Sprained Ankle / Ankle Sprain

What is a sprained ankle?

A sprained ankle is a very common type of ankle injury. The most common is an inversion sprain where the ankle turns inwards damaging the ligaments on the outside of the ankle. A medial ligament sprain is rare but can occur particularly with a fracture. A sprain is stretching and or tearing of ligaments. (You sprain a ligament and strain a muscle).

The most common damage done in a sprained ankle is to the talo-fibula ligament shown towards the front of the image opposite. If the sprain is worse there might also damage to the calcanao-fibula ligament which is further back towards the back of the heel. In addition to the ligament damage there may also be damage to tendons, bone and other joint tissues.

A sprained ankle is classified into three categories depending on severity:

First degree ankle sprain:

• Some stretching or perhaps tearing of the lateral ankle ligaments.
• Little or no joint instability.
• Mild pain
• Little or no swelling swelling
• Some joint stiffness or difficulty walking or running.

Second degree ankle sprain:

• Some tearing of the ligament fibres.
• Moderate instability of the joint.
• Moderate to severe pain and difficulty walking.
• Swelling and stiffness in the ankle joint.

Third degree ankle sprain:

• Total rupture of a ligament.
• Gross instability of the joint.
• Severe pain initially followed by no pain
• Severe swelling

Ankle sprain treatment

Treatment of a sprained ankle can be separated into immediate first aid and longer term rehabilitation and strengthening.

Immediate First Aid for Ankle Sprains:

Aim to reduce the swelling by DR .ICE. (Diagnosis Rest, Ice, Compression, Elevation) as soon as possible. Getting the diagnosis right from the start is important.

• D is for diagnosis. It is important to get the correct diagnosis from the start. If other factors such as an avulsion sprain (where a bone fragment is pulled away from the bone) are suspected then treatment may be different.
• R is for rest. It is important to rest the injury to reduce pain and prevent further damage. If you need crutches then use them! People with crutches get more sympathy! Many therapists advocate partial weight bearing as soon as pain will allow. This is thought to accelerate rehabilitation.
• I is for ICE or cold therapy. Applying ice and compression can ease the pain, reduce swelling, reduce bleeding (initially) and encourage blood flow (when used later).
• C is for compression - This reduces bleeding and helps reduce swelling. A Lousisana wrap bangdaging technique is excellent for providing support and compression to a recently injured ankle.
• E is for Elevation - Uses gravity to reduce bleeding and reduces swelling by allowing fluids to flow away from the site of injury. So put your feet up and get someone else to wait on you.
•  

In addition to immediate first aid the athlete can do the following:

• Protect the injured ankle by taping or an ankle support. Tape can also be used during the rehabilitation phase to protect the joint and give proprioceptive feedback to the ankle without risking further injury. When partial weight bearing an ankle support or taping method can protect the lateral ligaments (allowing them to rest) while ensuring forwards and backwards motion is allowed keeping the rest of the joint healthy.

What can a sports injury specialist do about it?

• A sports injury specialist will undertake a thorough assessment of the injury so time is not wasted treating the wrong condition.
• A doctor may prescribe anti inflammatory medication to help with pain and swelling.
• Reduce swelling by compression devices or taping techniques.
• Use ultrasound and laser treatment.
• Use cross friction massage.
• Prescribe a full ankle rehabilitation programme.

Learn more about how an ankle sprain is diagnosed

Assessment and diagnosis of the ankle sprains

The following examples are for information purposes only. We recommend seeking professional advice before attempting and rehabilitation.

Aims of assessment

• To assess the degree of instability.
• Grade of ligament damage.
• Identify any reduction in range of motion or reduced strength.
• Identify any other additional or associated injuries such as an avulsion sprain where a piece of bone at the end of a ligament has come away from the main bone itself.

It is important to understand that no single test can give a conclusive answer or diagnosis but can helps to build an overall picture of the problem in the therapists head from where they use professional judgment and experience to make a diagnosis.

The assessment

As with any sports injury the therapist will usually follow a set procedure to diagnose an injury. The following is one example:

• Read medical records if available or X-rays. Previous treatment should be taken into account when diagnosing an injury, even one as simple as an ankle sprain.
• Listening - asking a number of questions to build up a picture of what might have happened. For ecample:

• How did it happen?
• Was there any pain at the time?
• Was the pain sudden onset or gradual?
• Was there any swelling and was it sudden onset or gradual? - a sudden swelling often indicates a bleeding into the joint rather than a gradual increase in synovial fluid within the joint.
• Did you hear any noises? - this could indicate ligaments tearing or bones breaking!
• Did you apply any emergency procedures such as RICE?
• Is there anything you do which makes it worse / better?
• is this the first time you have injures the ankle in this way or is it recurrent?

• Observe the patient as they stand and when lying or sitting on a couch with the legs out in front. They will look for any abnormal position, deformity and of course swelling.

Active movements

• The patient moves the foot from plantar flexion to dorsi flexion.
• Looking for reduction in normal range of movement and any pain in performing these movements.
• Then repeat moving from eversion to inversion (image 2).

Passive movements

• The therapist moves the ankle and foot from plantar flexion to dorsi flexion and then inversion to eversion looking again at range of movement, comparing one foot with the other and and painful movements.
• The athlete remains relaxed and does not resist or actively move the foot or ankle. Any pain at the extreme range of inversion may indicate ligament damage as it is the ligament that is being stressed.
• The anterior drawer test is a special test which assesses the integrity of the ankle ligaments, particularly the anterior talo fibula ligament and the calcaneo fibula ligament.

Resisted movements

• The therapist gently resists the athlete as they try to move the ankle from inversion to eversion (image 4).
• Pain when performing this test may be an indication of tendon damage or inflammation (possibly peroneal tendons) as it is the tendons connecting muscle to bone that are stressed when performing this test.

Functional tests

• These can only be performed if pain allows. A badly injured ankle will not be capable of performing these tests.
• The lunge test involves the athlete leaning forwards over one knee keeping the heel of the front foot in contact with the ground.
• It measures dorsi flexion in comparison to the uninjured ankle.
• Other tests include one leg standing balance (eyes closed) test and hopping tests.
• Note - hopping on a recently injured ankle is definitely to be avoided but this test may be of benefit much later in the rehabilitation process.

Palpation (touching and feeling).

• Finally the therapist will touch or feel certain points of the ankle to identify any specific painful areas.
• The following are usual points to palpate: distal fibula (bottom of the fibula bone), lateral malleolus (bony bit on the outside of the ankle - peroneal tendon dislocation / inflammation), lateral ligaments (most likely to be painful), talus (bone at the top of the ankle which the tibia or shin bone sits on), peroneal tendon, base of 5th metatarsal (where the peroneus brevis attaches to) and medial ankle ligaments.

Does it need an X-Ray?

• If the sprain is severe and the athlete has trouble weight bearing an X-Ray may be beneficial in identifying possible fractures.
• However, an experienced sports medicine professional should be capable of palpating to identify if the pain is worse on the bone (lateral or medial malleolus) or on the ligament itself.

The therapist should then record any significant signs or symptoms and test results for future reference and as a record of what was found.

he following guide is intended for information purposes only. We recommend seeking professional advice before attempting any rehabilitation.

Aims of rehabilitation

The aims of rehabilitation of an ankle sprain can be broken down into separate phases:

• Decrease initial pain and swelling.
• Improve mobility and flexibility.
• Improve the strength of the joint.
• Re-establish neural control and co-ordination.
• Return to full fitness.

Phase 1 - Early

Decreasing pain and swelling

This should start as soon as possible after you have injured the ankle. This phase can last from 2 days to 2 weeks (or more) depending on how bad the injury is.

• Protection of the ankle from further injury by taping, splints or a cast or brace. Research has suggested that limited stress on the ankle can promote faster and stronger healing. By allowing the ankle to move forwards and backwards (in the sagittal plane) and not laterally, the ankle can keep moving but strain on the injured ligaments is significantly reduced.
• A useful support at this stage is the aircast gel type ankle support which prevents most sideways movement but still allows limited use of the ankle. The cold gel can also be beneficial by compressing and reducing swelling (image 2). This support is useful in the early stages but will not prevent sprains and re-injury during later stages and functional rehabilitation.
• The Louisiana wrap strapping technique using cohesive bandage can also be beneficial in applying compression and support and is quick and easy to apply.
• The Open Basketweave Taping technique also accomplishes early medial and lateral protection while allowing plantar flexion and dorsi flexion.
• Rest - this is essential. Use crutches with partial weight bearing to get about with if necessary. A healing ligament needs a certain amount of stress to heal properly but overdoing it early on in the rehabilitation process can prevent healing.
• Isometric exercises can be performed early on so long as they are not too painful. Avoid inversion and eversion though as this will stress the injured ligaments.
• Ice - use cold therapy throughout the rehabilitation process. Apply ice for 20 minutes every hour initially for the first day then reduce this to 4 to 5 times a day from then on. In the acute stage ice will constrict blood vessels and further bleeding. Longer term benefits include reduction of pain and muscle spasm.
• Ice should not be used for longer than 30 minutes at a time as nerve palsy may occur. Ice should be used for as long as it is beneficial. As soon as the rehabilitation process plateaus the therapist may decide to change to heat to progress further. However this may not be for weeks or even months sometimes.
• Compression - use a tube grip bandage or taping. Even better are products that specifically apply compression at the same time as cooling. The Open Basketweave taping technique also contributes to compression and helps to control swelling or 'edema'.
• Elevation - put you feet up and read all about your injury. Elevating the leg will help swelling run away from the site of the injury. Elevate the leg while icing and for 10 minutes after.

Phase 2 - Rehabilitation phase

The rehabilitation phase begins when swelling stops increasing and pain lessens. This means the ligaments have reached the point in the healing process where they are not in danger of being re-injured from mild stress.

Improve mobility and flexibility

• Manual joint mobilization (image 4) in the anteriorposterior direction (forwards and backwards).
• Seated wobble board exercises may be beneficial for an ankle that has reduced mobility. Initially plantar flexion / dorsi flexion and then progress to inversion / eversion as pain allows.
• For the first 2 to 7 days after injury you can start to move the ankle straight up and down but do not turn it in or out. This will help increase mobility and start to strengthen it up. Do as much as pain will allow. Try 2 sets of 40 reps whilst the ankle is iced and elevated and build up on that.
• As swelling and pain lessen you can start to invert and evert the ankle (move the soles of you feet inwards and upwards and the outwards and upwards). This will start to put more stress on the damaged structures so be careful not to do too much. See mobility exercises.
• Stretching the achilles tendon regularly is important. Having available a specific achilles stretching board (image 5) throughout the day to ensure a few minutes stretching a day.

Strengthening the ankle joint

• Again as the ankle improves you can start to do strengthening exercises where you pull the foot and toes up and hold for 10 sec's and then push down and hold for 10 sec's This can also be done for inversion and eversion as pain allows. Try 3 sets of 10 reps twice a day and build on that.
• Continue to apply cold therapy to the joint regularly - at least 3 times a day for 20 minutes.
• If you see no further improvement with ice then start to apply heat in the form of a hot bath / bucket or via a specialist with ultrasound.
• Strapping and taping may still be beneficial here.
• You should be able to maintain fitness by swimming or cycling if pain allows.

Re-establish co-ordination and proprioception

• Proprioception exercises are thought to be important in avoiding recurrent ankle sprains. Early weight bearing is thought to help reduce proprioception loss. Try balancing on one leg with your eyes closed. This will improve proprioception (the neuromuscular control you have over your muscles). This will have been damaged when you injured the ankle. Aim to be able to balance for 1 minute without wobbling.
• A wobble board is a useful piece of kit to have. It is a flat board that you stand on with a semi-spherical bottom. By balancing on this you strengthen the ankle and improve proprioception. A series of progressive wobble board exercises can be seen by clicking here.

Return to full fitness / functional training

• In order to start the functional rehabilitation phase (activity and sports specific training) it is important the athlete has full range of motion and 80 to 90% of pre-injury strength. When you can comfortably do all of the above then you are ready to start phase 3 and begin your return to activity
• Cardiovascular exercises is important and should begin the first day after injury depending on what pain will allow. It is important that the athlete maintain some kind of CV exercise not just for the physical benefits but for psychological well being as well. Stationary cycling, hand cycle ergometer, running in water and swimming are all possibilities depending on severity of injury and what pain will allow.
• Running may begin as soon as walking is pain free. It is a good idea to tape the ankle before starting running training particularly during early sessions until confidence, proprioception and strength has returned. A laced ankle brace can also provide support and is less expensive in the long run, particularly if laxity in the ligaments means a support needs to be worn permanently.
• Running should begin on a clear flat surface such as a running track. Grass or bumpy surfaces will increase the risk of re-injury. Jog the straights and walk the curves.
• Speed should be gradually increased over time to a sprint.
• Sports specific drills using cones can be introduced. Changing direction, running in a figure of 8 pattern and zig zagging between cones.

Prevention of ankle sprains

It is estimated that 30 to 40% of all ankle inversion sprains end in re-injury. To avoid being one of the 30 to 40% it is important not to stop the rehabilitation process but continue with it until full fitness is regained. It is a common complaint that once an athlete goes over on the ankle they become prone to doing the same thing again. If the original sprain is a bad one and joint laxity has resulted then it may be for certain sports where fast changes of direction are required that strapping of the ankle or wearing a brace is necessary to prevent re-injury.

If the sprain does not result in joint laxity then a recurrence may be avoided by the following:

• Re-establish proprioception. This involves lots of balancing exercises on one leg. Essential to avoid re-injury. If you start to turn the ankle over then you will find you automatically right it without even thinking about it. If the proprioception is damaged then you lose this ability.
• Strengthening the ankle. This will provide a far more stable joint. Also, if the ankle does start to turn and the proprioceptors work properly, the ankle starts to right itself, the muscles need to be strong enough to pull the ankle back in a split second.

Strapping - Louisiana Wrap

The following guidelines are for information purposes only. We recommend seeking professional advice before attempting any rehabilitation.

The aim of this strapping is to provide compression and prevent inversion sprains. This strapping can be removed and re-applied easily, which is useful during the early stages when cold therapy is required.

What is required?

• 5cm Compression bandage - cohesive bandage that sticks to itself is ideal for this strapping.

Step 1

• Position the ankle with the athlete seated and the ball of the foot resting on the therapists knee.
• Place the foot with the toes slightly pointing upwards (dorsi flexed) and foot slightly rolled inwards (pronated).
• Starting at the front of the ankle, go outwards, around the back, to the front (image 2).

Step 2

• From there, go across the front to the inside of the foot and then underneath (image 3).

Step 3

• Come up across the front, around the back (image 4) and down again to the inside of the foot again in a figure of 8.

Step 4

• This time when the bandage is passed under the foot it comes up the outside of the ankle (image 6) and around the back.
• Slight tension can be applied pulling the outside of the foot up giving support where it is needed to prevent inversion sprains.

Step 6

• The bandage then goes around the back of the ankle and across the foot to the outside of the foot and under.

Step 7

• Again, instead of going up and across the foot again the bandage goes up the inside of the ankle and around the back.
• This pattern is repeated for 2 to 3 more times or as length of bandage allows.

Step 8

• Finish off by wrapping a number of times around the ankle, working upwards.
• Be sure to allow enough bandage at the end to do this.
• Secure the end with a little non stretch tape or just tuck in the loose end.

Taping Technique 2 - Simple support taping

The following guidelines are for information purposes only. We recommend seeking professional advice before attempting any rehabilitation.

The aim of this taping is to provide support for weak and unstable ankles preventing them from turning over or spraining. There are a number of different methods of taping the ankle but I have found this to be the simplest, cheapest and most comfortable to apply. Done correctly it should prevent the ankle from inverting yet allow the athlete to move. It has been tried and tested on long mountain runs. Taping will provide excellent support when it is first done but over time it loses its support properties as the tape stretches naturally. Therefore it may need to be re-done at regular intervals, particularly if it gets wet.

What is required?

• Foam underwrap (optional)
• Spray adhesive (optional)
• 5 cm Elastic Adhesive Bandage - elastic type tape
• 2.5 cm non stretch zinc oxide tape.

Step 1

• Prepare the foot and ankle either by shaving or applying spray adhesive and underwrap.
• The underwrap protects the skin and hairs from direct contact with the tape but you will get a better result if tape can be applied directly to the skin but beware of putting tape onto hairy legs as it will hurt when it is removed!
• The foot should be placed in a slightly dorsi flexed and everted position (foot, toes and outside of the foot pointing upwards - image 2)

Step 2

• Using the 5 cm elastic tape start at the top middle of the ankle and take the tape around the back of the achilles tendon and down the inside of the ankle (image 3).
• Do not pull tight around the back of the achilles tendon.

Step 3

• Pass the tape under the foot and back up the outside of the ankle to lock the heel (image 4).

Step 4

• Pass the tape around the back of the achilles tendon and this time over the top of the foot at the front (image 5).
• Pass the tape under the foot and up the inside of the ankle (image 6).

Step 6

• Go around the back of the achilles and back over the front of the foot (image 7).
• Under the foot again and up the otherside, this time passing the tape in front of the ankle (image 8).

Step 7

• Pass the tape a couple of times around the ankle to finish this part off (image 9).
• For moderate support this is all that is required. For even stronger support continue on.

Step 8

• Using the 2.5 cm non stretch tape apply a strip starting on the inside top of the foot, passing down and then underneath the foot.

Step 9

• Pull the tape firmly up the outside of the ankle and secure at the front top of the ankle.
• Repeat steps 8 and 9 with a second strip of tape slightly overlapping the first and a third if required.

The taping should be comfortable and not too tight, yet make it virtually impossible for the ankle to turn over or invert.

Mobility and Stretching Exercises

The following examples are for information purposes only. We recommend seeking professional advice before attempting and rehabilitation.

1. Manual joint mobilization

• The therapist holds the ankle firmly in one hand and the foot in the other and moves the foot against the ankle in a forwards and backwards motion.

2. Seated wobble balance board exercises.

• Sit on a chair with the feet resting on a wobble board or rocker board. Move the feet forwards and backwards to mobilize the ankle.
• Later on this can be done with one foot on the wobble board or rocker board in a lateral motion.

3. Planter flexion / Dorsi flexion

• This isometric exercise can be done in the early stages and will help prevent the ankle from seizing up. Simply pull the foot up as far as it will go, hold for the count of 6 (Dorsi flexion) and then point it away from you (Plantar flexion). A good method to start with is to perform 2 sets of 40 reps whilst the ankle is iced and elevated.
• The advantage of this exercise is that the damaged ligaments will not be stressed by sideways movement.

4. Inversion / Eversion

• This exercise will mobilize the ankle 'sideways' and so starts to stress the damaged ligaments. It should only be started when pain allows and healing is established.
• Simply turn the feet so the soles point towards each other and then away from each other (image 5). The movement should be gradual and with the limits of pain.

Stretching exercises

1. Gastrocnemius stretch

Place the leg to be stretched behind and lean forward (image 6), ensuring the heel is kept in contact with the floor at all times. Hold the stretch for 20 to 30 seconds and repeat 5 times. Repeat daily. The stretch should not be painful, relax into it. A good piece of equipment to help with achilles tendon stretching is an achilles tendon stretching platform such as that shown in image 6a.

2. Soleus stretch

Place the leg to be stretched in front and with the toes raised onto a step and the knee bent. This will stretch the Soleus muscle lower down the leg. Again, hold for 20 to 30 seconds and repeat 5 times. Repeat daily.

3. Front of the leg stretch

Kneel on the floor and try to push the foot gently downwards so the front of the ankle is in contact with the ground. To make this harder, you can raise the knee a little. Hold for 20 to 30 seconds, repeat 5 times and stretch daily.

4. Front of the leg stretch 2

This stretch is similar to the one above, although one leg at a time is stretched. By pulling up on the knee, the stretch is increased.

Sports Massage

The following sports massage guide i6ws intended for information purposes only. We recommend seeking professional advice before attempting any self help treatment.

IMPORTANT: Before starting any massage treatment the therapist will check for contraindications (if any apply to you, then massage is not allowed) Click for details.

Massage to the injured ligament

 

After the acute phase, cross friction massage directly to the ligament can help in preventing scar tissue formation that is inelastic and may cause pain. Massage can usually be started around five days after the injury.

Oil or any other lubricant should not be used as you need to get a good feel of the ligament. Oil will mean the finger slides around and is unable to function correctly.

Cross friction massage should be applied with the ligament in the stretched position. Apply direct pressure with a single finger to the tendon and massage deeply (but within the limits of pain) backwards and forwards across the tendon - not along its length. The ligament should be felt under the skin. This is why it is important to have a knowledge of the anatomy involved and where the ligament attaches to.

Gradually massage deeper but within the limits of pain. This technique is likely to be a little painful but not so much that the athlete tightens up with pain. It might be easier to start treatment slightly away from the point of injury and gradually work in towards it.

The duration of treatment can be for around five to ten minutes. It is a good idea to use massage techniques every other day rather than every day. This gives you a chance to assess how the injury responds. If swelling increases of pain is worse the next day then refrain from massage until the acute stage has passed.

 

 

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