Ankle Sprains

An ankle sprain is a very common musculoskeletal injury (muscle and bone related). It can happen during any daily activity and is very common in sporting activities. The most common mechanism of injury is usually a ‘twist’ in the ankle while walking, climbing stairs, running or changing directions.

Our ankles are small but complex joints that bear a large portion of our body weight. There are many crucial muscles attached to the joint which help in movement. For us to understand ankle sprains in more detail, it will be necessary to understand the basics of the ankle’s anatomy.

As seen in the diagram above, ankle joint is mainly formed by three bones- the tibia on the inside, the fibula on the outside and the talus below. This joint allows our ankle to move up and down. There are also other complex movements that take place within the joint, namely, inversion and eversion where our foot can go inwards towards the midline of the body and the outwards, that is away from the midline of the body. The bones of the ankle are connected by structures called ligaments. An ankle sprain is a damage or overstretching of these ligaments.

The most common type of ankle sprain is an inversion or lateral ankle sprain. In an inversion ankle sprain, the foot is ‘twisted’ inwards causing damage to the outer ligaments of the ankle. According to a study published by Journal of Athletic Training in 2019, 73% of ankle sprains are inversion sprains. There can be many reasons for an inversion sprain which include:

• Previous history of ankle injury

• Foot posture (flat feet, high arch, etc)

• Weak peroneal muscles (muscles responsible for eversion of the foot)

• Stiff ankle joints

• Poor single leg or postural balance

• Biomechanical reasons like tight calf muscles, weak glutes, and weak leg muscles.

There are three grades of lateral ankle sprain:

Grade 1- Stretching of the ligament with mild swelling and pain

Grade 2 - Incomplete tear of the ligament with moderate swelling and pain

Grade 3 - Complete tear of the ligament severe swelling and pain

Common symptoms of ankle sprain are- pain over the outer part of the ankle or the entire ankle, mild or significant amount of swelling depending on the severity of the tear, bruising, stiffness of the ankle, inability to bear full weight on the leg, and tender to touch. Depending on the severity of the symptoms, healthcare professionals may consider a conservative approach to the treatment or opt for surgery.

For acute episodes of ankle sprain however, there is a self-treatment protocol that everyone can follow irrespective of the severity of the injury. These protocols have changed with time. There have been lot of studies discussing widely about RICE (Rest Ice Compression Elevation) which later became PRICE (Protection Rest Ice Compression Elevation). Latest evidence suggests the that MICE (Movement Ice Compression Elevation) may be the most useful treatment protocol. Movement in this case means early mobilization after injury (within the first week) as this has proven to improve swelling and have better long-term effects in terms of return to work and return to sport. As a precaution, use of tape or brace could be beneficial along with exercises. (Vuurberg G, et al. Br J Sports Med 2018;52:956).

History of previous ankle injury poses biggest risk for another ankle sprain. Usually ankle sprains that were not managed well conservatively, end up in a state of chronic ankle instability (CAI) where the ligaments and muscles keep giving way due to lack of strength and efficiency. Research now suggests that at least 20% of ankle sprains develop chronic ankle instability if not properly rehabilitated.

The key to successfully curing any ankle sprain is graded functional rehabilitation. This is irrespective of the grade of injury. In case a surgery is being planned, pre-habilitation is of utmost importance and rehabilitation post-surgery is crucial to avoid Chronic Ankle Instability (CAI). Overall recommendations for an ankle sprain suggest that post the initial rest, protection, ice, elevation and compression, a guided rehabilitation programme is necessary to successfully return to sports and activities of daily living as well as to prevent further complications or recurrence of the same injury.