur?

An ankle sprain can happen when the ankle joint undergoes an abnormal movement such as twisting, turning, and rolling of the foot.

This can happen:

• when walking over an uneven surface,
• when stepping off the curb of a sidewalk ,
• during a sudden fall,
• due to a blow that forces the ankle joint out of its normal position,
• while participating in sports,
• while wearing inappropriate shoes and,
• due to a previous ankle or foot injury that has weaken the ankle ligaments.

Prevention of ankle sprains

The best way to prevent ankle sprains is to maintain good strength, muscle balance and flexibility.

• Warm-up before doing exercises and vigorous activities
• Pay attention to walking, running or working surfaces
• Wear good shoes
• Pay attention to your body’s warning signs to slow down when you feel pain or fatigue

Diagnosis of ankle sprains

Most people will go to the emergency department to have their acute ankle sprain treated. The emergency room(ER) doctor will obtain a thorough history of your symptoms and examine your foot. X-rays or other advanced imaging studies may be ordered to help determine the severity of the injury.

How are ankle sprains classified?

The amount of force determines the grade of the ankle sprain.

• A mild sprain is classed Grade 1.
  Slight stretching and some damage to the fibers of the ligament.
• A moderate sprain is classed Grade 2.
  Partial tearing of the ligament.
  If the ankle joint is examined and moved in certain ways, abnormal looseness (laxity) of the ankle joint occurs.
• A severe strain is classed Grade 3:
  Complete tear of the ligament.
  If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs.

Why prompt medical attention is needed for ankle sprains?

4  reasons why an ankle sprain should be promptly evaluated:

1.  An untreated ankle sprain may lead to chronic ankle instability. This scenario will be marked by a persistent discomfort and a “giving way” of the ankle.
2.  A more severe ankle injury may have occurred along with the sprain. This might include a serious bone fracture. If the fracture is left untreated it could lead to troubling complications.
3.  An ankle sprain may be accompanied by a mid-foot soft tissue injury that could become a chronic injury.
4. Rehabilitation of a sprained ankle needs to begin right away. If rehabilitation is delayed the acute ankle sprain will become chronic.

What are the symptoms of an ankle sprain?

The symptoms of ankle sprains may include:

• Pain or soreness
• Swelling
• Bruising
• Difficulty walking
• Stiffness in the joint

These symptoms may vary in intensity, depending on the severity of the sprain. Sometimes pain and swelling are absent in people with previous ankle sprains. Instead, they may simply feel the ankle is wobbly and unsteady when they walk. Even if there is no pain or swelling with a sprained ankle, treatment is crucial.

Non-surgical treatment of ankle sprains

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 ER doctor may advise you to use a removable plastic protective cast if your ankle sprain is determined to be a grade 2 or 3 sprain. Even a grade 3 or complete ligament tear can heal without surgical repair if it is immobilized appropriately.
Most ankle sprains only a require period of protection to heal. The healing process takes about 4 to 6 weeks. The ER doctor may suggest you to incorporate motion early in the healing process to prevent stiffness. Motion will aid you in re-establishing position, location, orientation and movement of the ankle joint (proprioception). Proprioception training is very important. Poor proprioception is a major cause of repeat ankle sprains and an unstable ankle joint. When you have an ankle sprain, rehabilitation is crucial! It begins the moment your treatment begins. Your ER doctor will recommend one or more of the following treatment options in the acute stage:

• Rest.
  Stay off the injured ankle. Walking may cause further injury.

• Ice.
  Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.

• Compression.
  An elastic wrap may be recommended to control swelling.
• Elevation.
  The ankle should be raised slightly above the level of your heart to reduce swelling.
• Medications.
  Non-steroidal anti- inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation. In some cases, prescription pain medications are needed to provide adequate relief.

• Early physical therapy.
  Your ER doctor, GP or physiotherapist will start you on a rehabilitation program as soon as possible to promote healing and increase your range of motion. This includes doing prescribed exercises which will include muscle strengthening and balance exercises to re-establish proprioception around the ankle ligaments. Proprioception training is very important. Poor proprioception is a major cause of repeat ankle sprains and an unstable ankle joint.

• Ankle Manipulations
  Osteopathic manipulations have been demonstrated to reduce pain and edema in grade 1 and 2 ankle sprains the emergency department setting. There was also a significant improvement in ankle range of motion.

When is surgery needed after an ankle sprain?

In more severe cases, surgery may be required to adequately treat an ankle sprain. Surgery often involves repairing the damaged ligament or repairing fractured bones with screws and plates. Your orthopedic foot and ankle surgeon will select the surgical procedure best suited for your case based on the type and severity of your injury as well as your activity level.

After surgery, completing your rehabilitation program is crucial to a successful outcome. Rehabilitation after surgery involves time and attention to restore strength and range of motion so you can return to pre-injury ankle motion. The length of time you can expect to spend recovering depends upon the extent of injury and the amount of surgery that was done. Rehabilitation may take from weeks to months.

Rehabilitation is used to help to decrease pain and swelling and to prevent chronic ankle problems. Rehabilitation exercises may involve active range of motion or controlled movements of the ankle joint without resistance. Balance exercises or proprioception training is very important. Poor proprioception is a major cause of repeat ankle sprains 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.

Be sure to attend your follow-up appointments with your orthopedic foot and ankle surgeon during the rehabilitation period to ensure that your ankle heals properly and function is restored.

What the difference between an acute and chronic ankle sprain?

If you have sprained your ankle in the past, you may continue to sprain your ankle if the ligaments did not have time to completely heal. If the sprain happens frequently and pain continues for more than four weeks to six weeks, you may have a chronic ankle sprain. Activities that tend to make an already sprained ankle worse include stepping on uneven surfaces, cutting actions and sports that require rolling or twisting of the foot, such as cross country running, basketball, volleyball, tennis, football and soccer.

Possible complications of ankle sprains and treatment include abnormal proprioception. Proprioception training is very important, as poor proprioception is a major cause of repeat sprain and an unstable ankle joint. There may be imbalance and muscle weakness that causes a re-injury. If this happens over and over again, a chronic situation may persist with instability, a sense of the ankle giving way (gross laxity) and chronic pain.

Chronic ankle sprains and foot manipulations

One of the complications of a chronic ankle sprain is pain in the midfoot in the area of the navicular and cuboid bones. Ankle and foot manipulations can help to realign the cuboid and navicular bones which can be forced out of alignment during an ankle sprain. A misaligned cuboid and navicular bone can cause significant discomfort long after the initial ankle sprain injury. If you have mid-foot pain and have a prior history of ankle sprains you may benefit from foot and ankle manipulations.