Sports Medicine

Ankle Sprain

Anatomy

The ankle joint connects the leg and the foot. It is formed by three separate bones, the tibia, fibula and talus. The shinbone (tibia) supports most of a person's weight when standing. The outer bone (fibula) is the smaller bone of the lower leg. A small, irregular-shaped foot bone (talus) connects the tibia and fibula. Acting as a hinge, these bones form the ankle. The ankle joint allows movement such as walking, running and jumping, and also contributes to lower limb stability.

The ankle is reinforced by fibrous tissue (ligaments) that connects bone to bone. Ligaments have an elastic structure that allows them to stretch, within their limits, and then return to their normal positions. Ligaments protect the ankle from abnormal movements—especially twisting, turning and rolling of the foot.

Description

When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers of the ligament. A sprained ankle is a very common injury that produces pain and swelling. If the sprain is a result of excess force, you may hear a "pop" sound when the injury occurs. The grade, or severity, of the sprain is determined by the amount of force that caused the injury.

• Grade 1, mild sprain—Slight stretching and some damage to the fibers (fibrils) of the ligament.
• Grade 2, moderate sprain—Partial tearing of the ligament. If the ankle is moved in certain ways during examination, abnormal looseness (laxity) of the ankle joint occurs.
• Grade 3, severe sprain—Complete tear of the ligament. If your physician pulls or pushes on the ankle joint in certain movements, gross instability occurs.

Symptoms

The amount of pain and tenderness resulting from a strain depends on the amount of stretching and tearing of the ligament. The ankle may be swollen and painful, and walking may be difficult. Instability occurs when there has been complete tearing of the ligament or a complete dislocation of the ankle joint.

Causes

A sprained ankle can happen to anyone, child or adult, athlete or not. It can occur during sports and physical fitness activities, or it can be the result of something as simple as stepping on an uneven surface or stepping down at an angle. When the foot twists, rolls or turns beyond its normal range of motion and the ligaments stretch in an extreme or abnormal position, the ankle may be sprained.

Diagnosis

If an ankle sprain is not recognized and treated with the necessary attention and care, chronic problems of pain and instability may result, so it is important to seek care right away. A broken bone or fracture can have similar symptoms of pain and swelling, so your physician may order X-rays to be sure there are no broken bones in the ankle or foot. Once a break can be ruled out, your physician may be able to diagnose the grade of the sprain based on the amount of swelling, pain and bruising. Although the ankle may be tender or painful, it may be necessary to move it in various ways during the exam to determine which ligament has been hurt or torn. After swelling and bruising subsides, an MRI (magnetic resonance imaging) scan may be needed to help ensure a correct diagnosis if your physician suspects a severe injury to the ligaments, injury to the joint surface, a small bone chip, or other problems.

Nonsurgical Treatment

Most ankle sprains need only a period of protection to heal. Swelling and pain usually last 2 to 3 days, however, the healing process takes about 4 to 6 weeks. During this time, use rest, ice, compression and elevation (R.I.C.E.) to help with pain and swelling, and you may also need to use crutches if walking causes pain.

A Grade 1 sprain is commonly treated with R.I.C.E. If your sprain is Grade 2, it make take longer for healing to occur and your physician may use a splint or other device to immobilize the ankle. Grade 3 sprains can be associated with permanent instability. Surgery is rarely needed, however a short leg cast or cast-brace may be used for 2 to 3 weeks.

• Rest—Discontinue participation in athletic activities and avoid walking on the injury.
• Ice—Combine ice with wrapping to decrease swelling, pain and dysfunction. Ice can be applied for 20 to 30 minutes, 3 or 4 times daily.
• Compression—Immobilize and support the injured ankle with ACE™-type elastic bandages or wraps, or other supportive dressings or bandages.
• Elevation—Keep your ankle raised above your heart level for 48 hours.
• Nonsteroidal anti-inflammatory medication (NSAIDs)—Drugs such as ibuprofen or naproxen may help relieve pain, inflammation and swelling. Most people are familiar with nonprescription NSAIDs such as aspirin and ibuprofin, however, whether using over-the-counter or prescription strength, they must be used carefully. Using these medications for more than one month should be reviewed with your primary care physician. If you develop acid reflux or stomach pains while taking an anti-inflammatory, be sure to talk to your doctor.

Surgery

Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for persistent instability following months of rehabilitation and nonsurgical treatment. Surgical options include:

• Arthroscopy—During this minimally invasive surgical procedure, the surgeon looks inside the joint to see if there are any loose fragments of bone or cartilage, or part of the ligament caught in the joint.
• Reconstruction—A surgeon repairs the torn ligament with stitches or sutures, or uses other ligaments and/or tendons found in the foot and around the ankle to repair the damaged ligaments.

With any surgery there are some risks, and these vary from person to person. Complications are typically minor, treatable and unlikely to affect your final outcome. Your orthopaedic surgeon will speak to you prior to surgery to explain any potential risks and complications that may be associated with your procedure.

Rehabilitation

The length of time you can expect to spend recovering after surgery will depend on the extent of injury and the amount of surgery that was required. Rehabilitation to restore strength and range of motion to a level that allows you to return to pre-injury function may take from weeks to months. If appropriate, a foot and ankle conditioning program may also be prescribed.

Prevention

The best way to prevent ankle sprains is to maintain good strength, muscle balance and flexibility, as follows:

• Warm-up before doing exercises and vigorous activities.
• Pay attention to walking, running or working surfaces.
• Wear appropriate shoes for your activity.
• Pay attention to your body's warning signs and slow down when you feel pain or fatigue.

VIDEO: Ankle Injuries with Kirk Cousins & Dr. Bruce Stewart, Holland Hospital Sports Medicine