Ankle Sprains: The Acute Phase

WHAT HAPPENS IN A SPRAINED ANKLE?

A sprained ankle is a common injury said to be up to 20% of all sports injuries. It typically involves the overstretching of the ligaments in the ankle. In most cases, the ligaments on the outside of the ankle are overstretched when the foot is rolled inwards. These ligaments include the posterior talofibular ligament (PTFL), the calcaneofibular ligament (CFL) and commonly, the anterior talofibular ligament (ATFL).

The ligament on the inside of the ankle is known as the deltoid ligament. The deltoid ligament is stronger and more stable meaning it is much less commonly injured (around 10% of all ankle sprains).

A greater risk of ankle sprains may be associated with:

Lack of strength and stability in the ankle
Poor balance
Previous ankle injuries
Sports with sudden changes in direction
Altered ankle biomechanics

HOW DO I KNOW IF I'VE SPRAINED MY ANKLE?

After rolling the ankle, there is likely to be some swelling in the area with ankle pain. It will be tender to touch around the affected ligaments and occasionally you may hear a ‘pop’ at the time of injury. Walking on the injured ankle may feel quite painful and unstable.

GRADES OF ANKLE SPRAINS

There are three grades of ankle sprains differentiated by the extent of the damage to the ligament. An early visit to a physiotherapist can help to identify which ligament has been damaged, and also ascertain the grade of ligament sprain.

Grade I – Described as ‘mild’ stretching of the ligament with minor microscopic tears. Stability is generally not affected. Any initial swelling and pain with normal daily activities should be alleviated within 3 weeks. Despite the short recovery time, strengthening the muscles around the ankle and re-training balance and proprioception is important in order to prevent recurrence and avoid overuse of other joints/muscles to compensate.

Grade II – Is a ’moderate’ or partial rupture with moderate pain and swelling including problems with weight-bearing. Generally, recovery for Grade II sprains is in the 4-6 week range.

Grade III – A ‘severe’ is a complete ligament rupture with substantial pain, swelling, bruising and pain. This includes significant problems with weight-bearing and stability. This level of damage may require surgery and can take up to 12 weeks to manage.

ANKLE SPRAIN MANAGEMENT - INITIAL PHASE (48-72HRS)

Proper management of ankle sprains is essential as research suggests within 1 year, athletes have twice the risk of a recurrent ankle sprain. Additionally, there is evidence that, without proper management there is a 70% increase in likelihood of re-spraining the ankle.

The initial phase of management (48-72 hours) focuses on the ‘R.I.C.E’ principles as with most soft tissue injuries in order to control pain and swelling.

Rest – involves avoiding aggravation of the injury through weight-bearing activity.
Ice – Using an ice-pack or ice wrapped in a towel to control swelling and help with pain-relief (avoid direct skin contact with ice)
Compression – A compression bandage (e.g. tubigrip) can be used around the ankle to assist with swelling management
Elevation – Elevating the injured ankle, in combination with compression and ice can also assist in reducing blood flow and in turn the swelling in the ankle.

Your physiotherapist can help to diagnose the grade of ankle sprain and to provide early management strategies including taping to help support the damaged ligaments. Simple ankle movements may also be prescribed to encourage activation of the surrounding muscles and to reduce swelling.

Ankle Pumps

Ankle Taping

ANKLE SPRAIN MANAGEMENT - REHABILITATION (72HRS-2WKS)

After a full assessment of the damaged ligaments, ankle rehabilitation with the guidance of a physiotherapist will involve range of motion, strength and balance exercises to address any deficits that have occurred.

Range of Motion and Pain

Restoring of range of motion can be achieved through various techniques including soft tissue massage of tight muscles, mobilisations of the ankle joint as well as stretching exercises.

Strengthening

Once pain has settled and range of motion has improved, strengthening exercises will be prescribed for the muscles in the lower leg which have experienced weakness due to the injury. A commonly prescribed strengthening exercise is calf raises for the gastrocnemius (calf) muscle.

Double-leg Calf Raise

Once adequate strength is achieved, this can be progressed to a single leg calf raise which places the full load of the body on the affected leg to further strengthen the calf muscle.

Single-leg Calf Raise

Balance/proprioception

The next stage of management is to train balance and proprioception. Ankle proprioception refers to the body’s ability to recognise where the ankle is relative to the other parts of the body. This sense is important to prevent recurrence of the ankle sprain as well for stability before returning to sport.

Check out our next blog to find out about common balance and proprioception exercises as well as the last stage of ankle rehabilitation: return to activity.

References

Doherty, C., Delahunt, E., Caulfield, B., Hertel, J., Ryan, J., & Bleakley, C. (2013). The Incidence and Prevalence of Ankle Sprain Injury: A Systematic Review and Meta-Analysis of Prospective Epidemiological Studies. Sports Medicine, 44(1), 123-140. http://dx.doi.org/10.1007/s40279-013-0102-5
Fong, D., Hong, Y., Chan, L., Yung, P., & Chan, K. (2007). A Systematic Review on Ankle Injury and Ankle Sprain in Sports. Sports Medicine, 37(1), 73-94. http://dx.doi.org/10.2165/00007256-200737010-00006
Kerkhoffs, G., van den Bekerom, M., Elders, L., van Beek, P., Hullegie, W., & Bloemers, G. et al. (2012). Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal Of Sports Medicine, 46(12), 854-860. http://dx.doi.org/10.1136/bjsports-2011-090490
Ligament injury grading [Image] (2014, October 13). Retrieved April 10, 2018, from https://www.ibphysio.com.au/management-acute-ankle-sprains/ligament-injury-grading-2/
Myrick, K. (2014). Clinical Assessment and Management of Ankle Sprains. Orthopaedic Nursing, 33(5), 244-248. http://dx.doi.org/10.1097/nor.0000000000000083
Petersen, W., Rembitzki, I., Koppenburg, A., Ellermann, A., Liebau, C., Brüggemann, G., & Best, R. (2013). Treatment of acute ankle ligament injuries: a systematic review. Archives Of Orthopaedic And Trauma Surgery, 133(8), 1129-1141. http://dx.doi.org/10.1007/s00402-013-1742-5
Waterman, B., Belmont, P., Cameron, K., Svoboda, S., Alitz, C., & Owens, B. (2011). Risk Factors for Syndesmotic and Medial Ankle Sprain. The American Journal Of Sports Medicine, 39(5), 992-998. http://dx.doi.org/10.1177/0363546510391462