Foot & Ankle

Sprained Ankle

Every day, approximately 25,000 people sprain an ankle.

Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions. When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers. When a sprain occurs, you may fall or be unable to stand on that foot. You may even hear a “pop.” Pain and swelling will occur.

Sprains are graded as follows:

Severity Physical Examination Findings Impairment Pathophysiology Common Treatment Protocol
Grade 1 Minimal tenderness and swelling Minimal Microscopic tearing of collagen fibers Weight bearing as tolerated

No splinting / casting

Isometric exercises

Full range-of-motion and stretching / strengthening exercises

Grade 2 Moderate tenderness and swelling, along with a decreased range of motion and possible instability Moderate Complete tears of some but not all collagen fibers in the ligament Immobilization with air splint

Physical therapy with range-of-motion and stretching / strengthening exercises

Grade 3 Significant swelling, tenderness, and instability Severe Complete tear / rupture of ligament Immobilization

Physical therapy similar to grade 2 sprains, but over a longer period

Possible surgical reconstruction

Reprinted with permission from Bernstein J (ed): Musculoskeletal Medicine, Rosemont, IL; American Academy of Orthopaedic Surgeons, 2003, p.242.

Symptoms

The amount of pain and swelling you experience will depend on the amount of stretching and tearing of the ligament. Instability occurs when there has been complete tearing of the ligament or a complete dislocation of the ankle joint.

Swelling and pain typically last 2-3 days. Walking may be difficult and crutches may be needed.

Diagnosis

When an ankle sprain is suspected, your doctor will perform a physical exam which may be painful. The doctor may need to move your ankle in various ways to determine which ligament has been damaged. Your doctor may be able to tell you the grade of your ankle sprain based upon the amount of swelling, pain, and bruising.

If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. If this occurs, it is possible that the injury may also have caused damage to the ankle joint surface itself.

Your doctor may order X-rays to make sure you don't have a broken bone in the ankle or foot. A broken bone can produce similar symptoms of pain and swelling. An MRI (magnetic resonance imaging) scan may be ordered if your doctor suspects a very severe injury to the ligaments, injury to the joint surface, a small bone chip, or other problem. The MRI may be delayed in order to allow any swelling and bruising to resolve itself.

Treatment

Most ankle sprains need only a period of protection to heal. The healing process takes about four weeks to six weeks. The acronym R.I.C.E is a good way to remember what to do:

  • Rest your ankle by not walking on it.
  • Ice should be immediately applied. It keeps the swelling down. It can be used for 20-30 minutes, 3-4 times per day.
  • Compression dressings, bandages, or ace-wraps immobilize and support the injured ankle.
  • Elevate your ankle above your heart level as much as possible for the first 48 hours.

Depending upon the grade of injury, your doctor may recommend a cast boot, air splint, and/or crutches. Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately.

Your doctor may tell you to incorporate motion early in the healing process to prevent stiffness. Even with a chronic tear, your ankle can still be highly functional because overlying tendons help with stability and motion.

Rehabilitation is used to help decrease pain and swelling and prevent chronic ankle problems. Rehabilitation may include:

  • Ultrasound
  • Electrical stimulation
  • Active range of motion exercises or controlled movements of the ankle joint without resistance
  • Water exercises if land-based strengthening exercises, such as toe-raising, are too painful.
  • Lower extremity exercises and endurance activities as tolerated.
  • Proprioception training

Non-steroidal anti-inflammatory drugs (NSAIDs) may be used to control pain and inflammation.

Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to non-surgical treatment and for persistent instability after months of rehabilitation and non-surgical treatment. Surgical options include:

  • Arthroscopy – A surgeon looks inside the joint to see if there are any loose fragments of bone or cartilage, or part of the ligament caught in the joint.
  • Reconstruction – A surgeon repairs the torn ligament with stitches or suture, or uses other ligaments and/or tendons found in the foot and around the ankle to repair the damaged ligaments.

Recovery

All ankle sprains recover through three phases:

  • Phase 1 – 1 Week – Resting, protecting the ankle, and reducing swelling.
  • Phase 2 – 1 to 2 Weeks – Restoring range of motion, strength, and flexibility.
  • Phase 3 – Weeks to Months – Gradually returning to activities that do not require turning or twisting the ankle and doing maintenance exercises. Later followed by activities that require sharp, sudden turns (cutting activities) such as tennis, basketball or football.

If an ankle sprain is not recognized and treated, chronic problems of pain and instability may result.