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Introduction

You hear a ‘snap’, ‘crackle’ or ‘pop’ and there’s no breakfast cereal in sight. Your ankle becomes painfully swollen and your ability to walk is slightly impaired. Ankle sprains account for 38 to 45 percent of all athletic injuries and have been linked to such activities as basketball, soccer, running, skiing, and ballet [1-5]. Falls from a height or missteps from stairs or curbs are also common mechanisms for this type of injury. Studies estimate that the incidence of ankle sprains is as high as 1 per 10,000 persons per day [4,6,7].

Sprain or Strain: Is there a difference?

Simply put, sprains refer to injuries of ligaments-an ankle sprain implies damage had occurred to one or more of the ligaments surrounding the ankle joint. Sprained ligaments can be stretched, partially torn, or completely torn. Strains, on the other hand, refer to injuries of muscles and/or tendons. Can the two occur simultaneously? Certainly. Ankle injuries are notoriously complex and can present with sprains, strains, and always pains.

Ankle Joint Anatomy

The ankle joint is composed of two bones from the lower leg (tibia and fibula) and one bone from the foot (talus) (figure 1 shown below). The stability of the ankle joint when standing is provided by the alignment of these bones [8]. These bones are held together by ligaments on either side. These ligaments provide further stability by resisting abnormal movements of the ankle joint—particularly when the foot is not firmly planted on the ground [9].

What causes an Ankle Sprain?

Ankle sprains occur when abnormal forces are sustained at the ankle joint. Eighty-five percent of all ankle sprains involve the lateral (outside) ankle ligaments in which the foot turns inward, rolling over on its outer edge [10]. This is known as an inversion injury. The opposing eversion injury is less likely due to inherent stability by the skeletal structure of the foot and the more robust deltoid ligaments.

Injury to the lateral ankle ligaments tends to occur in a step-wise fashion starting in front of the ankle with the anterior talofibular ligament, which is most prone to injury. This is followed by injury to both the anterior talofibular and calcaneofibular ligaments, and finally involvement of all three lateral ankle ligaments. As the severity of injury progresses, there is a tendency for more instability and inability to bear weight on the affected limb.

It is important to emphasize that not all injuries to the ankle are isolated to its ligaments. Ligamentous injuries are often accompanied by damage to other structures, such as bone, muscle, and/or tendon. For this reason, Fallat et. al. proposed the term “Sprained Ankle Syndrome” to more accurately reflect of the complexity surrounding this type of injury [11].

Signs and Symptoms of Ankle Sprains

Patients with a lateral ankle sprain may recall hearing a “popping” noise at the time of injury. A tearing sensation accompanied by a sound similar to that of crunching celery is also commonly described. Egg-shaped swelling and bruising along the outside of the ankle and foot are common, along with guarding (protecting) of the injured part. Pain is an almost certainty. Mild injuries, those commonly associated with incomplete sprains (incomplete tears within the ligament) or single ligament injury, may still allow for weight bearing on the affected limb—albeit with a significant limp. More severe injuries, those with multiple ligament involvement or complete ligament rupture, are associated with increased instability that may preclude weight bearing on the affected extremity.

Diagnosis and Classification

Injuries to the ankle joint often display specific characteristics on x-ray that your doctor can use to determine the extent of injury. Images of both ankles may be taken for comparison. First and foremost, an x-ray of the ankle can determine presence of fracture. Second, by placing the foot in specific positions and measuring the space and angles between bones on x-ray, the doctor can assess which ligaments are likely involved.

Classification systems provide doctors and patients with an understanding of the severity of an injury. Leach’s classification of ankle sprains (first described back in 1979) is based on the appearance and amount of ankle joint function retained [12]. A grade I injury presents with minimal loss of function, local tenderness and mild swelling. Grade II injuries are characterized by the patient experiencing difficulty with weight bearing, moderate swelling and diffuse tenderness. Grade III injuries represent the most severe form of ankle sprain and include significant functional disability with minimal ability to bear weight accompanied by severe swelling, bruising and tenderness. As the degree of injury increases, the time to rehabilitate from the injury also tends to increase.

Treatment Options for Ankle Sprains

Treatment plans for the sprained ankle are doctor and patient dependant. The spectrum ranges from immobilization with cast or splint to surgical repair of the damaged ligaments. Studies have shown 75 to 100 percent good to excellent outcomes with both non-surgical and surgical treatment plans [13]. Surgical treatment of acute ankle sprains is normally reserved for those sprains that also involve a fracture or in cases of competitive athletes. By following proper treatment, most ankle sprains heal within two to six weeks, but may take longer depending on injury severity and patient compliance.

RICE Therapy: No, Uncle Ben’s will not relieve your ankle pain. RICE is an acronym for rest, ice, compression and elevation—the initial steps in treating most traumatic injuries. Swelling is the body’s way of forcing you to rest and avoid further injury. This may require the use of crutches or a walker to assist during ambulation. Gradual increases in activity level should be directed by your physician to reduce the risk of re-injury and setbacks. Unfortunately, the edema (swelling) that forces you to rest can also cause pain due to stretching of nerves and irritation of surrounding muscles and tendons. Applying ice in 15 to 20 minute intervals several times a day to the injured ankle is a good way to reduce swelling and control pain. A bag of frozen vegetables does a fantastic job of conforming to the joint. Application of ice to skin for longer than 20 minutes at a time can result in injury, so caution is advised. Compression therapy, consisting of elastic wraps, air casts, splints or soft casts, assists in the reduction of edema and protects the ankle from movement that may result in re-injury. Elevating the injured part is important to avoid increased edema in the ankle due to pooling of blood as a result of gravity. Keeping the ankle elevated on 2-3 pillows, ideally above heart level, will decrease swelling and pain of your injury.

Anti-Inflammatory Medication: The use of non-steroidal anti-inflammatory drugs (NSAIDs) in over-the-counter or prescription strengths can provide pain relief and reduce swelling around the ankle. These medications may not be appropriate for all patients—a thorough history should be performed by your foot and ankle specialist to ensure the safe use of these medications.

Ankle Support: Patients will likely require a form of ankle brace to provide support and stabilization to prevent abnormal motions responsible for injury. Bracing may include air splints, lace-up ankle braces, elastic wraps, taping or removable cast boots.

Crutches: Although less severe injuries may permit a patient to walk unassisted, it is not recommended practice. Because ankle injuries are such insidious creatures, it is ‘best to rest’ the ankle as much as possible within the first days following the injury. Depending on your physical conditioning, other modalities may be considered (i.e., wheelchair or walker).

Physical Therapy: Mobilization of the ankle should be performed as soon as tolerated to avoid long-term stiffness and swelling of the joint [13-15]. A physical therapy program consisting of range of motion exercises, stretching, and muscle strengthening can be implemented for this purpose.

Another component of this rehabilitation process includes retraining the ankle joint to protect against abnormal movements. Proprioception is the body’s ability to sense movement and position of body parts. Nerve endings in the ankle joint and the muscles that surround the joint may be injured during an ankle sprain. Retraining these nerve endings facilitates the return to normal activity and the body’s ability to protect itself against abnormal motion. This is accomplished by using physical therapy devices such as a wobble board to retrain the ankle for uneven surfaces.

Shoegear: Shoes worn after ankle injury should have greater support around the heel and may extend above the ankle joint to provide additional stability. Trained personnel at your local athletic store can direct you to the shoes that would best support your vulnerable ankle.

Long-Term (Chronic) Pain

Although most patients respond well to initial treatment, long-term complications can arise. In fact, 20 to 40 percent of patients who suffer an ankle sprain will experience chronic discomfort sufficient enough to limit activity [16]. Common complaints include persistent swelling, pain, nerve irritation and chronic instability or sprains.

Surgery: Patients who fail to respond to conservative treatment and/or suffer from chronic symptoms that limit activity may require surgery to address these problems. Decisions with regard to surgical intervention are complex and patient dependant. Surgical options that may be considered include ankle arthroscopy, direct repair of the damaged ankle ligaments, or stabilization of the ankle joint by utilizing tendons from the leg to replicate the function of the injured ankle joint ligaments. Patients should ensure that they understand the risks, benefits and convalescence required for the planned procedure prior to pursuing this treatment option. Communication between patient and doctor is critical in making an informed decision when contemplating surgical intervention.

Conclusion

Ankle sprains are the bane of many competitive athletes. Once an ankle is injured, it is more susceptible to future injuries. For this reason, seeking proper treatment the first time an ankle is injured and following a strict treatment protocol prescribed by your physician is essential. Furthermore, providing proper support to the ankle through bracing and well-constructed shoegear can greatly reduce your risk of future ankle sprains.

References

1. Glick, JM et al: The prevention and treatment of ankle injuries. Am J Sports Med, 4: 136-141, 1976.
2. Garrick, JM et al: Epidemiologic perspective. Clin Sports Med, 1: 13-18, 1982.
3. Bosien, WR et al: Residual disability following acute ankle sprains. J Bone Joint Surg, 37-A: 1237-1243, 1955.
4. Norris, SH et al: The value of mobilization and non-steroidal anti-inflammatory analgesia in the management of inversion injuries of the ankle. Br J Clin Pract, 39: 69-72, 1985.
5. Lassiter, TE et al: Injury to the lateral ligaments of the ankle. Orthop Clin North Am, 20: 629-640, 1989.
6. Brooks, SC et al: Treatment of partial tears of the lateral ligament of the ankle: A prospective trial. Br Med J, 282: 606-607, 1981.
7. Ruth, CJ et al: The surgical treatment of injuries of the fibular collateral ligament of the ankle. J Bone Joint Surg, 43-A: 229-239, 1961.
8. Stormont, DM et al: Stability of the loaded ankle: Relation between articular restraint and primary and secondary static restraints. Am J Sports Med, 22: 601-606, 1994.
9. Rasmussen, O et al: Stability of the ankle joint: Analysis of the function and traumatology of the ankle ligaments. Acta Orthop Scand Suppl, 211: 1-75, 1985.
10. McGuire, JB: ACFAOM Review Text in Podiatric Orthopedics and Primary Podiatric Medicine. Data Trace Publishing, Maryland. pp235-237, 1997.
11. Fallat, L et al: Sprained Ankle Syndrome: Review and Analysis of 639 Acute Injuries. J Foot Ankle Surg, 37(4): 280-285, 1998.
12. Leach RE: Acute ankle sprain: Treat vigorously for best results. J Musculoskeletal Med, 83: 266-269, 1979.
13. Eiff MP et al: Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med, 22: 83-88, 1994.
14. Dettori JR et al: Early Ankle Mobilization Part I: The immediate effect on acute, lateral ankle sprains (a randomized clinical trial). Milit Med, 159: 15-20, 1994.
15. Dettori JR et al: Early Ankle Mobilization Part II: A one year follow up of acute lateral ankle sprains (a randomized clinical trial). Milit Med, 159: 20-24, 1994.
16. Renstrom, PA: Persistently painful sprained ankle. J Am Acad Orthop Surg, 2(5): 270-280, 1994.

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