The incidence of ankle sprain is highest in the sporting population but is not limited only to this group of people. It has been shown that poor rehabilitation following an ankle sprain greatly increases the chances of the injury to reoccur. Repeated ankle sprains can lead to long term problems, including chronic ankle pain, arthritis and on-going instability.
Ankle Injuries – what makes up the ankle joint?
The ankle joint consists of the tibia, fibula and the talus. The joint is stabilised by 3 ligamentous systems: the lateral ligament complex, the medial deltoid ligament and the syndesmotic ligaments.
It has been shown that roughly 85% of ankle sprains are lateral ligament injuries. These are generally not as strong as the inside or medial ligament complex (deltoid ligaments), but the mechanism of injury will also determine which ligaments are affected.
What is a lateral ankle ligament?
The lateral ankle ligament complex consists of:
- ATFL (anterior talofibular ligament)
- CFL (calcaneofibular ligament)
- PTFL (posterior talofibular ligament)
These ligaments tend to be injured in this order with the ATFL being most commonly injured as it is the weakest of these lateral ligaments.
What is the medial deltoid ankle ligament?
The medial deltoid ligament complex is the strongest of the ankle ligaments. The deltoid ligament complex consists of:
- PTTL (posterior tibiotalar ligament)
- TCL (tibiocalcaneal ligament)
- TNL (tibionavicular ligament)
- ATTL (anterior tibiotalar ligaments)
The syndesmotic ligaments join the tibia and fibular together. These are less common ankle injuries but important not to miss these injuries. Usually a considerable amount of force is required for this type of ankle injury. This is also known as a high ankle sprain.
Signs and Symptoms of an ankle injury:
- Often a history of previous ankle injury is reported (in up 70% of acute injuries)
- History of twisting ankle movement
- Pain when standing on the affected ankle
- Tenderness, swelling and bruising can occur on either side of the ankle
- Ability of the sports physiotherapist to replicate the pain felt by the patient
- Positive anterior draw, talar tilt or squeeze test (depending on the affected structures)
X-rays are not routinely used to evaluate acute ankle injuries. Ligaments are the most common source of ankle pain following the appropriate mechanism of injury. Ligaments do not show up on x-rays.
The only reason to request an x-ray is to rule out a fracture in the foot or ankle. Your physiotherapist can refer you for an x-ray should it be deemed appropriate.
What should you do if you have a sprained ankle?
The first goal following an ankle injury is to decrease pain and swelling as well as protecting the ligament from further injury.
PRICE – Protection Rest Ice Compression Elevation are the generally accepted used protocols for the acute ankle injury.
- Protection: Protect the ankle from further injury by resting and avoiding activities that may cause further injury and/or pain
- Rest: Resting the ankle for the 1st 72 hours after the injury is helpful. Often crutches may be used so that you are not putting more strain through the ankle than is necessary. Adjustments need to be made to work, sport and exercise requirements as needed. Gentle range of movement exercises can be introduced as pain allows. It has been shown that early movement speeds up the recovery process. Ask your physiotherapist for advice on this.
- Ice: Apply ice over the swelling and bruised areas (10 minutes, one to three times per day)
- Compression: Compression is helpful to reduce the swelling. When you have swelling around the ankle joint, you will have more pain and reduced ability to move it, thus it is important to try and keep the swelling to a minimum. This can be done with an elastic bandage or a lace up ankle support
- Elevation: Swelling can be reduced by elevating your ankle above the level of your heart where possible.
Ankle injuries can be graded according to how much ligament disruption that has taken place.
Grade I – microscopic injury without stretching the ligament on a macroscopic level (Recovery time 1-3 weeks)
Mild pain, swelling and tenderness. Usually no bruising. No joint instability. No difficulty weight bearing.
Grade II – macroscopic stretching with partial damage/tear to the ligaments (Recovery time 3 – 6 weeks)
Moderate pain, swelling and tenderness. Possible bruising. Mild to moderate joint instability. Some loss of movement and function. Pain with weight bearing and walking.
Grade III – complete ligament rupture (Recovery time a few months)
Severe pain, swelling, tenderness and bruising. Considerable instability and loss of function and movement. Unable to weight bear or walk.
If your ligament injury is severe, it is advised to go into a moonboot or supportive brace. Once again, your physiotherapist can guide you on this.
It is recommended that all patients undergo conservative treatment to improve stability, muscle reflex, strength and proprioception of the lower limb stabilising muscles. Although this will help some individuals, it is not sufficient for all cases and surgery is sometimes required in extreme cases.