Ankle Sprains

Ankle Sprains treatment and information

The ankle, unlike the common mistake made, isn’t a joint, but an anatomical region including 4 joints: the talocrural joint, the subtalar joint and the tibiofibular joints (inferior and superior – which is located in the knee). The bones forming the ankle are the tibia and fibula, ending with both malleoli (bony protuberances on each side of the ankle), articulating with the talus sitting on top of the calcaneus (which is the bone forming the heel).

The ankle is a key weight bearing joint in the gait mechanism, allowing the push off, initiating the movement of walking. The movements allowed by the ankle are the plantar and dorsiflexion, which are made in the sagittal plane, as well as the more complex inversion and eversion made in the frontal plane.

The two main groups of muscles attaching around the ankle are the “shin” anteriorly (mainly the tibialis anterior and posterior) and the calves posteriorly (gastrocnemius, soleus and plantaris).

In the case of an ankle sprain, depending on the mechanism of the injury and the degree of sprain, the symptoms can vary. The patient usually describes feeling pain in the ankle, which can frequently be associated with swelling of the area. In the case of an inversion ankle sprain (where the movement of inversion is forced, stressing the outside aspect of the ankle), there is a risk of ligaments strain or sometimes tear in the worst scenarios. This can lead to a visible bruising of the outside aspect of the ankle.

In the case of an eversion ankle sprain (in this scenario the inside aspect of the ankle is stressed), a risk of fracture is higher than in the other type of sprain. This is because of the forced contact between the foot and the lateral malleolus. The fracture can be present on the low aspect of the fibula, close to the ankle, or higher closer to the head of the fibula and therefore the knee. In the case of a fracture, bruising isn’t always visible, but pain will be intense when standing (weight bearing) on the injured foot, sometimes described as sickening.

This type of injury is commonly traumatic, on one brutal movement when applying weight bearing on one limb. It can be caused in the motion of a brutal change of direction, in the case of an awkward landing on one foot. An Ankle Sprain is also greatly predisposed by poor shoewear that does not support the stability of the foot, as well as an uneven ground which can stress the foot and ankle. A dedicated section of your training for warming up and dynamically “activating” the muscles of your legs will help reduce the chances of an Ankle Sprain from occurring.

There are signs and symptoms which can be helpful when suspecting an ankle sprain as stated previously. However, a valid verified medical diagnosis, determining the level of sprain, including the grade, can only be diagnosed using an ultrasound scan, an MRI, or even an X-Ray in case of the suspicion of a fracture.

Sprained ankles can be categorised into 3 graded levels:

• Grade I: the sprain is mild, there is an overstretch of the ligaments, maybe some swelling, but you are able to weight bear on the affected ankle.
• Grade II: the ligaments have been overstretched, but there may also be a partial tear, associated with swelling, bruising and pain around the ankle. Weight bearing on the affected ankle is made difficult.
• Grade III: in this situation, the sprain is severe and leads to a full tear of the ligament(s). The swelling, bruising and pain around the ankle are exacerbated. Weight bearing on the affected ankle is almost impossible without intense pain.

In the case of a mild sprain, the injury can be self managed.
In the case of a moderate to severe ankle sprain, where the pain is too intense or doesn’t seem to improve over a few weeks, it is recommended to consult your GP or a physical therapist in order to get a specific examination, which may eventually lead to a referral to your local hospital.

There are different ways and steps in the approach of an ankle sprain rehabilitation on the way to an optimal recovery.

At first, rapidly after the initial onset of the injury you are recommended to self manage it following R.I.C.E. protocol, standing for:

• Rest: no physical activity, weight bearing the ankle or putting it in discomfort or pain.
• Ice: the use of ice will help limit the swelling, and is also efficient in pain management. It is recommended to use ice applied on the ankle for periods of 10-15 mins at a time only, 2-3 times a day.
• Compression: again, similar to the ice, the compression will limit the effusion leading to the swelling, which can be associated with icing by compressing an ice pack with a bandage around the affected ankle.
• Elevation: elevating your ankle, especially at night will help with reducing any ankle swelling thanks to the effect of gravity. This will help drain the excess fluid produced during the injury mechanism.

Whether the pain eventually dissipates after a few weeks or not, it is recommended to consult a physical therapist such as an Osteopath or Physiotherapist, as this will help increase the chances of an optimal recovery. During your session the physical therapist will: evaluate ankle stability and overall strength of the area, assess the peripheral joints (such as the knee or the hip) and the eventual compensations that occurred during the healing process. This will be key to minimise the risks of an injury relapse and help the patient return to an improved physical state compared to before the initial injury.

Usually, for a mild ankle sprain, after 2 weeks the symptoms would have dissipated and a return to normal activity can be planned progressively. In the case of a more severe form of ankle sprain, with a partial or full tear of ligaments, the recovery can take up to a few months, sometimes requiring a repairing surgery.

In this latter scenario, a thorough and specific rehab program will need to be put in place to help strengthen the ankle and improve the overall balance, in order to minimise the existing risks of relapse and aggravation of the injury in the first four to six weeks of the return to activity.

Because Ankle Sprains are usually the result of a traumatic injury, it is difficult to properly prevent them. The main element in reducing the risk of an Ankle Sprain injury is to increase the stability and proprioception (balance qualities) of the ankle joint (refer to exercises listed in the rehab below).

Prior to any physical activity, a good thorough warm up aiming to activate and mobilise the feet, ankles, legs and thighs is necessary to significantly reduce the risks of a weight bearing ankle sprain. Running on an even and stable surface will also put the individual in the best conditions possible to avoid any ankle injury.

The aim of any exercise to rehab an Ankle Sprain is to reinforce the ankle stability, mobility and strength. Here is a non exhaustive list of 3 exercises designed to hit these 3 targets.

• Wobble board stability. A basic exercise consisting of standing, one leg at a time, on a wobble board (can easily be found online or in sports shops), with a mild knee bend (in order to unlock the knee joint and make the muscles work more efficiently). Be sure to find your stability, resisting the collapsing of the ankle inwards, or the body weight shift towards the outside. Can be done every 2 days, aiming to work on each leg for approximately 10 mins in total.
• Elastic band resistance ankle mobilisation. With an elastic band wrapped around a pole or a stable immobile object, attach the other end of the band on your midfoot. Against the resistance and traction generated by the band, pull your foot towards the outside (pronation movement), towards the inside (supination movement), towards yourself (dorsiflexion movement) and push it away from you (plantar flexion movement). The aim is to initiate the movement against the elastic resistance, and control the return to a neutral position, keeping the muscles active at all times. Repeat each direction 10 times for a total of 3 sets.
• Isometrics loaded calf raise. This exercise is designed to strengthen the calf muscles, which with their insertion at the back of the ankle via the Achilles tendon will play a key role in the ankle strength and stability. For this simple exercise, stand on both feet tiptoed. Take one foot off the ground contact, shifting your body weight onto one leg. To help find your stability, you can assist yourself by lightly placing a hand against an immobile and stable object. To increase the load of the muscles and the tendon, hold a weight in your hand, to be determined by your level of strength and comfort/stability in doing the exercise. Hold the position for 10 seconds, repeat 3 times, for 3 sets (on each set the weight can be increased to challenge the ankle).

*It is advised to get the OK from your GP, osteopath or physiotherapist before carrying out any of these exercises.