Injury fact sheets: ankle sprain

Introduction

Ankle sprains are one of the most common injuries seen on the sporting field, in physio practices and in our hospitals with approximately 275 people presenting to ED each day in Australia. (1)

They are the most common athletic injury world-wide, (3,4) representing up to 56% of all injuries in some sports(2) and hugely prevalent in netball, basketball, volleyball all codes of football. (1,2)

In the US there are an estimated 2 million ankle sprains every year and high school soccer and basketball they amass USD1.1 billion in treatment costs annually. (2)

If those statistics aren’t alarming enough there is a 74% chance that if you’ve rolled your ankle it will happen again and almost 50% of people have ongoing problems with their ankle after spraining it. (2)

Now before you pull out the bubble wrap and develop a phobia of uneven ground, the great news is that if managed by a good physio from day 1 over 90% of ankle sprains heal really well and you’ll generally be back running within a couple of weeks. (4)

The bad news is that if you go down the standard ‘rest for a couple of weeks and take some anti-inflammatories’ treatment pathway that is dished out by almost all the EDs and GPs that I’ve had experience with, it could be a much more tumultuous journey for you.

Ankle anatomy 101

N.B. If you’re reading this because you’ve just got home after rolling your ankle skip straight to the treatment section and come back once you’ve got your ice-pack sorted!

Your ankle is a pretty complicated but very clever joint which is ingeniously designed to cope with the quick acceleration, twisting and navigating the different surfaces that we do every day.

The main joint is the talo-crural joint which looks like a wrench locked onto a bolt.

You can move the wrench forwards and backwards (the equivalent of pointing your foot then bringing it back up) but it locks onto the bolt when you move it side.

Underneath that joint is the subtalar joint which is shaped like someone sitting on a horse’s saddle; they can slide side to side, aka turning the foot in and out, but the forwards and backwards movement is restricted by the bony equivalent of the pummel.

The ankle moves a lot further inwards due to the shape of the bones and the three lateral (outside) ligaments being much smaller and weaker than the massively strong fan-shaped medial (inside) ligament. (1-4)

This means that if you sprain it there is an 80-90% (1,4) chance that you’ll roll it inwards and injure one or more of the lateral (outside) ligaments.

The most common ways this occurs are when your foot stays planted on the ground and your body keeps moving (pivoting whilst running), when you step off a curb or onto someone’s foot, (1-4) or the classic ‘stiletto sprain’ which we see a lot of after a long weekend (Google ‘models rolling ankles’ for a perfect demonstration).

The other 10-20% of injuries involve the ligaments in-between your shin bones (there are 2 of them!), that big fan ligament on the inside of your ankle or the bones themselves.

Like most injuries, being in this minority isn’t a good thing because these injuries are generally a lot trickier to manage and take longer to heal. (1,3,4)

Treatment

Now you’ve hopefully got a bit of an idea as to what your ankle looks like and we can get to the all-important treatment bit and get you back on your feet as soon as possible!

The key for getting the best outcome after an ankle sprain is seeing your physio (ankle sprains are our bread and butter!) as soon as you can.

I’m talking within a few hours, or the next day at the latest, because the earlier we get the chance to guide you in the right direction, the shorter the road to recovery is.

The stages and goals of the rehab process after any ankle sprain are pretty much the same regardless of the severity (1,4) and surgery should only be considered after trying 3 months of conservative (physio-based) rehab first even for really bad sprains. (1,2,4)

Stages of treatment

Stage 1: find out what we’re dealing with

If we’re concerned about a broken bone we’ve got a set of guidelines called the OTTAWA Ankle Rules which are almost 100% accurate in picking up clinically significant/important fractures and an x-ray should only be done if called for by this test, (3) rather than for every bad-ish looking sprain that presents to ED which I’ve found is the current standard practice (there are some exception s of course, and even if an x-ray is done it might miss a fracture that is more obvious 6 weeks later if another x-ray is done). (1)

Most ligament sprains will have an accompanying crack/snap/pop and this has absolutely no bearing on how bad the sprain is or the structure that is damaged. (1,3)

Instead we use pain, swelling and laxity to determine the severity of the sprain.

As a general rule – the more pain, swelling and looseness in the joint, the worse the injury.

Even mild sprains tend to have a fair bit of swelling associated with them (1) and may look really bad which is another reason to see your physio early on.

We see a lot of ankles and what might look concerning to you may not be so bad in the grand scheme of things.

Stage 2: manage pain and swelling (0-72 hours)

There is irrefutable evidence that we need to get the ankle moving as soon as possible(1-4) following a sprain but sometimes the pain and swelling gets in the way.

The usual RICE principles apply as per any early injury management (1-4) and should be followed religiously for the first 72 hours minimum, even longer if the swelling persists.

Pain killers are really important at this stage as well because they allow us to move more comfortably and put weight through the ankle sooner, which means you’ll recover quicker and provide the added convenience of being able to walk! (1,3)

I get a lot of patients reluctant to take pain killers because they’re worried they’ll do more damage because they can’t feel as much, but as long as you’re sensible and not going to be running around, you’re not going to impede your healing.

It is worth noting that anti-inflammatory drugs like ibuprofen (Nurofen) and diclofenac (Voltaren/Voltarol) should be avoided in the first few days as they can prolong the inflammatory stage (3) but paracetamol is fine!

If the ankle really is causing a lot of grief there is evidence for allowing a short period of immobilisation with either tape, a brace or a bandage(4) but the same study emphasises the importance of removing the immobilising device and moving as soon as pain and swelling allows.

Stage 3: get moving! (ongoing from day 1)

In case I haven’t made it clear enough already, the ankle needs to move as soon as possible after a sprain.

Physios often get a bad rep for being physio-terrorists but for the most part we don’t want to see you in pain (most physios I know got into the profession because we want to help people get rid of pain rather than cause it) and the exercises in the early stages should be relatively comfortable.

If not, take a couple of pain killers and try them again (I promise they won’t cause any damage!)

The key movement we want to get back ASAP is dorsiflexion (1,2) (pulling your foot up towards you) because it is the position where the joint is the most stable and is often the movement we lose first.

Things like toe and heel taps and ankle circles should be done hundreds of times a day, which sounds like a lot but if you’re sitting in an office for 8 hours a day and then watch TV for an hour or 2 at night you could get through almost 3,000 just by doing 5 minutes’ worth every hour!

If moving it yourself is too sore, your physio will able to perform some mobilisations (fancy word for us moving it for you) until it’s easier for you to do it.

Stage 4: fire up the muscles (from day 1 or 2)

The transition from general movement to strengthening should start as soon as there is semi-decent ankle mobility and manageable levels of pain. (1,2,3)

As with the previous stage, we’ve got a plethora of exercises of varying difficulty and complexity, all of which should be relatively pain free!

The focus of this stage is improving proprioception or body awareness. Sounds like it might be tricky but it’s basically all about getting you really good at balancing on the injured ankle and it is the quickest way back to sport/running/everyday life and the key strategy of preventing another sprain. (1-4)

If you have rolled your ankle previously try standing on one leg (with your eyes closed if it’s too easy) and you’ll probably notice it’s harder to do on the one you sprained.

This has been demonstrated in heaps of studies and is evident in almost everyone I’ve seen after an ankle sprain. The best thing about it though is you don’t have to go out of your way to do it!

Whenever you find yourself standing in the same place for a few minutes (waiting for the kettle to boil, peeling vegetables, talking to a colleague) simply stand on one leg instead of two!

You don’t need to go full crane pose as taught by the world famous karate master Mr. Miyagi, just subtly lift your uninjured foot off the ground a little bit so it’s a touch harder to stay balanced but not so much that your arms turn into windmills.

Balance exercises are a great way to improve your general ankle strength but we also want to focus specifically on the muscles on the outside of your shin (fibularises/peroneals). (1-3)

These little guys work hard when you turn your foot out which in turn helps stop your foot from rolling inwards, and if we get them Schwarzenegger strong they’ll help prevent your ankle moving back into a compromising position.

Ideally we do it with your toes pointed as this is the point the ankle is most at risk and the spot we want the fibularises to be at their strongest. (3)

These muscles are often sluggish to kick in after an ankle sprain and are usually weak in people who have had multiple sprains, which increases the risk of re-injury. (2)

Step 5: getting up and running (hopefully at week 2, usually by week 3-4)

This step applies to everyone regardless of whether you play sport or not because you may become an unwilling participant in a sprint for the bus, be required to perform a pirouette around a small child that emerges from a sea of legs in the shops or artfully sidestep a dog belting down the footpath towards you, and although you may not be getting scored for your execution of these moves, it is mighty inconvenient and often painful if your ankle gives way during them!

The return to sport stage will commence when your physio is happy that you’ve got sufficient movement and strength in your ankle to perform complex and challenging exercises without risking further injury (1) and will generally start in a safe environment like a rehab gym where there are plenty of things to grab onto if you do lose your balance.

Once your physio is satisfied that there is a low risk of injury (we can’t nullify it completely) they’ll let you loose on the local park to try some agility work and gradually ease you back into training if applicable.

Wearing a brace or ankle tape whilst you get back into these high level movements is highly recommended (1-3) as the beginning of this stage is the most risky part of the rehab process.

Step 6: avoid re-injury! (continue for 6-10 weeks after injury resolution)

The re-injury rates after an ankle sprain are ridiculously high (just shy of 75%) and almost 50% of people still have symptoms such as pain, instability or persistent swelling years down the track. (2)

Unfortunately once stretched to their limits, ligaments struggle to return to their former tensile glory but this deficit can be compensated for by strengthening up the muscles, which is why it is so important to start moving as early as possible and carry on with your exercises for at least 6-10 weeks after you feel like you’ve reached 100%. (3)

Wearing tape or a brace when returning to sport (not in everyday life) for 6-12 months can also help reduce the risk of re-injury. (1,3)

It works by improving your proprioception so your muscles know when to kick in rather than actually restricting the amount of movement you have.

Unfortunately there is no evidence that taping an uninjured ankle prevents injury. (1,3)

Stage 7: specialist’s opinion

If you’re one of the unlucky 10% of people that have had 3 months of physio and are still getting moderate pain, catching, giving way or not progressing as we’d expect, the next step is getting the opinion of one of our surgical colleagues.

They’ll generally do some more scans to rule out anything that was missed in the early stages (cartilage damage, sneaky fractures etc.) and if nothing comes up except for the suspected torn ligaments they may consider performing surgery to tighten the ligaments or reinforce them with a tendon. (4)

After surgery you’ll be sent back to us to go down exactly the same stages of rehab with the added benefit of knowing exactly what you’re in for!

Most surgeons follow the guidelines recommended by the huge amount of research done into the topic and advocate for a trial of physio before having surgery if you haven’t already.

The long term outcomes are similar whether you have physio or surgery, and physio is a lot cheaper and less risky than going under the knife. (1,3,4)

Surgery doesn’t work nearly as well in old ankle sprains which are still causing grief but can give some improvement up to 7 years after the initial injury, but the same principle of trialling physio still applies. (3)

Sorry, there’s just no way of escaping us!

Conclusion

Ankle sprains are one of the most common injuries going around and have a massive impact on society, sporting teams and the health system as a whole.

Despite a lot of research and clear guidelines dictating the best ways to manage them there is a lot of bad advice being given as to how long to rest for, the type of exercises to do and when to return to your normal life, but it doesn’t have to be this way!

As physios we love treating ankle sprains because if they’re managed well from day 1 we get excellent results almost across the board regardless of the severity of the injury by following a simple motto of ‘move as much as you can as soon as you can with relative comfort’.

As you get better all we have to do is make the exercises harder and more complex and within 2 weeks you’ll be feeling really optimistic and hopefully considering your return to your chosen athletic pursuit if you haven’t done so already!

References

1. Brukner, P., Khan, K. (2007) Clinical Sports Medicine 3rd Edition, Mcgraw-Hill Professional
2. Kobayashi, T., Gamada, K. (2014), Lateral Ankle Sprain and Chronic Ankle Instability. Foot and Ankle Specialist (Aug ’14), 298-326
3. D’Hooghe, P., Fulcher, M., (2018). FIFA Diploma of Sports Medicine – Ankle. Retrieved from www.fifamedicinediploma.com/courses/ankle
4. Karlsson, J., Samulesson, K. (2014). Ligaments of the Ankle Joint. APESTAR Sports Medicine Journal. 3(2). 382-287