How do you classify ankle sprains. What are the main mechanisms of ankle injuries. Which diagnostic methods are most effective for assessing ankle sprains. What are the key components of RICE treatment for ankle sprains. How long does full recovery from an ankle sprain typically take.

Understanding Ankle Sprains: Types, Causes, and Anatomy

Ankle sprains are among the most common musculoskeletal injuries, accounting for a significant portion of sports-related injuries in young athletes. With an estimated 1 million cases presented to physicians annually, understanding the intricacies of ankle sprains is crucial for effective management and prevention of chronic problems.

Classification of Ankle Sprains

Ankle sprains are typically classified into three grades based on severity:

• Grade I: Partial ligament tear with mild symptoms and minimal functional loss
• Grade II: Incomplete ligament tear with moderate pain, swelling, and some instability
• Grade III: Complete ligament tear with severe symptoms and significant instability

Another approach divides ankle sprains into two categories:

1. Uncomplicated: Treated without surgery, suitable for early motion and rehabilitation
2. Complicated: May require surgical intervention due to associated issues

Mechanisms of Injury

The most common mechanism for ankle sprains is a combination of plantar flexion and inversion. This movement often affects the lateral stabilizing ligaments, including:

• Anterior talofibular ligament (most frequently injured)
• Calcaneofibular ligament
• Posterior talofibular ligament (rarely injured in inversion sprains)

Medial ankle sprains, though less common, occur due to excessive eversion and dorsiflexion. The strong deltoid ligament, anterior tibiofibular ligament, and bony mortise contribute to medial ankle stability.

Diagnostic Approaches for Accurate Assessment of Ankle Sprains

Proper diagnosis of ankle sprains is crucial for determining the appropriate treatment plan. How can healthcare providers effectively assess ankle injuries?

Key Components of Ankle Sprain Diagnosis

1. Detailed History: Gathering information about the injury mechanism, previous injuries, and circumstances surrounding the incident
2. Physical Examination: Conducting a thorough inspection, palpation, and assessment of weight-bearing status
3. Special Tests: Performing specific maneuvers to evaluate ligament integrity

Diagnostic Tests for Ankle Sprains

Several tests can be used to assess the integrity of ankle ligaments:

• Anterior Drawer Test: Evaluates the anterior talofibular ligament
• Inversion Stress Test: Assesses the calcaneofibular ligament
• Palpation: Examines the entire length of the tibia and fibula to detect potential fractures

Is imaging necessary for all ankle sprains? While not always required, imaging studies such as X-rays or MRI may be recommended in cases of severe pain, inability to bear weight, or suspected fractures.

RICE Protocol: The Foundation of Initial Ankle Sprain Treatment

The RICE protocol (Rest, Ice, Compression, and Elevation) forms the cornerstone of early management for ankle sprains. How does each component contribute to the healing process?

Breakdown of the RICE Protocol

1. Rest: Allows the injured tissues to heal without further stress
2. Ice: Reduces swelling and pain by constricting blood vessels
3. Compression: Minimizes edema and provides support to the injured area
4. Elevation: Promotes drainage of excess fluid, further reducing swelling

When should the RICE protocol be implemented? Ideally, RICE should be initiated as soon as possible after the injury occurs and continued for the first 24-48 hours.

Rehabilitation Strategies for Optimal Recovery from Ankle Sprains

Effective rehabilitation is crucial for restoring function and preventing chronic instability following an ankle sprain. What are the key components of a comprehensive rehabilitation program?

Phases of Ankle Sprain Rehabilitation

1. Acute Phase: Focus on pain and swelling reduction
2. Subacute Phase: Emphasis on restoring range of motion and strength
3. Functional Phase: Integration of sport-specific exercises and balance training

Essential Rehabilitation Exercises

• Range of motion exercises (e.g., ankle circles, alphabet tracing)
• Strengthening exercises for ankle and lower leg muscles
• Proprioception and balance training
• Functional exercises simulating daily activities and sports movements

How long does rehabilitation typically last? The duration varies depending on the severity of the sprain, but full ligamentous strength may not return for several months after the initial injury.

Surgical Interventions for Complicated Ankle Sprains

While most ankle sprains can be managed conservatively, some cases may require surgical intervention. When is surgery considered for ankle sprains?

Indications for Surgical Management

• Grade III sprains with complete ligament tears
• Persistent instability despite appropriate conservative treatment
• Associated injuries such as osteochondral lesions or fractures

Surgical Techniques for Ankle Sprains

Several surgical approaches may be utilized:

1. Direct Repair: Reattachment of torn ligaments to their anatomical insertion
2. Reconstruction: Use of tendon grafts to recreate ligamentous support
3. Arthroscopic Procedures: Minimally invasive techniques for addressing associated intra-articular pathology

Does surgical treatment guarantee better outcomes? Interestingly, late instability rates are similar between surgical and non-operative treatments for severe ankle ligament injuries. However, late reconstruction can be effective for patients initially treated non-operatively who develop chronic instability.

Long-Term Considerations and Prevention Strategies for Ankle Sprains

Given that over 40% of ankle sprains have the potential to cause chronic problems, what strategies can be employed to prevent recurrent injuries and long-term complications?

Prevention Techniques for Ankle Sprains

• Proper warm-up and cool-down routines
• Strengthening exercises for ankle and lower leg muscles
• Balance and proprioception training
• Use of appropriate footwear and ankle supports when indicated
• Gradual return to activities following injury

Addressing Chronic Ankle Instability

For individuals who develop chronic ankle instability, several treatment options are available:

1. Conservative management with focused rehabilitation
2. Bracing or taping for additional support during activities
3. Surgical intervention for cases refractory to conservative measures

Can chronic ankle instability be completely resolved? While complete resolution may not always be possible, proper management can significantly improve function and reduce the risk of future injuries.

The Role of Ankle Supports and Bracing in Sprain Management

Ankle supports and braces play a crucial role in both the treatment and prevention of ankle sprains. How do these devices contribute to the management of ankle injuries?

Types of Ankle Supports

• Elastic bandages
• Lace-up braces
• Semi-rigid braces
• Rigid braces

Benefits of Ankle Supports

1. Provide additional stability during the healing process
2. Limit excessive motion that could exacerbate the injury
3. Offer proprioceptive feedback to enhance awareness of ankle position
4. May reduce the risk of re-injury during sports activities

When should ankle supports be used? Ankle supports are typically recommended during the early stages of recovery and may be advised for use during high-risk activities even after full healing has occurred.

By understanding the complexities of ankle sprains and implementing comprehensive management strategies, healthcare providers and patients can work together to ensure optimal recovery and minimize the risk of long-term complications. From accurate diagnosis to effective rehabilitation and prevention techniques, a multifaceted approach is key to successfully addressing this common musculoskeletal injury.

Management of Ankle Sprains | AAFP

MICHAEL W. WOLFE, M.D., TIM L. UHL, PH.D., A.T.-C., P.T., CARL G. MATTACOLA, PH.D, A.T.-C., AND LELAND C. MCCLUSKEY, M.D.

This is a corrected version of the article that appeared in print.

Am Fam Physician. 2001;63(1):93-105

Without adequate care, acute ankle trauma can result in chronic joint instability. Use of a standardized protocol enhances the management of ankle sprains. In patients with grades I or II sprains, emphasis should be placed on accurate diagnosis, early use of RICE (rest, ice, compression and elevation), maintenance of range of motion and use of an ankle support. Sprains with complete ligament tears (grade III) may require surgical intervention. [ corrected] Although early motion and mobility are recommended, ligamentous strength does not return until months after an ankle sprain.

The ankle is one of the most common sites for acute musculoskeletal injuries, and sprains account for 75 percent of ankle injuries.¹ Acute ankle trauma is responsible for 10 to 30 percent of sports-related injuries in young athletes.² Each year, an estimated 1 million persons present to physicians with acute ankle injuries.² More than 40 percent of ankle sprains have the potential to cause chronic problems.^3,4

Classification of Ankle Sprains

Ankle sprains range in severity from grade I to grade III (Table 1⁵ and Figure 1). A simpler approach is to divide these injuries into two groups: complicated and uncomplicated. Uncomplicated ankle sprains are treated without surgery. They include injuries not associated with concomitant problems that contraindicate early motion and rehabilitation. Complicated ankle sprains usually require surgical management. Of note, late instability is as common after surgical treatment as after nonoperative treatment of severe ankle ligament injury. Furthermore, late reconstruction is effective in patients initially treated non-operatively.⁶

Grade	Signs and symptoms
I: partial tear of a ligament	Mild tenderness and swelling
	Slight or no functional loss (i.e., patient is able to bear weight and ambulate with minimal pain)
	No mechanical instability (negative clinical stress examination)
II: incomplete tear of a ligament, with moderate functional impairment	Moderate pain and swelling
	Mild to moderate ecchymosis
	Tenderness over involved structures
	Some loss of motion and function (i. e., patient has pain with weight-bearing and ambulation)
	Mild to moderate instability (mild unilateral positivity of clinical stress examination)
III: complete tear and loss of integrity of a ligament	Severe swelling (more than 4 cm about the fibula)
	Severe ecchymosis
	Loss of function and motion (i.e., patient is unable to bear weight or ambulate)
	Mechanical instability (moderate to severe positivity of clinical stress examination)

Pathoanatomy and Mechanisms of Injury

The most common mechanism of injury in ankle sprains is a combination of plantar flexion and inversion. The lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular and posterior talofibular ligaments, are most often damaged. The anterior talofibular ligament is the most easily injured. Concomitant injury to this ligament and the calcaneofibular ligament can result in appreciable instability.⁵ The posterior talofibular ligament is the strongest of the lateral complex and is rarely injured in an inversion sprain.^5,7

The anterior drawer test can be used to assess the integrity of the anterior talofibular ligament⁸ (Figure 2), and the inversion stress test can be used to assess the integrity of the calcaneofibular ligament (Figure 3).

Medial ankle stability is provided by the strong deltoid ligament, the anterior tibiofibular ligament and the bony mortise (Figure 4). Because of the bony articulation between the medial malleolus and the talus, medial ankle sprains are less common than lateral sprains. In medial ankle sprains, the mechanism of injury is excessive eversion and dorsiflexion.

Diagnosis

Ankle trauma is evaluated with a careful history (situation and mechanism of injury, previous injury to the joint, etc. ) and a careful physical examination (for example, inspection, palpation, weight-bearing status, special tests).

Gross deformity should not occur with an ankle sprain, although severe swelling can give the impression of deformity. The entire length of the tibia and fibula should be palpated to detect fracture of the proximal fibula (Maisonneuve fracture), which may be associated with syndesmosis injury.

Tenderness along the base of the fifth metatarsal may indicate an avulsion of the peroneal brevis tendon.

Palpable pain and effusion along the talocrural joint line should raise suspicion of an osteochondral talar dome lesion. This lesion results from direct trauma between the talus and fibula (anterolateral lesion) or between the posteromedial talus and tibia (posteromedial lesion). A talar dome lesion may not be apparent on radiographs until two to four weeks after the injury.⁹

Lack of swelling with an eversion or hyperdorsiflexion mechanism of injury, along with tenderness at the distal tibiofibular joint, may indicate a syndesmosis sprain. ⁶

Special tests are useful to further substantiate the presence of a syndesmosis sprain. A “squeeze test,” performed by compressing the fibula and tibia at the midcalf, is considered positive if pain is elicited distally over the tibia and fibular syndesmosis. An “external rotation test” is also recommended to identify a syndesmosis sprain. This test is performed with the patient’s knee resting over the edge of the table. The physician stabilizes the leg proximal to the ankle joint while grasping the plantar aspect of the foot and rotating the foot externally relative to the tibia. If pain occurs with this maneuver, the test is positive.¹⁰

RADIOLOGY

The Ottawa ankle rules can be used to determine when radiographic studies are indicated in the patient with ankle trauma (Figure 5).¹¹ According to these rules, radiographs should be obtained to rule out fracture when a patient presents (within 10 days of injury) with bone tenderness in the posterior half of the lower 6 cm (2. 5 in) of the fibula or tibia or an inability to bear weight immediately after the injury and in the emergency department (or physician’s office). Bone tenderness over the navicular bone or base of the fifth metatarsal is an indication for radiographs to rule out fracture of the foot.

Implementation of the Ottawa rules has reduced unnecessary radiography, decreased waiting time for patients and lowered diagnostic costs. These rules have been reported to have a sensitivity of 100 percent for the detection of malleolar fractures (95 percent confidence interval [CI]; range: 82 to 100 percent) and a sensitivity of 100 percent for the detection of midfoot fractures (95 percent CI; range: 95 to 100 percent).¹¹

If indicated on the basis of the Ottawa ankle rules, anteroposterior, lateral and mortise radiographs should be obtained after the initial physical examination. The mortise projection is an anteroposterior view obtained with the leg internally rotated 15 to 20 degrees so that the x-ray beam is nearly perpendicular to the intermalleolar line. The radiographs of an uncomplicated ankle sprain should appear normal, or they may show some lateral tilt of the talus on the anteroposterior or mortise projection.

Radiographs may reveal malleolar fractures, talar dome fractures or disruption of the ankle syndesmosis. Any of these findings should prompt referral to an orthopedic specialist. Talar dome lesions occur in 6.8 to 22.0 percent of ankle sprains, but they can be missed during the initial assessment.^9,12 It may take weeks for these transchondral fractures to manifest the bony changes of osteonecrosis (seen subjacent to the site of injury).

Tarsal navicular stress fractures also present a diagnostic challenge. Instead of localized pain, patients with these fractures may have diffuse, vague pain along the medial longitudinal arch or dorsum of the foot.¹³ This stress reaction may be misdiagnosed as medial longitudinal arch pain or plantar fasciitis.

For ankle sprains that remain symptomatic for more than six weeks, computed tomographic (CT) scanning or magnetic resonance imaging (MRI) should be considered to rule out talar dome lesions. CT or MRI studies should also be considered for ankle injuries that involve crepitus, catching or locking, because these symptoms may be associated with a displaced osteochondral fragment.

MRI studies may be helpful in identifying syndesmosis sprains and peroneal tendon involvement.¹³ Injury to the tibiofibular syndesmosis ligaments, which bind together the distal ends of the tibia and fibula, is commonly referred to as a high ankle sprain. Although this injury accounts for only about 10 percent of ankle sprains, it represents a more disabling problem and requires different treatment than common ankle sprains.¹⁴ The mechanism of injury is excessive dorsiflexion and eversion of the ankle joint with internal rotation of the tibia (Figure 6). Radiographically, a syndesmosis sprain manifests as widening of the tibiofibular “clear space” to greater than 6 mm¹⁵ (Figure 7¹⁶). Rarely, the syndesmosis is frankly disrupted, and the injury is obvious.

INDICATIONS FOR REFERRAL

The history, physical examination and radiologic evaluation should be adequate for determining whether orthopedic referral is indicated. Specific indications for referral include the following: fracture or dislocation, neurovascular compromise, tendon rupture or subluxation, a wound that penetrates the joint, mechanical “locking” of the joint and injury to the syndesmosis. Patients with symptoms out of proportion to the degree of trauma, or in whom the diagnosis is uncertain, should probably also have at least a diagnostic consultation. Once complicating features have been excluded, initial management and functional rehabilitation of the ankle sprain can be instituted.

Initial Management

The family physician can successfully manage uncomplicated ankle sprains. Because increased swelling is directly associated with loss of range of motion in the ankle joint, the initial goals are to prevent swelling and maintain range of motion.

Early management includes RICE (rest, ice, compression and elevation). Cryotherapy should be used immediately after the injury.¹⁷ Heat should not be applied to an acutely injured ankle joint because it encourages swelling and inflammation through hyperemia.

Crushed ice in a plastic bag may be applied to the medial and lateral ankle over a thin layer of cloth. Alternatively, the foot and ankle may be cooled by immersion in water at a temperature of approximately 12.7°C (55°F). The foot and ankle should be cooled for approximately 20 minutes every two to three hours for the first 48 hours, or until edema and inflammation have stabilized. Benefits of cryotherapy include a decrease in metabolism that limits secondary hypoxic injury.¹⁷

While cold therapy is being used, exercises should be initiated to maintain range of motion and assist lymphatic drainage.

To milk edema fluid away from the injured tissues, the ankle should be wrapped with an elastic bandage. The bandaging should start just proximal to the toes and extend above the level of maximal calf circumference. A piece of felt cut in the shape of a “U” and applied around the lateral malleolus increases hydrostatic pressure to an area that is prone to increased swelling.

Next, the injured extremity should be elevated 15 to 25 cm (6 to 10 in) above the level of the heart to facilitate venous and lymphatic drainage until the swelling has begun to resolve.¹⁷ Nonsteroidal anti-inflammatory drugs are preferable to narcotics for pain relief.

In most patients, the use of two properly fitted crutches should be considered during the initial, most painful period after injury. Weight-bearing should occur as tolerated. Gait should be normal and nonantalgic, and can be advanced as tolerated.

A painful, edematous sprained ankle tends to stiffen in a plantar-flexed, slightly inverted position. Unless this stiffening is prevented, rehabilitation has to be delayed until range of motion is slowly regained. To facilitate early rehabilitation and cryotherapy, an easily removable device, such as a plastic ankle-foot orthosis or simple plaster posterior splint, may be employed for immobilization. Circumferential casting generally is not recommended. Air-filled or gel-filled ankle braces that restrict inversion-eversion and allow limited plantar flexion-dorsiflexion facilitate rehabilitation.¹⁸

Functional Rehabilitation

The importance of proper rehabilitation after an ankle sprain cannot be overemphasized, especially when the debilitating consequences of decreased range of motion, persistent pain and swelling, and chronic joint instability are considered. After initial acute treatment, a rehabilitation regimen is pivotal in speeding return to activity and preventing chronic instability. In a recent military series¹⁹ it was found that lack of rehabilitation of ankle sprains delayed return to duty for several months.

Prolonged immobilization of ankle sprains is a common treatment error.^20,21 Functional stress stimulates the incorporation of stronger replacement collagen.²⁰ Functional rehabilitation begins on the day of injury and continues until pain-free gait and activity are attained. The four components of rehabilitation are range-of-motion rehabilitation, progressive muscle-strengthening exercises, proprioceptive training and activity-specific training.

Ankle joint stability is a prerequisite to the institution of functional rehabilitation. Because grades I and II ankle sprains are considered stable, functional rehabilitation can begin immediately.

RANGE OF MOTION

Range of motion must be regained before functional rehabilitation is initiated (Table 2). Regardless of weight-bearing capacity, Achilles tendon stretching should be instituted within 48 to 72 hours after the ankle injury because of the tendency of tissues to contract following trauma (Figure 8).

Component		Procedure	Duration and frequency	Comments
Range of motion
Achilles tendon stretch, nonweight-bearing		Use a towel to pull foot toward face.	Pain-free stretch for 15 to 30 seconds; perform five repetitions; repeat three to five times a day.	Maintain extremity in a nongravity position with compression.
Achilles tendon stretch, weight-bearing		Stand with heel on floor and bend at knees.	Pain-free stretch for 15 to 30 seconds; perform five repetitions; repeat three to five times a day.
Alphabet exercises performed		Move ankle in multiple planes of motion by drawing letters of alphabet (lower case and upper case).	Repeat four to five times a day.	Exercises can be in conjunction with cold therapy.
Muscle strengthening
Isometric exercises		Resistance can be provided by immovable object (wall or floor) or contralateral foot.	For each exercise, hold 5 seconds; do 10 repetitions; repeat three times a day.	Strengthening exercises should only be done in positions that do not cause pain.
	Plantar flexion	Push foot downward (away from head).
	Dorsiflexion	Pull foot upward (toward head).
	Inversion	Push foot inward (toward midline of body).
	Eversion	Push foot outward (away from midline of body).
Isotonic exercises		Resistance can be provided by contralateral foot, rubber tubing or weights.	For each exercise, hold 1 second for concentric component and perform eccentric component over 4 seconds; do three sets of 10 repetitions; repeat two times a day.	Emphasis is placed on the eccentric component; exercises should be performed slowly and under control.
	Plantar flexion	Push foot downward (away from head).
	Dorsiflexion	Pull foot upward (toward head).
	Inversion	Push foot inward (toward midline of body).
	Eversion	Push foot outward (away from midline of body).
	Toe curls and marble pickups	Place foot on a towel; then curl toes, moving the towel toward body.	Two sets of 10 repetitions; repeat two times a day.	Toe curls can be done throughout the day, at work or at home.
		Use toes to pick up marbles or other small object.
	Toe raises, heel walks and toe walks	Lift body by rising up on toes. Walk forward and backward on toes and heels.	Three sets of 10 repetitions; repeat two times a day; progress walking as tolerated.	Strengthening can occur from using the body as resistance in weight-bearing position.

MUSCLE-STRENGTHENING EXERCISES

Once range of motion is attained, and swelling and pain are controlled, the patient is ready to progress to the strengthening phase of rehabilitation. Strengthening of weakened muscles is essential to rapid recovery and important in preventing reinjury.²² Exercises should focus on the conditioning of peroneal muscles, because insufficient strength in this muscle group has been associated with ankle instability and recurrent injury.²³

Strengthening begins with isometric exercises performed against an immovable object in four directions of ankle movement. The patient then progresses to dynamic resistive exercises using ankle weights, resistance bands or elastic tubing (Figure 9).

Resistance exercises should be performed with an emphasis on eccentric contraction.²³ The patient is instructed to pause one second between the concentric and eccentric phases of exercise and to perform the eccentric component over a four-second period. “Concentric” contraction refers to the active shortening of muscle with resultant lengthening of the resistance band, whereas “eccentric” contraction involves the passive lengthening of muscle by the elastic pull of the band.

Toe raises (Figure 10), heel walks and toe walks may also be attempted to regain strength and coordination.

PROPRIOCEPTIVE TRAINING

As the patient achieves full weight-bearing without pain, proprioceptive training is initiated for the recovery of balance and postural control (Table 3). Various devices have been specifically designed for this phase of rehabilitation. Use of these devices in concert with a series of progressive drills can effectively return patients to a high functional level.^24,25

Component	Procedure	Duration and frequency	Comments
Proprioceptive training
Circular wobble board	In sitting position, rotate board clockwise and counterclockwise using one foot and then both feet; in standing position, rotate board using one leg and then both legs.	Do five to 10 repetitions; repeat set two times a day.	Wobble board exercises can be performed with eyes open or closed and with or without resistance.
Walking on different surfaces	Walk in normal or heel-to-toe fashion over various surfaces; progress from hard, flat floor to uneven surface.	Walk 50 feet two times a day.	Walking exercises can be performed with eyes open or closed and with or without resistance.
Training for return to activity
Walk-jog	Do 50 percent walking and 50 percent jogging in forward direction and backward direction; progress to jogging; jog in a pattern (e.g., circle, figure-eight).	Increase distance in increments of one-eighth mile.	Increase intensity and incorporate activity-specific training.*
Jog-run	Do 50 percent jogging and 50 percent running in forward and backward directions; run in a pattern (e.g., circle, figure-eight).	Increase distance in increments of one-eighth mile.	Increase intensity and incorporate activity-specific training.*

The simplest device for proprioceptive training is the wobble board, a small discoid platform attached to a hemispheric base. ⁷ The patient is instructed to stand on the wobble board on one foot and shift his or her weight, causing the edge of the wobble board to move in a continuous circular path (Figure 11). Training can be advanced by having the patient perform this maneuver at different heights and with closed eyes.

TRAINING FOR RETURN TO ACTIVITY

When walking a specified distance is no longer limited by pain, the patient may progress to a regimen of 50 percent walking and 50 percent jogging. When this can be done without pain, jogging eventually progresses to forward, backward and pattern running. Circles and figure-eights are commonly employed for pattern running. Although these routines are time-consuming, they represent the final phase of ankle joint rehabilitation, and completion of the program is essential for the recovery of ankle stability.

A patient who will be returning to sports participation may require additional athletic therapy. This component of the rehabilitation process should be supervised by a certified athletic trainer or sports physical therapist who is familiar with the physical demands of the patient’s sport. Use of a stabilizing orthotic device or tape, with subsequent weaning, may be recommended during the early period of activity-specific training.

High Ankle Sprain vs. Ankle Sprain: What’s the Difference?

Ankle sprains are one of the most common injuries in the United States. But what is the difference between a common ankle sprain and a high ankle sprain? Why must athletes who sustain high ankle sprains stop playing sports for a longer period than those with common ankle sprains? The reason lies in the anatomy of the leg and ankle and the different ligaments injured in a high ankle sprain.

• Ankle and lower leg anatomy
• What is a common ankle sprain?
• What is a high ankle sprain?
• What causes a high ankle sprain?
• What are the symptoms of a high ankle sprain?

• How is a high ankle sprain diagnosed?
• What is the treatment for a high ankle sprain?
• What is the surgery for a high ankle sprain?
• How do you rehab a high ankle sprain?
• What is the recovery time for a high ankle sprain?

Ankle and lower leg anatomy

The ankle joint is formed by three bones in the lower leg: the tibia (shin bone), the fibula (the bone next to and parallel to the tibia in the outer calf), and the talus (a dome shaped bone in the foot below the tibia). These bones act together to form the ankle joint, which may sustain loads of up to three times a person’s body weight during normal daily activities.

The bony prominences on the inside and outside of the ankle are called malleoli. The malleoli on the outside of the ankle are formed by the fibula. Ligaments connect bone to bone and help stabilize the ankle. Tendons connect muscle to bone and allow for movement and dynamic stabilization.

Anatomy of the Ankle (courtesy of the Journal of Musculoskeletal Medicine. © Todd Buck, CMI 2008).

What is a common ankle sprain?

The common ankle sprain ranges in severity and usually involves an injury to the anterior talofibular ligament (ATFL). Injury can also involve other tendons or ligaments and can range from a partial tear to a complete tear. The ATFL is one of the primary stabilizers of the ankle and is frequently injured when an athlete internally inverts or “rolls” the ankle with excessive force.

After an ankle sprain, athletes will often have swelling and bruising that may spread to the foot. It is important to be evaluated by a healthcare provider to ensure there is no fracture or more severe injury. It often takes 6 to 12 weeks for return to full sports participation after an ankle sprain.

Prior to returning to sport, it is important for an athlete to have full range of motion and full strength in the injured ankle. Balance and coordination are equally important to prevent reinjury and a rehab program is beneficial to optimize full return to sport and prevent reinjury. During the early return to sport period it is often recommended that an athlete wear an ankle brace to help prevent reinjury.

What is a high ankle sprain?

A high ankle sprain involves different ligaments than a common ankle sprain. These ligaments are located above the ankle joint and between the tibia and fibula. They form what is known as the syndesmosis (pronounced “SIN-des-MO-sis”). These account for only about 14% of ankle sprains.

When you bear weight on the leg, the tibia and fibula experience high forces that spread them apart. The ligaments of the syndesmosis serve as shock absorbers, preventing the tibia and fibula from spreading too far apart. When you run, and especially when you run and quickly change direction, these ligaments of the syndesmosis experience very high forces.

What causes a high ankle sprain?

A high ankle sprain is caused by an external rotation and/or dorsiflexion (foot bending toward the shin) trauma to the ankle, usually resulting from a sudden twisting, turning or cutting motion while a person is running, jumping or falling. They are most common in athletes who play high-impact running sports like football, soccer, basketball and lacrosse.

How can you prevent a high ankle sprain?

Some warm-ups that involve neuromuscular training − movements focused both balance and coordination − may decrease injury rate. In one study of young basketball players, a warm-up reduced the rate of ankle and knee injuries by 35% (SHRed study). Unfortunately, there is no high ankle sprain brace that has been shown to prevent these injuries.

The best way to avoid this injury is continual performance training for strength, balance and performing a dynamic warmup that engages all the major muscle groups prior to practice and competition. Adequate sleep and good nutrition are also important for performance and injury prevention.

What are the symptoms of a high ankle sprain?

You will typically feel pain that radiates up your leg from the ankle. Pain is often worse with weightbearing or when pivoting on your foot.

High ankle sprains do not typically cause a great degree of swelling or bruising. This can be frustrating to athletes and coaches, because a high ankle sprain generally does not “look that bad.” For this reason, many people can be unaware of how severely they have injured themselves and may not rest and rehabilitate as necessary for complete healing.

How is a high ankle sprain diagnosed?

Your doctor will ask you what motion you were performing when your injury took place, assess your symptoms, and conduct a physical exam. The exam may include a fibular compression test (also sometimes called a “high ankle sprain test” or “syndesmosis squeeze test”). For this test, your doctor will place hands on each side of your lower leg and squeeze the tibia and fibula together in a few different spots. If this causes pain that radiates down your leg, this suggests a high ankle sprain. However, additional tests (for example, X-rays) may also need to be conducted to be sure you do not have a fractured fibula or compartment syndrome.

What is the treatment for a high ankle sprain?

High ankle sprains can be serious and have a long-term impact on pain and function. You should see a doctor to guide management for a high ankle sprain. Basic concepts can be helpful in treating a high ankle sprain. The acronym RICE protocol (Rest, Icing Compression and Elevation) is a helpful reminder for many injuries. However, unlike the early mobilization that is beneficial for a lateral ankle sprain, many high ankle sprains require a short period of limited weightbearing and may need more substantial bracing. Surgery may be needed for severe injuries with notable instability.

RICE protocol

• Rest – Keep your weight off the affected leg. The amount of rest required to permit healing is usually much longer than for the common ankle sprain – nearly twice as long, according to most studies.
• Icing – During the first couple of days after the injury, apply ice for about 15 minutes every few hours to reduce inflammation and swelling.
• Compression – Wrap the lower leg with an elastic bandage to minimize swelling, but not tight enough to cut off circulation.
• Elevation – Sit or lie down with your foot elevated to a position above the level of your heart to reduce swelling and pain.

How do you rehab a high ankle sprain?

After the initial two weeks of protected weightbearing and RICE protocol, your physician will often recommend you start physical therapy to regain strength, range of motion and proprioceptive training.

Proprioception training has been shown to reduce the rate of recurrent injury. (Proprioception is your body’s ability to sense the position of your foot and ankle.) It is also recommended that you use an ankle brace for a period when returning to sports participation.

What is the surgery for a high ankle sprain?

Most high ankle sprains do not require surgery. However, in severe cases or if a ligament has been completely torn, the standard surgical procedure is to insert a screw between the tibia and fibula to hold the two bones together. This relieves pressure on the ligaments and allows them to scar in place and heal.

What is the recovery time for a high ankle sprain?

High ankle sprain healing and recovery times vary. Some people are able to return to their sports within six weeks, but about 50% will experience symptoms for as much as six months.

Do sprains take longer to heal than breaks?

A sprain is an injury to a ligament. The ligaments are stabilizing tissues between bones. A strain is an injury to a muscle or tendon. A tendon connects the muscle to the bone. A fracture is a break in the bone itself. Every sprain and fracture requires a different amount of time to heal. Factors that affect healing include quality of blood supply, nutrition, rest, and the overall health of the patient.

Some sprains may take longer to heal than some fractures and pain can persist well past the initial healing phase for both of these injuries. You should see a doctor if you are ever injured and unable to move a joint appropriately or put weight on the joint.

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Dr. Nicholas Sgrignoli is a sports medicine physician, at Hospital for Special Surgery (HSS) with offices in Stamford and Wilton in Fairfield County, Connecticut. He treats patients of all ages and especially enjoys working with youth athletes. An athlete himself, Dr. Sgrignoli plays volleyball, soccer, Gaelic football, and is an avid snowboarder who is well versed in managing ski and snowboarding injuries.

Updated: 6/13/2022

Authors

Nicholas Sgrignoli, MD

Assistant Attending Physician, Hospital for Special Surgery

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References

• Delahunt E, Bleakley CM, Bossard DS, Caulfield BM, Docherty CL, Doherty C, Fourchet F, Fong DT, Hertel J, Hiller CE, Kaminski TW, McKeon PO, Refshauge KM, Remus A, Verhagen E, Vicenzino BT, Wikstrom EA, Gribble PA. Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. Br J Sports Med. 2018 Oct;52(20):1304-1310. doi: 10.1136/bjsports-2017-098885. Epub 2018 Jun 9. PMID: 29886432.
• Doherty C, Bleakley C, Delahunt E, Holden S. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. Br J Sports Med. 2017 Jan;51(2):113-125. doi: 10.1136/bjsports-2016-096178. Epub 2016 Oct 8. PMID: 28053200.
• Emery CA, Owoeye OBA, Räisänen AM, Befus K, Hubkarao T, Palacios-Derflingher L, Pasanen K. The “SHRed Injuries Basketball” Neuromuscular Training Warm-up Program Reduces Ankle and Knee Injury Rates by 36% in Youth Basketball. J Orthop Sports Phys Ther. 2022 Jan;52(1):40-48. doi: 10.2519/jospt.2022.10959. PMID: 34972488.
• Rivera MJ, Winkelmann ZK, Powden CJ, Games KE. Proprioceptive Training for the Prevention of Ankle Sprains: An Evidence-Based Review. J Athl Train. 2017 Nov;52(11):1065-1067. doi: 10.4085/1062-6050-52.11.16. Epub 2017 Nov 15. PMID: 29140127; PMCID: PMC5737043.
• Vancolen SY, Nadeem I, Horner NS, Johal H, Alolabi B, Khan M. Return to Sport After Ankle Syndesmotic Injury: A Systematic Review. Sports Health. 2019 Mar/Apr;11(2):116-122. doi: 10.1177/1941738118816282. Epub 2018 Dec 14. PMID: 30550364; PMCID: PMC6391553.

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Ankle sprain: severity and treatment Most often, it occurs due to the incorrect position of the leg (with a traumatic inward turn) and is accompanied by severe pain in the ankle area.

Anatomy of a sprain

Ligaments are made up of strong connective tissue. They usually stretch a certain amount and then return to their normal state. A severe sprain actually tears the ligaments, at which point you can feel or hear something like popping or crackling.

Ankle sprain is a common injury. Lateral ligament injuries of the inversion type account for approximately 85% of all cases. According to statistics, at the beginning of 2020, the highest incidence rate occurs between the ages of 15 and 19.years. Half of all ankle sprains occur during sports activities, such as basketball (41.1%), football (9.3%). And in relation to all sports injuries, it manifests itself in 77-83% of the total number of cases.

The most common risk factor is a previous sprain. It can compromise the strength and integrity of the stabilizers by interrupting sensory nerve fibers. Gender, height, weight, limb dominance, postural wobble, and foot anatomy are intrinsic risk factors that may also affect the possibility of injury. External causes include how protective systems are attached, type of footwear, duration of competition, and intensity of activity.

In addition to sports injuries, ankle injuries can be caused by simply stepping on the wrong foot. For example, when a person stumbled and stood not on the plantar part of the foot, but on its lateral surface. This can happen when going down stairs or running.

Degrees of severity and time of treatment

Ankle sprains are classified according to the severity:

• Grade 1 – minor sprain and microscopic damage;
• 2 degree – partial rupture;
• 3 degree – the ligament is completely torn.

Most sprains take 4 to 6 weeks to heal. Recovery from a severe sprain can take several months.

When the ligamentous apparatus is damaged, the following symptoms appear:

• fever to subfebrile – 37.5 °C;
• chills and fever;
• weakness and dizziness;
• local swelling around the injury;
• hyperemia – hot ankle on palpation;
• local hyperthermia;
• soreness on palpation and movements in one or more directions, as well as when walking.

With a complete rupture of the ligaments, in addition to the above symptoms, there are:

• excessively active mobility in the projection of the joint;
• inability to stand on the affected leg;
• loss of consciousness;
• pain shock;
• circulatory disorders, manifested by cyanosis of the toes, their numbness, tingling in the projection of the injury.

Even with a minor clinical picture, you need to contact a traumatologist. It will help to choose the tactics of treatment and restore the functionality of the joint and ligaments.

Diagnosis

The doctor first collects an anamnesis and interviews the patient to clarify all the details of the injury. Next is a physical examination. Palpation is used to feel for structures that may be affected, including bones, muscles, and ligaments, followed by active and passive assessment of range of motion.

In addition, the traumatologist may need the results of the following tests and diagnostic measures:

• general blood and urine tests;
• biochemical blood test;
• rheumatic tests;
• x-ray – will allow you to assess whether there is a complete rupture;
• Ultrasound – to assess the degree of rupture;
• CT – used in case of long-term treatment or concomitant pathologies.

The clinical picture of ankle ligament injury is similar to fracture, dislocation, subluxation and fissure, so detailed diagnosis is required to rule out these injuries.

Treatment and rehabilitation

In case of severity 1, when there is a slight manifestation of the clinical picture, it is enough to give the injured leg a rest, excluding any load during the whole day. To relieve swelling, it is recommended to apply a cooling bandage. It is better to fix the ankle in one position – to prevent re-traumatization and optimal healing of microscopic injuries.

For grade 2, the doctor prescribes NSAIDs in the form of tablets or creams/ointments (for topical use). Immobilization is often carried out by means of a bandage with metal ribs, but you can resort to a plaster cast. This should not be neglected, otherwise the fusion will not happen correctly, there will be complications. With severe pain syndrome, analgesics or anesthetics are prescribed for local use.

For grade 3, in addition to grade 1 and 2 therapy, a plaster cast will be required.

In case of damage of 1 degree of severity, rehabilitation is not required. After 2 and 3, it is better to take a course of DLFK, massages and electrophoresis in order to prevent the possibility of re-injury. For a complete recovery, traumatologists recommend using warming foot baths once a week for 6 months.

Possible complications

If the traumatologist is not contacted in time, repeated damage to the ankle can occur, up to a complete rupture of the ligaments. Other complications are possible:

• impaired function and pinched nerves;
• transition to chronic pathology;
• limitation of joint mobility;
• epicondylitis – inflammation of ligaments and tendons;
• degenerative destruction of the joint – arthrosis.

In case of improper accretion, the pain syndrome in 80% of cases haunts the patient all his life, with enviable frequency.

Prevention is better than cure

Warm up before starting any workout. It is enough to take a light walk for 5-10 minutes and start warming up the muscles and joints, depending on the sport. The correct structure of training is the key to a healthy sport. Before starting, be sure to assess your general condition. Other things to look out for:

1. Surface. Before performing the exercises, it is imperative to check on what surface they will be carried out (hard and even or loose and soft) in order to be ready to adapt to it.
2. Shoes. When training, you need solid shoes, as close as possible to the size.
3. Protection. If there was previously an injury to the joint and ligaments, additional support (bandage, tape or bandage) is required.

After the end of the workout, you need to give the body a rest and take care of the elimination of toxins released during exercise.

Even small injuries should not be neglected. The musculoskeletal system is the most traumatic, and the consequences of improper healing of its components lead to serious consequences and constant pain throughout life.