If you're like me, at some point in life you have likely had the unpleasant experience of rolling and spraining your ankle. Maybe you were on the golf course day-dreaming about that beautiful bomb of a drive you just hit when you step into a depression in the fairway; maybe you were passing an opponent on the track or in a road race and you miscalculated your step; or maybe you were playing basketball and landed on an opponent's foot. No mater what the mechanism of injury, sprained ankles are frustrating and annoying.
Given the fact that this is a common injury in active people, and that 20-40% of people who sustain ankle sprains experience long-term ankle instability, it is extremely important to get your ankle sprain treated completely with the guidance of a trained professional.
The ankle complex is composed of three joints:
the talocrural joint: formed by the tibia (shin bone) and talus. This is the primary joint of the ankle and allows for the foot to move up and down (dorsiflexion and plantarflexion, respectively)
the subalar joint: formed by the talus and calcaneus (heel bone). This allows the foot to twist in and out (inversion and eversion), which is key for balance and stability on unstable surfaces.
the distal tibiofibular joint: formed by the tibia and fibula (outer bone of your ankle). This joint expands just a little bit and allows for force absorption on landing.
The ligaments around the ankle provide passive stability, think of them as cables with a little bit of stretch that help limit motion. Ligaments run from bone to bone and we don't have to think about "turning them on" like muscles. Our ligaments have lots of nerves and joint position receptors to automatically tell our brain about the position of the foot and ankle. These nerves and receptors can be extremely painful. They also are not accurate after an ankle sprain because of swelling and ligament stretching (or laxity). Ligaments have poor blood supply, thus poor potential for healing, making rehabilitation all the more important.
The lateral ligaments (on the outside of the ankle) are more commonly injured than the medial ligaments (on the inside of the ankle) due to the mechanism of landing on the outside of the foot and rolling the foot and ankle inwards. While the lateral ligaments are commonly injured, typically people also experience pain at the inside of the ankle or foot due to the bones approximating when the foot rolls inward. This pain is typically related to a bone bruise.
Predisposing Factors to an Ankle Sprain
A number of factors can be present that increase the risk of someone sustaining an ankle fracture, including:
A past history of ankle sprains – due to prior ligament laxity and instability – typically this is clinically accepted as a risk factor, however not well proven in the literature.
Poor running technique
Inappropriate footwear selection
Tight or weak calf muscle strength
Poor ankle balance and proprioception
Poor hip stability
Change in training surface or playing surface
External factors – such as the playing surface, running track quality or type of sport being played
What are the Signs and Symptoms of an Ankle Sprain?
Tenderness over the lateral ligaments on palpation.
Loss of ankle range of pain-free motion
Loss of end feel on specific ankle laxity testing
Inability to walk and weight-bear
Pain and swelling – usually worse at the end of the day
Poor standing balance and stability
Pain with running, kicking, calf raise and jumping activities
Should I get an X-Ray?
The Ottawa Ankle rules are a set of guidelines developed to help decide whether an x-ray is necessary. These include:
tenderness with touching the medial or lateral malleolus (the bony bumps on the inside and outside of the ankle)
an inability to weight bear immediately and over 4 steps
How can a Physical Therapist Help with an Ankle Sprain?
The main goals of physiotherapy in the acute rehab phase of a lateral ankle sprain are to:
Minimise swelling accumulation at the ankle injury site
Support the ankle via taping or utilise crutches to de-load the injury ankle ligaments
Maintain maximal range of pain-free range of ankle motion
Avoid further injury and irritation of sprained ankle ligaments
Stimulate the ligament healing processes
What Should I do About My Ankle Sprain?
Traditionally, a PT would manage an ankle sprain with RICE: rest, ice, compression, and elevation. The newest research shows that the best practice is PEACE & LOVE.
Protection - avoid activities and movements that increase pain for the first few days after injury
Elevate - elevate the limb higher than the heart as often as possible
Avoid anti-inflammatories - avoid anti-inflammatories such as ibuprofen as they can impair healing. Also avoid ice except for brief bouts (10 minutes) once or twice a day for pain.
Compression - use elastic bandage and taping to reduce swelling
Education - avoid unnecessary treatments such as MRI, injections, or splinting (except for severe injuries). let nature do it's job
Load - let pain guide your return to normal activities. Your body will tell you when it is safe to increase load.
Optimism - condition your brain for optimal recovery by being confident and positive
Vascularization - choose pain-free, low impact cardiovascular exercise to increase blood flow to healing tissues
Exercise - restore mobility, strength, and proprioception (stability and balance) through an active approach and graded exercises
What Should I Not Do with an Ankle Sprain?
Avoid heat over the injured, swollen area - heat will attract fluid and slow down recovery
Limit your alcohol consumption - this encourages fluid retention and leads to more swelling
Avoid too much weight bearing early on - rest is important. Limit long duration walks, jumping, or other high impact activities
When Should I Start with Physical Therapy?
Generally, your rehab starts immediately by following the PEACE & LOVE principles above. Typically the better you take care of your ankle in the early stages, the better and faster your rehabilitation process will be! Call your PT as soon as possible to receive a specific, individualized treatment plan to assist you in a full recovery.
Stay Tuned for Part 2 of this blog series in which we discuss best practice exercises and stretches!
Beynnon, B. D., Murphy, D. F., & Alosa, D. M. (2002). Predictive Factors for Lateral Ankle Sprains: A Literature Review. Journal of Athletic Training, 37(4), 376–380. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164368/
Dubois, B., & Esculier, J.-F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine, 54(2), 72–73. https://doi.org/10.1136/bjsports-2019-101253
Weindel, S., Schmidt, R., Rammelt, S., Claes, L., Campe, A. v., & Rein, S. (2010). Subtalar instability: a biomechanical cadaver study. Archives of Orthopaedic and Trauma Surgery, 130(3), 313–319. https://doi.org/10.1007/s00402-008-0743-2