No matter what your favorite sport or activity – basketball, tennis, lacrosse, hiking, volleyball, soccer, or Ultimate – there is a good chance at some point you will sustain an ankle sprain. This can even happen by rolling your ankle when wearing heels, or stepping wrong off of a curb. This is one of the most common athletic injuries, so I wanted to take some time to talk about ankle sprains and their treatment.
An ankle sprain is a twisting injury to the ankle that stretches or tears at least one of the stabilizing ligaments around the ankle. The most commonly injured ligament is the anterior talofibular ligament (ATFL), which is one of the lateral ankle ligaments. More severe sprains may also involve the other lateral ankle ligaments (calcaneofibular ligament and the posterior talofibular ligament), or the medial ankle ligaments, commonly referred to collectively as the deltoid ligament of the ankle. If the twisting injury involves the foot rolling inward, this is termed an inversion ankle sprain and makes up approximately 80% or more of all ankle sprains. An inversion sprain usually injures the lateral ankle ligaments. If the foot rolls outward, this is termed an eversion ankle sprain and usually injures the medial deltoid ligaments.
Ankle sprains are graded according to severity:
- Grade 1 (first degree) sprain – stretching of the ligaments, some pain on weightbearing, minimal swelling, bruising, and stiffness
- Grade 2 (second degree) sprain – torn ligament fibers, moderate pain with weight bearing especially initially accompanied by varying degrees of swelling, bruising, and stiffness
- Grade 3 (third degree) sprain – complete rupture of ligaments, extreme pain with weight bearing with large amounts of swelling and bruising, some instability of the joint
At the instant the ankle sprain occurs, you may feel or hear a “pop”. This does not necessarily mean that the ankle is broken, as the ligaments can pop when torn. Ankle sprains usually swell almost immediately and thus the best initial treatment is to focus on decreasing this swelling. Generally, the RICE protocol is used in treating ankle sprains, which is an acronym for Rest, Ice, Compression, and Elevation.
- Rest – get weight off the ankle, using crutches if necessary if pain is severe with weight bearing
- Ice – in addition to icing immediately after injury, continue to ice 20 minutes at a time at least three times a day for the first 3-5 days
- Compression – an elastic bandage such as an ACE wrap applied to the ankle can help reduce the swelling the first few days after injury
- Elevation – keep the ankle above the level of the heart as much as possible to control the swelling; simply resting the ankle on a table or chair in the sitting position is not enough
In the first 24-48 hours after an ankle sprain, avoid hot showers or baths, heating pads, heat rubs or creams, and drinking alcohol, as all of these things can increase the blood flow to the ankle and cause further swelling. An anti-inflammatory medicine such as ibuprofen or naproxen can be helpful in the early period in reducing the amount of inflammation and swelling in the ankle.
After the first few days once the swelling is under control, you may want to start alternating icing the ankle with applying gentle heat to increase the blood flow to help with tissue healing. Begin to wean yourself off crutches when weight bearing no longer causes severe pain. You may begin some simple exercises at this point to increase the range of motion of the ankle such as drawing different sized circles or spelling out the alphabet with the toes. Once you have regained full range of motion of the ankle (equal to your other side), then you may start some strengthening exercises with resistance bands.
As you progress through the healing process and you can walk without pain or a limp, you need to add some balance, or proprioception, exercises to your regimen. Try to balance on the injured ankle with your eyes closed, and do balance drills on a wobble board or foam tube if you have access to these. If not, do one leg balance drills while holding an object that someone else also holds and pushes and pulls.
When you feel ready to return to your sport or activity, which may take 3-6 months with a severe sprain, I recommend an ankle brace to help prevent repeat injury. I prefer less rigid lace-up type braces with Velcro straps to add extra stability. More rigid braces can also be used, but may limit your mobility somewhat.
When should you see a doctor about your ankle sprain? Initially, grade 3 sprains and some grade 2 sprains may be difficult to differentiate from ankle fractures. If a fracture is suspected or if the ankle is very unstable after injury, a visit to the orthopedist may be in order to take X-rays to rule out an ankle fracture. Quite often, a severe sprain may involve a small fracture, called an avulsion fracture, off the fibula, tibia, or talus. Sometimes the ligaments are so strong that when stressed during the sprain, the attachment of the ligament to the bone may actually break off before the ligament tears. These avulsion fractures of the ankle are treated the same as a severe sprain.
If your symptoms persist for several months and are not improving even if you have followed the above advice, you may need to see an orthopedist to rule out any associated injuries to the ankle. In a small percentage of cases, permanent ankle instability may result from a grade 3 sprain if the ligaments don’t heal back appropriately. With some severe sprains or with repeated sprains, the cartilage of the ankle joint either on the talus or the tibia can be injured and lead to persistent symptoms. In these uncommon cases, surgical attention may be necessary.