Everyone has had an ankle sprain. In fact, approximately 30% of all sports injuries are ankle sprains and they have been described as one of the most common causes of a trip to the emergency room. This brief review describes the anatomy of ankle sprains, different types of ankle sprains, when to seek professional attention, and what one can expect in terms of return to everyday and sport activity.
ANATOMY OF ANKLE SPRAINS
Sport participation is the number one cause of ankle sprains, yet anyone can turn their ankle stepping on an acorn on the way to the mailbox. No one is immune and virtually everyone will experience an ankle sprain at some point in their life. Approximately 85% of ankle sprain occur when the foot and ankle turn inwards(inversion) towards the opposite foot. The bones of the ankle, the large lower leg bone(tibia) is connected to the smaller long thin bone on the outside, termed fibula. Underneath the tibia is the talus the sits above the heel bone(calcaneus). Three ligaments connect the fibula to the underlying bones. The tibia/fibula/and talus all form the ankle joint.
When an ankle is turned inwards, the ligaments are stretched. A signal is sent to the brain to reflexively contract the outside muscles (peroneals) to prevent further inversion. If the force is extremely sudden or violent, the forces may exceed the ability of the ligaments to hold the ankle bones in place or exceed the strength of the peroneals to prevent further inversion. This can result in an ankle sprain or fracture.
GRADES AND TYPES OF ANKLE SPRAINS
Sprains involve injury to ligaments which are the structures that hold bones together. Think of an uninjured ligament as made of a substance(collagen) that resembles a box of spaghetti. Everything is lined up and is unbroken. A Grade I sprain involves stretching of the fibers but no break. A Grade II sprain involves breaking of some fibers but the majority are intact. A Grade III sprain involves complete rupture of all the fibers. Grading an ankle sprain can be very helpful as it can give a ballpark idea of when one can return to sport (or work, etc).
In addition to making note of the grade of a sprain is the common terminology of a high vs low ankle sprain. The low ankle sprain is by far the most common and is an injury to the lower three ligaments and is usually caused by inversion. The high ankle sprain is an injury that involves the ligament that connects the tibia to the fibula (syndesmotic ligament). In contradistinction to the low ankle sprain, a high ankle sprain usually results from eversion (foot rotates out and away from the body) which is opposite of the low ankle sprain inversion mechanism. The high ankle sprain is a more severe injury and takes about twice as long for clinical recovery.
If you have injured your ankle, you need to assess how severe is the injury. Obviously if there is a visual deformity of the ankle, you may have sustained a dislocation or a fracture. The ankle will be EXTREMELY painful and will look deformed and you, your family, coach, or trainer will get you splinted, iced and off to the emergency room for evaluation, x-rays, and treatment. Usually, the injury is less severe. Look at where it hurts. Palpate or have someone palpate the bones of the ankle. If there is severe boney palpation tenderness, one needs emergency evaluation by a professional that includes x-ray evaluation. Usually, the tenderness will be at the front of the small outside ankle bone in the soft spot between the tibia and fibula. This is the most common ankle sprain from an inversion mechanism. If it is higher up on the ankle, it could indicate a syndesmotic or high ankle injury.
Mild to moderate pain likely indicates a Grade I or at most a Grade II ankle sprain. A complete rupture of the ankle ligaments (Grade III) will result in almost immediate and severe swelling and discoloration.
Treatment of Grade I-III sprains of both high and low ankle sprains is usually conservative and successful.
Rarely, a complete ankle Grade III rupture will result in recurrent ankle injury and potentially requires stabilization. This is only after failing conservative treatment which again is usually effective in even Grade III injuries.
If there is obvious boney deformity, severe immediate swelling, inability to walk, and severe boney tenderness, seek immediate medical attention. The majority of ankle sprains respond well to conservative care.
CONSERVATIVE CARE or PRICE REGIMENT
If the patient, parent, coach, trainer or individual self-diagnoses a “sprain” the ankle should be Protected with an ace wrap, splint, or ankle brace. Crutches or a cane (in the opposite hand of the affected foot) will decrease forces on the ankle. Rest involves cessation of weight bearing or walking. Ice should be applied over the ace wrap and not directly on the skin. One should remove the ice every 20-30 minutes to avoid damage to the skin. Compression involves an ace wrap. During an acute injury some say to keep the shoe or cleat on to prevent swelling. That is not a bad idea but the shoe can be removed for a detailed exam and then the ankle can be wrapped in an ACE bandage for compression. Lastly, Elevation involves “toes above the nose” with the ankle on several pillows. Keeping your foot on a stool IS NOT effective elevation. The injured limb must be higher than the heart.
REHABILITATION AND RETURN TO PLAY
Most ankle sprains will respond to conservative treatment. This may require professional evaluation and formal physical therapy. That said, grades I-II will usually respond to a home program of PRICE followed by progressive weight bearing activities. Walking, rising on ones’ toes, walking on their heel and “pocketbook” exercises for resistance peroneal strengthening can successfully get one back to activity. A rough clinical guideline is that Grade I sprains may take 1-2 weeks, Grade II, 2-6 and Grades III can take 6 or more weeks and sometimes even lead to advanced intervention including surgery.
In summary, ankle sprains are common. Deformity, bone (not soft tissue pain), and a complete inability to weight bear indicate need for professional evaluation to exclude a fracture, dislocation, and to develop a therapeutic plan. For minor sprains, the PRICE regimen coupled with “pocketbook exercises” can guide a safe and effective return to play or work. Any severe pain, or failure to progress indicates the need for professional evaluation to make sure the injury sustained is an ankle sprain and not something more severe that may require emergent care. For a conservative approach, after one concludes they are dealing with a sprain and nothing more, I allow my athletes to return to sport when they can stand for a minute on the effected leg with their eyes closed and hop on that ankle for 10 times.
To close, most ankle sprains will get better with PRICE, TIME, and rehabilitation (peroneal strengthening.
Hopefully this introduction to ankle sprains will help guide you in determining when to seek professional input, when you can expect to return to work or play, and what you need to help recover from this common injury.
About Dr. Mark Geppert:
Dr. Mark Geppert graduated from Harvard College before earning his medical degree. During foot and ankle fellowship training in New York, Dr. Geppert worked extensively with the New York City Ballet and the Rutgers University athletic teams.
Dr. Geppert’s orthopedic interests include all surgery of the foot and ankle, in addition to sports medicine and a broad range of general orthopedic surgery.
He has published more than a dozen articles in peer-reviewed orthopedic journals and has given presentations at national meetings. Dr. Geppert has co-authored chapters in medical textbooks on surgery of the rheumatoid foot, ankle sprains, and sports-related foot and ankle injuries.
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