Ankle Sprain

Ankle sprains refer to stretching or tearing of the ligaments of the ankle.  Ankle sprains may be the most common injury we see at OrthoArizona.  Ankle sprains are often classified based on the grading system from grade I to grade III. Grade I ankle sprains are associated with mild ligamentous stretch, minimal swelling and tenderness, no instability, and little loss of ankle function. Grade II sprains represent partial ligament tears, increased swelling and tenderness, and mild to moderate ankle instability. Grade III sprains signify complete rupture of the ligament with severe swelling and tenderness, loss of ankle function, and significant instability.

The majority of ankle sprains are associated with inversion injuries (rolling the ankle inward). Rolling the ankle inward can cause damage to the lateral, or outer, ligaments of the ankle. The lateral ligaments of the ankle include the Anterior talofibular ligament (ATFL), Calcaneofibular ligament (CFL), and Posterior talofibular ligament (PTFL). The most commonly injured ligament of the ankle is the ATFL as this ligament acts as the primary restraint to inversion.

Ankle sprains are prevalent in all age groups but there is an increased incidence in athletes and those participating in cutting and twisting sports. People with high arches and foot alignment abnormalities tend to also have higher predisposition to sustaining ankle sprains and lateral ankle injuries.  For example, people with high arches may wear out the outer half of their shoe first giving them a tendency to roll the ankle inward.

Symptoms are dependent upon the severity or grade of the ankle sprain. Grade I ankle sprains tend to have only mild swelling and little overall loss of function in the ankle. However Grade III ankle sprains often result in significant swelling and bruising, associated tenderness over the torn ligament, significant loss of range of motion, and significant instability.

Ankle sprains are typically diagnosed with history and physical exam looking for the signs and symptoms described above. Instability is tested for using diagnostic physical exam tests of the ankle such as the anterior drawer test and talar tilt test. These tests can reveal significant instability of the ankle joint representing damage to the associated ligament. The ATFL is the primary restraint in the anterior drawer test and the talar tilt test assesses both the ATFL and CFL.

It is important to compare the injured ankle to the normal ankle as some patients have generalized ligament laxity (are more flexible). We have found that the exam for instability can be difficult immediately after the injury secondary to pain and swelling. Additionally, it is very important to repeat this portion of the exam at every follow-up visit if we are concerned about instability.

X-rays are usually taken to rule out fracture or bony abnormalities but advanced imaging, such as MRI, is mostly reserved for symptoms that fall outside of the normal ankle sprain and to rule out other conditions.

Treatment of an ankle sprain is directed depending on the severity of the ankle sprain and the patient’s current symptoms. Grade I and II sprains are usually treated with functional treatment and rehabilitation. This treatment normally includes rest, ice, compression, and elevation (RICE) along with a short period of immobilization, which may include bracing or taping. Anti-inflammatory medication can also help to reduce inflammation and discomfort that may be associated with these injuries. Physical therapy exercises may also be initiated shortly after injury focusing on active range of motion exercises, weight bearing as tolerated, proprioceptive training, and ankle strengthening focusing on peroneal muscle strengthening which can help improve dynamic function of the ankle. The peroneal muscles are the muscles on the outside of the leg that help stabilize the ankle.  A home exercise program focusing on range of motion exercises and resistance strengthening with elastic bands can also be helpful to help regain function and strength of the ankle once symptoms have decreased.

Additionally, regaining proprioception is very important. Proprioception the brain’s ability to know where the ankle is and what it is doing without actually thinking about it. For example, most people can walk on uneven ground without thinking about it because the brain senses uneven ground and appropriate muscle response is initiated. However, this proprioception is lost after a bad ankle sprain and needs to be learned again.

Some controversy remains around treatment of Grade III ankle sprains and many physicians differ slightly in their approach to these injuries. Treatment of Grade III injuries begins with immobilization in walking boot or brace followed by functional rehabilitation program as outlined above. Occasionally a cast may be used. The key is to assess how unstable the ankle is.  We believe the goal is to immobilize the ankle until it stiffens up and the ligamentous exam improves. This is followed by rehab. Although some may argue that primary surgical repair of the torn ligament can lead to better results, many studies have been completed comparing surgical versus conservative care for acute injuries and these have shown no improvement in outcome with surgical treatment.

Some people, despite appropriate conservative treatment, may continue to have ongoing issues related to the ankle. The most common chronic complaints include giving way of the ankle, weakness, poor balance, ankle pain, and feelings of instability. In cases of chronic instability and pain, which have failed conservative treatment, bracing, and physical therapy, surgical stabilization of the ankle may be indicated.

*This information is not intended as substitute for the medical recommendations of your medical provider. Please consult your physician regarding advice about a particular medical condition as several conditions may have similar presentations.