But if an ankle sprain causes more than slight pain and swelling, it's important to see a clinician. Without proper treatment and rehabilitation, a severely injured ankle may not heal well and could lose its range of motion and stability, resulting in recurrent sprains and more downtime in the future.
The most common type of ankle sprain is an inversion injury, or lateral ankle sprain. The foot rolls inward, damaging the ligaments of the outer ankle — the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament. Ligaments are bands of fibrous tissue that connect bone to bone; see illustration. Less common are sprains affecting the ligaments of the inner ankle medial ankle sprains and syndesmotic sprains, which injure the tibiofibular ligaments — the ligaments that join the two leg bones the tibia and the fibula just above the ankle.
Syndesmotic sprains, which occur most often in contact sports, are especially likely to cause chronic ankle instability and subsequent sprains. The severity of an ankle sprain depends on how much damage it does and how unstable the joint becomes as a result. The more severe the sprain, the longer the recovery see "Grades of ankle sprain severity".
Mild pain, swelling, and tenderness. Usually no bruising. No joint instability. No difficulty bearing weight. Moderate pain, swelling, and tenderness. Possible bruising. Mild to moderate joint instability. Some loss of range of motion and function. Pain with weight bearing and walking. Severe pain, swelling, tenderness, and bruising.
Considerable instability, loss of function and range of motion. Unable to bear weight or walk. The first goal is to decrease pain and swelling and protect the ligaments from further injury. This usually means adopting the classic RICE regimen — rest, ice, compression, and elevation. If you have severe pain and swelling, rest your ankle as much as possible for the first 24—48 hours. During that time, immerse your foot and ankle in cold water, or apply an ice pack be sure to cover the ankle with a towel to protect the skin for 15—20 minutes three times a day, or until the swelling starts to subside.
To reduce swelling, compress the ankle with an elasticized wrap, such as an ACE bandage or elastic ankle sleeve. When seated, elevate your ankle as high as you comfortably can — to the height of your hip, if possible. In the first 24 hours, avoid anything that might increase swelling, such as hot showers, hot packs, or heat rubs. Unless your symptoms are mild or improving soon after the injury, contact your clinician. He or she may want to see you immediately if your pain and swelling are severe, or if the ankle feels numb or won't bear weight.
He or she will examine the ankle and foot and may manipulate them in various ways to determine the type of sprain and the extent of injury. This examination may be delayed for a few days until swelling and pain improve; in the meantime, continue with the RICE regimen.
X-rays aren't routinely used to evaluate ankle injuries. Ligament problems are the source of most ankle pain, and ligaments don't show up on regular x-rays. To screen for fracture, clinicians use a set of rules — called the Ottawa ankle rules, after the Canadian team that developed them — to identify areas of the foot where pain, tenderness, and inability to bear weight suggest a fracture.
To recover from an ankle sprain fully, you'll need to restore the normal range of motion to your ankle joint and strengthen its ligaments and supporting muscles. Studies have shown that people return to their normal activities sooner when their treatment emphasizes restoring ankle function — often with the aid of splints, braces, taping, or elastic bandages — rather than immobilization such as use of a plaster cast.
Called functional treatment, this strategy usually involves three phases: the RICE regimen in the first 24 hours to reduce pain, swelling, and risk of further injury; range-of-motion and ankle strengthening exercises within 48—72 hours; and training to improve endurance and balance once recovery is well under way. Generally, you can begin range-of-motion and stretching exercises within the first 48 hours and should continue until you're as free of pain as you were before your sprain.
Start to exercise seated on a chair or on the floor. As your sprained ankle improves, you can progress to standing exercises. If your symptoms aren't better in two to four weeks, you may need to see a physical therapist or other specialist. Rest the heel of the injured foot on the floor. That's those good marrow elements that have a lot of stem cells and multi-potential healing cells that can form some scar cartilage over this whole area so that at least that joint has a better gliding surface.
That seems to help very well in most patients. Scenario 3 , a year-old female with multiple prior ankle sprains. Her last sprain was about eight months ago. She has persistent pain and swelling, doesn't trust her ankle. She avoids sports.
She has several episodes of giving way over the past six months. You examine her in the office, and this is just the textbook image that we saw earlier. Again, you see this sort of dimple sign. There's clear anterior instability. A patient who continues to be unstable at this stage, with giving-way episodes, they will often benefit at first from a course of physical therapy if they haven't had that already.
That's really to focus on proprioception and strengthening of the surrounding musculature to see if that can be adequately Sorry, to see if that can adequately restore their sense of stability and allow them to return to activity. These patients often need bracing for more strenuous sporting activity to give them the sense of stability that they need.
If those things fail, then surgery to repair the ligament is often very helpful. This is a diagram of the classic Brostrom-type repair. This is the fibula right here. This is the calcaneofibular ligament, which has been cut and shortened and repaired. You don't always actually have to repair this. The most important part is repairing what's called the anterior talofibular ligament.
That ligament is actually underneath here. This is the extensor retinaculum, which holds down the tendons on the front of the ankle.
We incorporate that into the repair for some additional stability. Underneath that is the ligament repair. That's very successful surgery. People do very well with that and they're able to return to most sporting activities, but it does take about six months before they can go back to real strenuous activity.
Scenario 4 is an year-old football player who twisted his ankle on the turf about a month ago. They did rest, ice, compression, elevation, and told him he'd be better in a couple weeks because it didn't look like that bad a sprain but he continues to have significant pain, pointing to the anterolateral aspect of the ankle.
The pain travels up the leg from that point. X-rays are negative, but an MRI shows this fluid right here in the recess of the syndesmosis. This, as we talked about earlier, is a syndesmotic injury, or your classic high ankle sprain. This is the injury to the syndesmotic ligaments that connect the fibula to the tibia, and so, when the ankle externally rotates, that's what puts stress on these ligaments.
You can diagnose this with what's called a squeeze test where you squeeze the fibula against the tibia proximally in the leg, just below the knee. That should recreate pain at the ankle. People often complain of pain over the tibia where you put your hand or your thumb. That's not a positive test. It has to be pain that they feel down in the ankle. The X-rays will be negative unless there's severe ligament disruption and instability.
That's a different sort of injury. These take a long time to heal. They need a good bit of bracing for a while and rehab, and mostly time, but they will almost always settle down.
Scenario 5 is a year-old female. She sprained her ankle about nine months ago. She got better for a while but has pain in the anterolateral ankle. No instability. She did some therapy, which didn't help, but she did get a cortisone injection in the ankle and that seemed to give her excellent relief for a period of time.
This scenario, this is really a diagnosis of exclusion until you get to this point. This is an arthroscopic image of the ankle. Patients can develop what's called an anterolateral impingement lesion.
What that is is essentially hypertrophic scarring of the lateral ankle ligaments or the capsule. That creates, essentially, an impingement lesion where, when the ankle dorsiflexes and comes up, this excess tissue that you see here in the ankle. Here is the talus and up here is the tibia.
When these two bones come together during activities, or even just walking, it pinches all this tissue here and causes pain. These patients respond very well to excision of this tissue, but oftentimes they'll get better with time or with a local cortisone injection.
MRIs are not very helpful. They often don't show this lesion. We're looking at some research to see if ultrasound may be more helpful in finding these lesions, but sometimes it's simply a diagnosis of exclusion. You've ruled out all the other things, their pain is appropriate and clinically appropriate to this sort of diagnosis, and you offer them an arthroscopy. That will often solve the issue for them.
Scenario 6 is a year-old female. She turned her ankle stepping off a curb about six weeks ago. They placed her in an air stirrup in the ED but that didn't really help. Her bruising and swelling has resolved but she continues to have a lot of pain over the lateral foot and ankle. Here are her X-rays.
What you'll notice here is some abnormality at the base of the fifth metatarsal. The point here is you always need to check the foot when people have an ankle sprain and turn it because you can sometimes end up with a fracture of the fifth metatarsal.
This is indeed a Jones fracture, and it is an area of the bone that sometimes doesn't heal very well, my point being here is that you just need to make sure you examine this as a possible source of their injury.
Treatment is often casting or a CAM boot. Most avulsion-type fractures will heal very readily. The Jones fracture, like we see in this image here, often gives us trouble healing, and so, especially in athletic patients, we'll consider putting a screw down the pike here to get this to heal more quickly.
Here is an example of that where you see the screw crossing the fracture line. The bone has better access to blood, whereas unfortunately, ligaments do not. Most ankle injuries—roughly 80 percent of cases—require no surgical intervention. Foot and ankle surgeons will always choose the most conservative treatment for the best long-term outcomes for a patient.
If just the outer ligament is injured, we can typically reduce pain and swelling with a combination of ice, wraps and rest to lessen the chance of further tearing the ligament. The other 20 percent of patients might have initially neglected their injury, and because they did not seek immediate care, what began as a grade one, may have turned into a more severe grade two or three injury, possibly requiring surgery.
Sprains not adequately rehabilitated, untreated or repeat injuries can cause chronic ankle instability—a condition marked by persistent discomfort and a giving way of the ankle from stretched or torn ligaments. Proper rehabilitation and treatment are needed to strengthen the muscles around the ankle and retrain the tissues within the ankle that affect balance to help prevent further sprains or injuries.
Surgery is sometimes also needed depending on the degree of instability or the lack of response to nonsurgical approaches.
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