Ankle sprains are one of the most common injuries of the lower extremities. They can happen to anyone, young or old, athletic or non-athletic. According to the American Academy of Orthopaedic Surgeons, approximately 25,000 sprained ankles occur each day. Missing a step while walking down stairs or taking a bad step while participating in sports are perfect examples of how a sprained ankle can occur. In sports, it is common to step on another player’s foot or in a hole on the field.
We have elastic ligaments located in our ankles that hold the ankle bones and joints in place. These ligaments also protect the ankle joint from twisting, turning, or otherwise moving abnormally. Because ligaments are elastic, they stretch within limits and return to their normal positions. When a ligament is stretched beyond its limit, a sprain occurs. If the ligaments tear, it is known as a Grade 3, or severe sprain. Sprained ankles can cause severe ankle pain, swelling, and inability to walk or stand. It is important to note that the ankle derives its strength from the tendons in the leg that cross the ankle joint and attach to the foot. That is why it is so important to strengthen the posterior tibial and peroneal leg muscles following an ankle sprain during the rehabilitation phase. Just because the patient can walk on it does not mean there is no fracture.
Types of Ankle Sprains
There are several types of ankle sprains. Here is a brief description of the most common types:
Inversion or lateral ligament ankle sprains occur when the foot is twisted inward. This affects the lateral (outside) ligaments. There are three ligaments making up the lateral ligamentous structures: the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament. The severity of the sprain depends on which ligaments are injured.
Eversion or medial ankle sprains are the opposite of inversion, and less common. They occur when the deltoid (inner) ligament is twisted outward. It is a strong ligament, and if injured it can frequently cause an avulsion fracture to the ankle.
High ankle sprains are less common, and are caused by outward twisting of the foot and ankle. These types of sprains are usually the result of a high-impact injury, and are often missed initially. The pain is felt above the ankle joint. Learn more about high ankle sprains.
Each of these sprains is graded based on damage done to the soft tissue structure/ligaments. Below is a guide to help you understand the grading scale used by podiatrists and doctors.
Sprained Ankle Grades and Symptoms
The different types of sprained ankles are graded by severity:
Grade 1: There is usually mild pain with this type of ankle sprain. The ligaments are stretched somewhat, and there may be minor tearing. There is little to no joint pain, swelling, stiffness, or difficulty walking. Impairment is considered minimal. Typical treatment consists of applying as much weight as can be tolerated, isometric exercises, and range-of-motion stretching and strengthening exercises.
Grade 2: You may experience a bit more pain, some instability in the joint, bruising, swelling, instability, stiffness, moderate to severe pain, and difficulty walking with this type of ankle sprain. Typical treatment involves immobilization with an ankle brace, and physical therapy with range-of-motion stretching and strengthening exercises.
Grade 3: This is the most severe type of ankle sprain. Symptoms include severe swelling, extensive bruising, and severe pain. The ligaments are totally ruptured, causing major instability in the joint. Typical treatment includes immobilization with a walking boot and physical therapy similar to what is done for Grade 2 sprains, but for a longer period. In some cases, surgical reconstruction is necessary.
Some people claim to hear a popping sound when the injury occurs. Your range of motion will become restricted, and pain will occur when pressure is applied to the sprain. Your doctor will determine the severity or grade of the sprained ankle according to the degree of swelling, pain, bruising, and range of motion.
Sprained Ankle Causes
Sprained ankles occur when the ligaments within the ankle are stretched beyond their capabilities, or when the foot twists inward or outward. Falling down, walking, or exercising on an uneven surface can cause your ankle to twist. The cause does not have to be sports-related. It can happen while walking down the street or while browsing in a retail store.
Diagnosing a Sprained Ankle
Your doctor will take a detailed history of your injury to find out how it happened, when it happened, whether you can walk on it, if you have injured it before, what you have done for initial treatment, how much it swelled initially, and whether you heard or felt a pop.
Your doctor will give you a physical exam and may take x-rays of your ankle to determine whether there is a fracture. Radiographic tests for children are sometimes inconclusive, due to the possibility of injury to the growth plate which, like ankle sprains, is not visible on an x-ray.
A physical examination by your doctor is essential for proper diagnosis and grading of the injured ankle. It may be painful, as the doctor will need to move the ankle and foot into various positions to determine which ligaments are injured. If your doctor feels the injury is severe, he or she may order further diagnostic tests, such as an MRI (magnetic resonance imaging) to ensure that the diagnosis is correct.
Sprained Ankle Treatment
There are generally three phases of recovery for a sprained ankle. The first phase involves rest, reducing swelling, and protecting the ankle. Generally, this takes one week. The second phase lasts one to two weeks and involves restoring range of motion, flexibility, and strength. The third phase allows the injured person to gradually resume normal activities, doing physical therapy and slower maintenance exercises at first, before gradually increasing their movements to allow the sharp, sudden turns their normal activities may demand. Depending on the severity of the sprained ankle, the third phase can last weeks or even months.
There are surgical and non-surgical treatment options available. Non-surgical treatment options include the PRICE method (Protection, Rest, Ice, Compression and Elevation). Most grade 1 sprains are treated in this manner. Grade 2 sprains are also treated with PRICE, but may take longer to heal. Your doctor may also want you to wear a splint or walking boot on the ankle to immobilize you. If you have a grade 3 sprain, you may be required to wear a leg cast or a cast-brace for two to three weeks. NSAIDS (non-steroidal anti-inflammatory drugs) can be used to control pain and swelling. Casts are usually avoided due to the possibility of “cast disease,” i.e., muscle atrophy, stiffness of the ankle (loss of range of motion), and loss of proprioception for the ankle.
In general, surgical treatment for ankle sprains are rare. Surgery is sometimes necessary if there is severe ligamentous injury or when non-surgical treatment methods fail. Your surgeon may want to perform an arthroscopy, which will allow him to look inside the joint to check for loose fragments of bone or cartilage. The surgeon will then perform any necessary procedures. If necessary, your surgeon may perform reconstructive surgery to repair torn ligaments. The repair is usually done with stitches (sutures), but your doctor may also use other ligaments or tendons already located in your foot to repair the damaged ligament.
Physical therapy may be required to strengthen leg muscles, restore balance and proprioception, and increase range of motion. Cross-training activities such as biking, swimming, and elliptical training can help restore strength and mobility to the injured ankle.
Preventing Sprained Ankles
Here are some tips to help you prevent a sprained ankle:
- Warm up before and cool down after each exercise or similar activity.
- Maintain good muscle strength and flexibility.
- Wear the proper footwear for your specific activity.
- Avoid high-heeled shoes if possible.
- Practice stability training, including balancing exercises.
- Use caution when walking, running, or working on uneven ground.
- Avoid sports and activities that you are not well conditioned for.
- Eat a proper diet and drink plenty of fluids each day.
- Pay attention to your body when it tells you it is fatigued or in pain.
- Be careful stepping off curbs!
Ankle circles are a type of exercise used to improve the range of motion of the ankle. They are performed by stretching your legs in front of you and rotating your ankle joint in a circular motion. Another exercise is the alphabet game. It’s simple—you sit in a comfortable position and draw the alphabet in the air with your toes. This exercise promotes flexibility and stretches the ankle ligaments. Theraband (surgical tubing) can be used for ankle-strengthening exercises.
Sprained Ankle Complications
A sprained ankle can complicate the healing process. You should never resume your normal activities before your doctor says you can. Never leave a sprained ankle untreated. Most importantly, always follow your doctor’s instructions throughout the healing process. It is important to gradually resume activity as it can be tolerated. You should wear an ankle brace until the ankle is strong (at least 80% of normal ankle strength). Here are some common complications that arise when these rules are not followed:
- Recurring ankle sprains
- Chronic ankle pain
- Chronic joint instability
- Arthritis in the joint
- Imbalance and muscle weakness
- Difficulty walking; dependence on a cane or other type of ambulatory device
Talking to Your Doctor
Here are some questions you may want to ask your doctor about ankle sprains:
- Considering the severity of my injury, should I avoid the activity that caused it once it is healed? If not, how likely is this injury to happen again?
- Would orthotics help to minimize ankle instability?
- Can you take a look at the various shoes I wear regularly and tell me if they are proper footwear?
- What types of shoes would help to support my ankles?
- What kinds of ankle braces are available for the activities I engage in?
- Can you teach me some of the best stretching and strengthening exercises?