Ankle sprains are one of the most common athletic injuries. Each day it is estimated that between 23,000 and 27,000 ankle sprains happen each day in the United States. Ankle injuries are occur most often in athletes participating in sports with side to side movement than that with straight ahead motion.Court sports such as Basketball, Tennis and Raquetball all create a fair share of ankle sprains. Running on level ground does not often result in an ankle sprain but cross country running, trail running and stepping in a pot hole all could potentially lead to an ankle sprain. Unfortunately the reinjury rate may be high and can approach 70% in sports such as basketball.

“Ankle sprains are more common in athletes participating in sports with side to side movement”

The most frequent ankle sprain is an inversion ankle sprain. This can injure the outer structures of the ankle. More rarely the medial (inner) ankle ligaments are sprained.

Anatomy: The ankle includes the Talus or ankle bone and the ankle mortise created by the lower Tibia (inner ankle bone, leg bone) and fibula (outer ankle, leg bone). There are three main outer ankle ligaments. The anterior talo-fibular ligament, the calcaneo-fibular ligament and the posterior talo-fibular ligament. Other structures in this area which your doctor will want to examine which can also be injured in an inversion injury include the peroneal tendons (which can sublux or move out of place), the calcaneo-cuboid ligament, and the base of the 5th metatarsal (which can break).

On the medial side of the ankle you'll find the broad, fan shaped deltoid ligament. This is less often sprained, but is more difficult to treat than lateral ankle sprains. One of the probable reasons that this ligament is harder to treat is that when the foot pronates either normally or abnormally in gait, the deltoid ligament is under tension and stretched. The continued stretching motion in this area would retard the healing.

Most Common Injury:

The most common injury resulting from an inversion ankle injury is a partial tear of the anterior talo-fibular ligament (ATFL). This ligament may also tear completely. The next most frequently injured ligament is the calcaneo-fibular ligament and least injured is the posterior talo-fibular ligament. On occasion the fibula itself may be fractured or the talar dome is injured which may include an osteochondral fracture. More serious ankle sprains can involve the anterior inferior tibio-fibular ligament.

As already mentioned, all of the other structures on the lateral side of the ankle should always be carefully examined to make sure they are not injured.

The grading of ankle sprains is officially done on an inadequate 3 point scale. Grade 1 is a mild "stretch" of the ligaments, Grade 3 is a complete tear of the ligament and Grade 2 is everything in between. In my office I use a subjective 10 point scale to finer grade the ligament injury for the benefit of the patient.

Physical Examination:

Palpate all key lateral ankle structures including: Lateral Malleolus, Anterior Talo-fibular Ligament, Calcaneo-fibular ligament, posterior talo-fibular ligament, Anterior Inferior Tibio-fibular Ligament, Talus, Calcaneo-cuboid ligament, Peroneal tendons, Base of 5th metatarsal (styloid process), shaft of 5th and 4th metatarsals.

Anterior Drawer Test - Stabilize lower leg. Grasp Calcaneus and pull forward. Look for a dimple anterio-laterally which might be easier to visualize than the movement itself. A positive Anterior Drawer sign indicates that at the least the Anterior Talo-fibular ligament is torn.

Xray studies are not routinely done, but are done if the "Ottawa Criteria" are met:

Ottawa Criteria:

Pain in the ankle and any one of the following:

1. Tenderness on palpation of the lateral malleolus or medial or medial.
2. Inability to bear weight both immediately and in the emergency facility (for 4 steps).

Foot Xray is indicated if there is pain in the midfoot and any one of the following:
3. Tenderness around the navicular bone.
4. Tenderness around the 5th styloid process.

These criteria are not for use in patients under age 18.
Ottawa Rules: Stiell, I. et al. BMJ 1995;311:594-597

High Ankle Sprain:

Tibiofibular Syndesmosis Injury
- Anterior Inferior tibiofibular ligament
- Interosseous membrane
- Ankle squeeze test positive
- Ankle external rotation test positive
- Tender at anterior ankle
- Pain at Tibiofibular joint - distal

Additional Injuries To Consider: Differential Diagnosis:

  • Anterior Talo-Fibular Ligament sprain
  • Calcaneo-fibular Ligament sprain
  • Posterior talo-fibular ligament sprain
  • Calcaneo-cuboid ligament sprain
  • Lateral malleolus fracture
  • Anterior inferior tibio-fibular ligament sprain
  • Posterior inferior tibio-fibular ligament sprain
  • Syndesmosis tear
  • Osteochondral injury to talus
  • Posterior-lateral talar process fracture
  • Anterior process of calcaneus (beak) fracture
  • Achilles tendon injury
  • Fifth metatarsal fracture (styloid process or base)
  • Subtalar joint injury

 

Instability: Mechanical And Functional

Physical instability occurs when disrupted ligaments cause true instability of the ankle joint. Chronic complaints include: swelling, pain during activbity, a feeling of giving out and repeted injury.

Functional instability includes impairment of joint position sense (proprioception), decreased strength, impaired postural control and impairment of neuromuscular control in the absence of ligamentions laxity.


Treatment For Minor Sprain:

It is impossible to guess via the Internet how badly injured you are. If you have doubts or your ankle swells very rapidly you should head for the emergency room. Immediate treatment should consist of R.I.C.E. or even better P.R.I.C.E.:


Protection

Rest

Ice

(Gentle) Compression

Elevation

The ice should be applied for about 20 minutes at a time and then off for about 40 minutes. Avoid damaging your skin with the chemical bags you can place in your freezer. Frozen corn or peas works just fine.

If the ankle does not respond quickly to this treatment, it is probably best to visit your sports physician for an evaluation and treatment. This way you'll avoid having your sprain be worse than a break.

Frequently for Grade 2 sprains, I'll recommend a plastic splint such as that made by Air Cast - Air Splint. This holds the ankle quiet as it heals and prevents most inversion and eversion. On occasion crutch walking for a few days (or longer) is needed. The first exercise I recommend after the ankle is starting to feel better is dorsiflexion - plantarflexion or just plain moving the ankle up and down. After more improvement small circles, painting the alphabet with your toes and other exercises can be done. Later still a theraband or other elastic band can be used to strengthen the muscles that help hold the ankle stable. Beam balance exercises and figure 8 running are also possible exercises later in recovery.

I recommend avoiding forcing your ankle to move in pain too soon. I also recommend avoiding weight bearing or walking in pain early in the course of an ankle sprain. There is no reason to start testing your ankle until it has had time to heal. Slow and easy gets more gain than rushing into painful exercises.

Rehab Regimen Mild to Moderate Ankle Sprains:

First Week:

  • Dorsiflexion-Plantar Flexion Range Of Motion Exercises
  • Night Splint To Keep Foot Dorsiflexed
  • Encourage guarded weight bearing with protection (brace or pneumatic walker)

Second Week:

Immediate Care through First Week:

RICE
Dorsiflexion - Plantar Flesion Exercises
Night Splint
Second Week:
Inversion - Eversion Exercises
Night Splint
Rocker (square or circular 20"): Front -Back
Third Week:
Same as week 2 +
Rocker (square or circular 20"): Side - Side
Fourth Week:
Same as week 3 +
Rocker (square or circular 20"): Circular Clockwise
Fifth Week:
Same as week 4 +
Rocker (square or circular 20"): One Foot. Front-Back
  • Continue Dorsiflexion-Plantar Flexion ROM Exercises
  • Night Splint
  • Inversion-Eversion Exercises
  • Square Rocker or 20" Circular Rocker: Anterior Posterior Exercises for proprioception
  • Theraband Strengthening Exercises

Third Week:

Continue: DF-PF Exercises and Inversion-Eversion

Circular Rocker: Anterior-Posterior and Side To Side Rocking

Theraband Strenghtening Exercises for peroneal muscles

Fourth Week+:

For optimal proprioceptive and strenght training, continue using the theraband for 6 weeks and the rocker 8 - 12 weeks. The rocker should be used for circular balance exercises in addition to front-back and side to side. It may also be used for unilateral balancing and motion such as front back.These exercises are additive. Add one more exercise to the rocker to those you have been doing:

  1. Front - Back
  2. Side to Side
  3. Circular Clockwise
  4. Circular Counterclockwise
  5. Balance 1 Foot
  6. Front - Back 1 Foot

Return To Activity:

When you can walk down the steps without any pain or hop on your foot as high as you can 4 times without pain, you are likely ready to resume your sports activity. A recent study correlated a test within the first few days of injury of hopping down 18 steps with an early return to running. If you can do that without pain ( or tripping and breaking your skull) you probably are not hurt badly and will return to running soon. I do NOT recommend trying that test. It is mentioned as what some researchers may attempt to study in looking for a statistically valid result.

Delayed Return To Activity:

In the event of prolonged pain and swelling and the inability to perform the "jump test" comfortably or a rapid stair descent, it will be important to futher evaluate the ankle for problems not initially detected. This includes osteochondral fracture of the dome of the talus (bone and cartilage chip). X-rays are often negative (nothing abnormal is seen) and further evaluation with an MRI or other diagnostic modality is indicated. Other diagnostic tests that may be used include CT scan and bone scan.

References:

 

Pribut, SM. Quick and Easy Look at Ankle Injuries 2012 Slideshare Presentation

Bachmann, L et. al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review BMJ 2003;326:417

Leddy JJ, Smolinski RJ, Lawrence J, et al. Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center: with a modification to increase specificity for identifying malleolar fractures. Am J Sports Med 1998;26(2):158-65

Stiell, I. et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. BMJ 1995;311:594-597

Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries: refinement and prospective validation. JAMA 1993;269(9):1127-32