Ankle sprains are an extremely common injury that are experienced in both the general population as well as in sporting environments. But astonishingly only 50% of people who experience an ankle sprain seek medical attention as a result!(1) This is despite large numbers of people going on to experience long term pain and, in some cases, instability.
Ankle sprains range in severity from a very mild sprain, that will likely resolve on its own in a few weeks, to severe ligament disruption, bone bruising, tendon and nerve damage and resultant ankle instability requiring medical intervention and significant amount of time to recover from. And, of course, anything in between.
What actually happens when you sprain your ankle?
There are many ligaments in the ankle and the image below shows the most common ones that get affected from an ankle sprain. The anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), posterior talofibular ligament (PTFL) are the three most commonly injured ligaments because of their attachment sites around the ankle in relation to the mechanism of injury during an ankle sprain. There are also two tendons that wrap around the lateral malleolus called peroneus longus and brevis, which can sometimes become injured too. Bone bruising may occur to certain parts of the foot and in some cases nerves in the area may get stretched or irritated due to the presence of swelling.
When you damage a ligament, i.e. tear it, it initiates the inflammatory process. Initially bleeding happens within the tissue and we see lots of swelling and sometimes bruising tracking along the outside of the foot. Then lots of chemical and cellular processes happen stimulating the repair of the ligament as the body produces scar tissue. Often though, in the aftermath of an ankle sprain we are left with:
- Restricted movement
- Reduced proprioception (your body’s awareness of where it is in space)
- Anxiety and reduced confidence
- Limited participation in sport
- Time off work
How does this injury occur?
Common ways that ankle sprains occur are mis-stepping off a curb, falling downstairs, landing awkwardly from a jump or even over balancing if you’re wearing high heels! In essence, your foot is forced into a position described as plantarflexion and inversion – medical speak for your foot was pointing down and turning in at the same time whilst being put under pressure. This puts stress through the ligaments on the outside of the ankle causing possible tearing of the ligament, and in more extreme cases total rupture of the ligaments.
What should you do if you think you’ve sprained your ankle?
First things first, you need an accurate diagnosis of the injury. It is not altogether uncommon for fractures (broken bones) to occur when you “roll” your ankle. So it needs to be certain that there aren’t any fractures. Depending on the situation you may or may not need investigative imaging to conclude this.
An X-ray will normally be administered at A+E if your symptoms are in line with a possible fracture, and this is normally sufficient to highlight the presence of a fracture. If you are unable to fully weight bear on the ankle and the time of the injury is followed by immediate swelling it is advisable to attend A+E so you can be assessed this way. If you are able to weight bear, there is delayed swelling and there isn’t any bony tenderness then its unlikely you have suffered a fracture, however on visiting a clinician they can fully assess you and make a decision on whether you ought to have an x-ray or not.
Once a firm diagnosis of a ligament sprain is concluded you need to start managing things correctly. This leads us to the Do’s and Don’ts list:
The ‘Do’ list
Whilst swelling after a soft tissue injury is pretty inevitable and necessary, its important to get it under control and reduced as soon as possible. Persistent swelling can bring with it its own problems. You may be familiar with the Rest Ice Compression Elevation (RICE) concept. This was promoted, historically, to manage swelling for most acute injuries and in particular ankle sprains. However, a study that was published in 2017 (2) concluded that there was no presently published literature supporting the use of this principle. Whilst there are some studies with suggestions that RICE provides benefit, the research is limited and so it is important not to rely solely on this method to manage swelling.
A more pragmatic approach, perhaps, is to employ a ‘PRICE’ plus early rehab approach. The ‘P’ in the PRICE acronym stands for protection. In the case of more severe ankle sprains, being put into a protective boot for up to 10 days may prevent further injury, aid swelling drainage and modulate pain. Less serious sprains will benefit from taping or ankle supports for a period of 4-6 weeks. In fact, the study suggested that being immobilised for long periods was linked with poorer prognoses and so use of protective boots should be limited to short term use before progressing to utilising a support (ankle supports/tape). In cases where a protective boot isn’t warranted supports and tape should still be encouraged in early management of an ankle sprain.
If you are sensible and deploy protection measures such as bracing/supports, incorporate some of the RICE principles ALONGSIDE early rehab and make sure you modify your activity levels you should be able to control and resolve the swelling within a few weeks depending on the extent of the injury.
*** Should I take Anti-inflammatories (NSAIDs) – based on the work by Vuurberg et al, 2017 they had the following recommendation; “NSAIDs may be used by patients who have incurred an acute LAS for the primary purpose of reducing pain and swelling. However, care should be taken in NSAID usage as it is associated with complications … and may suppress or delay the natural healing process.”***
As with most things in life exercise is our route to success. Whilst there are other things that a physiotherapist can do such as massage, joint mobilisations, taping etc the real golden ticket is exercise. Hands on therapy can facilitate the benefits of exercise (2) but progressive loading through rehabilitation is key.
Exercise is especially beneficial in preventing the recurrence of sprains, reducing the chances of getting instability and increasing the speed of recovery. Exercise should be prescribed in a progressive way taking into account the stage of healing, extent of pain and damage, and base line strength, range of movement and proprioception
Along with swelling reduction, restoring full ankle range of movement is very important for long term outcome and avoiding secondary problems further down the line. A full resolution of movement and swelling are often indicators used to progress rehabilitation. Exercise is an important method by which to build strength and restore ankle proprioception too.
Proprioception is your body’s awareness of where it is in space without you having to look. So for example, if you close your eyes right now whilst you are reading this, you’ll be able to describe the position that your legs are in, that your head is tipped down or facing forwards and that your left elbow is bent and your fingers are in a relaxed fist. When you lose proprioception around the ankle you are more likely to experience a second sprain because you aren’t receiving the same level of information about the joint position as before the injury.
For some exercise examples for rehabilitating from an ankle sprain click here to view Physio Pro’s Instagram page. But please don’t take these as being an exhaustive list of exercises. These are just a range of simple exercises from a range of stages in the recovery process. If you have experienced a significant injury it is always best to be guided by a clinician in your rehab.
Whilst there may be times when surgery is required after suffering an ankle sprain, current evidence would suggest that it is best to be reserved in the recommendation of surgery. Whilst there may be times where surgery is opted for in earlier time frames (such as in elite sport), conservative measures are still the primary option for treating ankle sprain injuries. The good news is that IF you do need ankle surgery, the post-surgical outcomes are often very good (as long as you rehab after). (2)
The ‘Don’t’ list
Assume all is well
As mentioned previously, ankle sprains often lead to persistent problems and ankle instability if not treated properly. In cases where the injury is mild, with minimal swelling and sustained by those who are better conditioned then a couple of weeks of modified activity may be enough to allow full recovery and return to life/sport.
However, in more significant cases an ankle sprain needs some TLC and nurturing to try and prevent long lasting effects. Just thinking that time passing, and resting is enough to recover is not the case in majority of situations. By not treating an ankle sprain correctly you stand a greater chance of joining the 70% of individuals suffering recurrent sprains (3). Don’t assume, be proactive and make sure!
Rely on frozen peas
Whilst they may be great in their mushed-up form on the side of some battered haddock and chips, or in a salad if you’re feeling whimsical, they aren’t going to fix your sprained ankle. From a cryotherapy (icing) point of view they do not stay cold enough for long enough to elicit a physiological effect to impact swelling. As we’ve discussed earlier, ice can be a part of swelling management, but it needs to be something that stays cold for 10-12 minutes and ideally that can be applied with compression.
Try to run it off
Anywhere between 1.5 up to 5 times body weight of force goes through each leg per step when running. If you’ve rolled your ankle and are then asking it to withstand significant forces you are likely to do one of three things, increase pain, increase swelling or risk rolling the ankle again. Acknowledge that you have an injury and deal with it appropriately
Hopefully this blog post has given you some insight on to things to do to take control of managing your ankle sprain and some things not to do as well. A key message here is that an ankle sprain, albeit common, is not to be taken lightly just because it happens a lot. It can, and in most cases does, lead to future complications if not dealt with properly. But equally important is the message that if you do the right things and treat it well it WILL get better and you stand a better chance of avoiding it happening again.
Verhagen EA, van Mechelen W, de Vente W. The effect of preventive measures on the incidence of ankle sprains. Clin J Sport Med. 2000;10(4):291-6.
Vuurberg G, Hoorntje A, Wink LM, van der Doelen BFW, van den Bekerom MP, Dekker R, van Dijk CN, Krips R, Loogman MCM, Ridderikhof ML, Smithuis FF, Stufkens SAS, Verhagen EALM, de Bie RA, Kerkhoffs GMMJ. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med.2018 Aug;52(15):956.
T J Hubbard, E.A. Wikstrom. Ankle sprain: pathophysiology, predisposing factors, and management strategies. 2010. Open Access Journal of Sports Medicine