Sprained Ankle in Depth AKA: Ankle Sprain

Sprained Ankle Injury Explained

A sprained ankle is one of the most common injuries caused by participation in sports. It refers to soft tissue damage (mainly ligaments) around the ankle, usually caused by an inversion injury (where the ankle is twisted inwards) or an eversion injury (where the ankle is twisted outwards).

Because of the position of the bones around the ankle, the inversion injury is far more common. This injury causes damage to the lateral ligaments, and other soft tissues, on the outside of the ankle.

The most commonly injured ligament is the Anterior Talo Fibular (ATF) ligament which, as the name suggests, joins the fibular and talus bones together. If the force to the ankle is more severe, the Calcaneo Fibular ligament (between the Calcaneus and Fibula) is also damaged. The Posterior Talo Fibular (PTF) ligament is very rarely damaged in comparison to the other two ligaments.

In the case of an eversion injury the damage occurs on the medial (inside) of the ankle. The ligament on the inside of the ankle is called the Deltoid ligament and is very strong. It is so strong in fact that the bone on the inside of the ankle can be pulled off, in what is called an avulsion fracture, before the ligament is damaged.

As well as damage to the ligaments, the capsule which surrounds the ankle joint can also be damaged. The damage causes bleeding within the tissues and the ankle begins to swell up and can be extremely painful.

Ankle sprains can be classified as follows:

• First degree, where only a few ligament fibres are damaged
• Second degree sprain refers to more extensive damage to the ligament with associated swelling
• Third degree sprain refers to a complete rupture of the ligament with swelling and a possible joint dislocation

In the more severe injuries there may be associated bone injury and it is wise to get an x-ray to determine whether there is a fracture.

Sprained Ankle Injury Signs & Symptoms

With a first degree sprain there is pain when turning the foot in or out and also pain when the damaged area is touched. With a second degree sprain the pain is more severe, there is swelling all around the area and it is painful to walk. With a third degree sprain the pain is excruciating and walking is impossible. There is gross swelling and there may be a great degree of joint laxity around the ankle or deformity if the ankle is dislocated.

Sprained Ankle Injury Treatment

David Beckham wearing a plastic cast walker following his injury in 2002

In the first 48-72 hours following the injury it is important the follow the PRICE protocol – protection, rest, ice, compression and elevation (never apply ice directly to the skin). Ice Packs for a period of twenty minutes every couple of hours may help with the pain and help reduce the initial inflammation, but pain-relieving medication may also be necessary. The Aircast Ankle Cryocuff is the most effective method of providing ice therapy, whilst protecting the injured tissues from further damage, and is the professional’s choice. It can provide continuous ice cold water and compression for 6 hours and significantly reduce pain and swelling in the early stages of injury.

It is important not to put too much weight on the damaged ankle, so walking should be limited where possible. Ankle injuries can be protected using a Reusable Plastic Cast Walker and these are regularly used by Premier League football players to dissipate weight bearing.

Where a fracture is suspected an x-ray should be carried out at an accident and emergency department. If a fracture is found or a Grade Three sprain is diagnosed, the advice of the attending doctor should be followed. It should be borne in mind that some hairline fractures do not show up on x-ray until about 10-14 days after the injury, so if the pain persists medical attention should be sought.

What you can do

	Consult a sports injury expert
	Apply ice packs/cold therapy to reduce swelling
	Wear a removable plastic cast for protection
	Wear an ankle support for protection

In the case of a Grade Two sprain, crutches should be used to protect the injured ankle. However, it is important not to be on the crutches for longer than necessary and as soon as the pain allows the patient should begin to gently put weight through the ankle by walking to maintain a normal gait pattern And Prevent compensatory movements being adopted. Reusable Plastic Cast Walkers can be very helpful as they protect the injured area and help to resolve ankle swelling.

Once the patient is able walk on the ankle, more active rehabilitation can be started.

In ankles that have been repeatedly sprained there is an inherent weakness which may require surgery. This can now be done arthroscopically where a camera is inserted into the ankle and flakes of bone and excess scar tissue can be removed. Because of the injury to vital mechanoreceptors within the ligaments and tendons around the ankle, continuing rehabilitation may be necessary for the months and years that follow an injury. This is because proprioception around the ankle can be greatly compromised with a severe injury and re-injury is often very likely.

Sprained Ankle Injury Prevention

What you can do

	Wear an ankle support for protection
	Use a wobble board for ankle strengthening

Ankle instability is characterised by ankle weakness and giving way, even though the ankle ligaments are intact and the joint is mechanically stable. It is due to an impairment of proprioception, which leads to a lack of balance and ankle joint position sense. Proprioception is the mechanism by which nerve receptors in skin, muscle, ligament and joint tissue relay information to the brain about body position sense, where this information is quickly processed and movement strategies are formulated and executed using nerve signals to muscles. This mechanism can help you ‘catch yourself’ when you are about to turn your ankle.

In the unstable ankle these receptors may have been damaged directly during an ankle sprain. The Peroneal muscles and tendons that run along the outside of the shin and are often involved in ankle inversion injuries are particularly rich in receptors. This impaired proprioceptive ability may, therefore, lead to a delay in protective muscle activity and the resultant loss of postural awareness and stability around a joint. This may explain why recurrent ankle sprains are so common.

The Wobble Board together with Ankle Braces are commonly used in the rehabilitation of ankle instability. Wobble Boards are designed to assist the re-education of the proprioceptive system by improving sensory receptor function. Previous research has also shown that wobble board training improves single leg stance ability and balance; while other studies have suggested that patients with ankle instability who underwent wobble board training experienced significantly fewer recurrent sprains during a follow-up period than those who did not follow the training programme. Exercise bands (Resistance Bands) are also useful to help restore muscle strength, especially in multi-directional planes of movement improving the strength and protection around the ankle.

Taping and Bracing the ankle can also help to reduce recurrent ankle injury. Previous research has shown the injury incidence in students with taped ankles was 4.9 ankle sprains per 1000 participant games, compared with 2.6 ankle sprains per 1000 participant games in students wearing ankle braces. This compared with 32.8 ankle sprains per 1000 participant games in subjects that had no taping or bracing.