An ankle sprain is a tear of the ligaments in the ankle. The most common ligaments injured are on the outside of the ankle. This type of sprain is called an inversion ankle sprain and is shown in the picture to the right. Ankle sprains occur with simple activities like stepping off a curve or walking on uneven surfaces and are common in sporting activities like soccer, tennis, football, hiking and running.
On the outside of the ankle, there are three main ligaments that help to stabilize the ankle:
• Anterior talofibular
• Posterior talofibular
Ankle ligaments labeled on the lateral aspect of the ankle
In the diagram to the left, the anterior talaoposterior talofibular ligament is not shown. It sits behind the ankle bone and the peroneal tendons, which are seen in the diagram.
When the ankle is twisted, one or more of these ligaments may be torn. Most ankle sprains involve partial tearing of one or more ligaments. Severe ankle sprains involve partial to complete tears of two or three ligaments.
Most ankle sprains will respond to immediate icing, compression, and elevation. Studies have found that icing within the first 36 hours leads to a faster recovery time.
Heat can delay the recovery time by increasing swelling. Protected weight bearing with a functional brace and early range of motion is also important. These general guidelines are recommended:
P – R – I – C – E – E
1. Protected walking
A lace-up ankle brace or air cast is a good way to protect the ankle when walking. In the early stages of ankle sprains, the ankle may be too swollen for a lace-up brace. For more severe ankle sprains a cast boot may be dispensed at the doctor’s office or ER. For more severe ankle sprains, casting and crutches may be necessary to assist with walking in the early stages of healing. But, it is important to keep the foot at 90 to the leg and start protected walking early.
Although early protected walking is important, this doesn’t mean doing your regular daily activities. Rest on the couch or chair and get up when necessary. Resting is especially important in the first 2-3 days.
Place an ice pack around the ankle for 15-20 minutes. During the first 2-3 days, ice for 15 minutes every hour or two, throughout the day. Icing helps decrease inflammation.
An ace wrap helps with compression and controls swelling. Swelling is an important part of the healing phase. Swelling helps support the ankle. But, too much swelling increases pain and slows healing. We also have ways to stabilize and support the ankle, and the swelling doesn’t have the same purpose as it did in the past.
Although an ace wrap helps considerably with compression, it does not protect the foot when walking. An additional brace should be used when walking with moderate to severe ankle sprains. Start wrapping near the toes, and continue up to the leg, holding the foot near 90 degrees when wrapping.
Elevate the foot and ankle above the heart. Elevation helps keep the swelling and inflammation down. The natural response of the body is to bring all the blood down to the area of injury during the first 2-3 days following the injury. Gravity will bring more blood than needed to the ankle and keep the blood around the ankle. Elevate the foot and ankle as much as possible during the first 2-3 days.
6. Early Mobilization:
One of the most common complaints following the recovery of ankle sprains is stiffness. After the first 2-3 days of resting, elevating, and icing, after the swelling starts to go down, range of motion exercises should be started. Initially start by bringing the toes back and then forward again. Do this slowly, up and down, ten times. Repeat this series three times.
Next, add in circles. Make a circle with the ankle in one direction, then the other direction. Make ten circles in each direction, repeat 3 times. Once you are comfortable with these exercises, try to write the alphabet with your foot.
Outlining the letter “A”, then “B”, and so on. There may be some discomfort when performing these exercises, but there should be no sharp pain.
A more detailed treatment regimen is based on the grade of ankle sprain. Ankle sprains are divided into three categories; grade 1, 2 and 3.
This is the most common type of ankle sprain and is considered a stretching of the ligaments without actually tearing. Microscopic damage is done to the ligaments, but no instability results. There is generally some pain and swelling and most people are able to walk with crutches.
Splinting or casting is not necessary and walking is recommended, as tolerated. Immediate icing within the first 36 hours is important, along with elevation and compression. Strength training and range of motion exercises can be started as soon as swelling and pain decrease, which is typically within the first 2-3 days after the injury.
The typical time to return to activities is 10-14 days. If pain, swelling, stiffness, or instability persist, physical therapy and a functional brace may be recommended.
The ligaments are partially torn, but no instability results from the sprain. There is generally significant swelling and there may be bruising as well. People generally find it difficult to walk without crutches initially but are able to bear weight on the foot and ankle.
Immediate application of ice is recommended and should be continued as long as there is swelling. The foot and ankle should be elevated as much as possible during the first few days after injury. The ankle should be immobilized with an air splint.
Weight-bearing is encouraged as tolerated and crutches may be needed. Range of motion exercises, stretching, and strengthening exercises should be done at home within the first 3-4 days.
Physical therapy may be initiated after 2-3 weeks to work on balance and proprioception. The recovery time is variable, between 2-6 weeks. Stiffness may persist and full recovery may take 6 months.
A complete tear of one or more ligaments results in instability. There is generally significant pain, swelling, and bruising and most find it impossible to walk without the ankle “giving way”.
Immediate ice and elevation are recommended and the ankle is usually immobilized in a protective boot and protected weight-bearing with crutches can begin as soon as tolerated. Physical therapy is initiated at 7-10 days and continued for 4-6 weeks depending on progress.
At two weeks, the cast boot is generally replaced with an air cast and after four more weeks (6 weeks after the injury) the air cast can be replaced with a lace-up brace. The lace-up brace, or some type of functional brace, should be worn for 3 months with regular activities and for six months or more for sporting events.
It’s common for the ankle to feel stiff and to experience some residual pain for a number of months after the injury. Full recovery can take up to a year. It’s also possible that surgical reconstruction may be needed.
After an ankle sprain heals, there is generally residual stiffness and in many cases, a feeling of instability. The instability may last for years and could result in repeated ankle sprains. New research suggests that 4-6 weeks of balance training will improve balance and ankle stability.
After fully healed from an ankle sprain the following balance training will help improve stability. Start with the first step and then progress to the other steps when the ankle feels stable. Don’t progress to the next step if there is still a feeling of instability. Do not perform with an injured ankle unless recommended by your physician.
- Stand on one leg while brushing your teeth.
- Stand on one leg and try not to wobble. Hold the stance for one minute. Rest for 30 seconds and then repeat this step 10 times. Stop when the leg feels fatigued or unstable. When you can hold the stance for 1 minute and repeat ten times, you can proceed to the next step.
- Perform the above set with your arms crossed over your chest. Proceed to the next step when you can perform this 10 times.
- Perform step #3 with your eyes closed. Proceed to the next step when you can perform this 10 times.
- Stand on one leg and hop up and down ten times. Rest and then repeat this step 10 times or until the leg fatigues. Do not hop repeatedly if the ankle feels unstable.
- Once you can complete the above step, start again with step #2 and use a pillow to mimic an unstable surface.