So you have gone over on your ankle? You are not alone. A sprained ankle, or lateral ankle ligament sprain, is frequently experienced in both the general and sporting population with 40% of these occurring during sports (1, 2.) Despite this high prevalence, it is thought that only 50% seek medical attention (3.)
A large proportion will develop chronic long-term ankle instability with symptoms including recurrent pain, swelling and giving way. So make sure you get an accurate diagnosis and appropriate physiotherapy treatment to reduce the risk of complications and recurrence.
In the first 72 hours, follow the guidelines for ‘RICE:’
- Rest (modified activities not complete rest)
- Ice (20 minutes every two hours)
- Compression (using a crepe bandage or Tubigrip)
- Elevation (foot above the knee, knee above the hip)
- Thereafter early weight-bearing and instigating range-of-movement exercises are encouraged.
- If you are unable to weight bear (difficulty standing or walking) due to pain. you need to keg an x-ray due to the risk of an ankle fracture (1,2.)
It is advisable to see a physiotherapist if there is significant bruising or swelling. This would typically indicate a more severe sprain. Another cause for self-referral to a physiotherapist is persistently high levels of pain 3 days post-injury.
A further referral to a sports doctor, orthopaedic consultant, x-ray, ultrasound scan or MRI, would be appropriate under a number of circumstances. These would include if, once we had carried out a detailed assessment of the ankle, we thought there was a chance of any of the following things;
- Locking of the ankle
- Tendon rupture
- Syndesmosis injury
- Persistent pain
- Severe or recurrent instability
1. It is vital to regain range of movement with the correct hands-on treatment and exercises (1,2,3.)
2. Once range-of-motion is regained, you should begin the strengthening phase, starting with isometric exercises.
3. You should then progress to dynamic resistive exercises using weights or resistance bands allowing for restoration of function to the ankle. These combine eccentric (muscle lengthening or stretching) and concentric (muscle contraction or shortening) exercises.
4. It is important to strengthen the peroneal muscles as research has shown weakness and delayed reaction time in these muscles lead to ankle stability and increased risk of recurrence (4.)
5. From this stage, the focus lies on retraining proprioception (awareness of your body in space – your body’s positional sense) and balance. These have both been highly correlated with risk of recurrence (4.)
6. Once this is restored and equal to the unaffected side you should commence a return to play program. These programs vary dependent upon the sport that you do but often begin with running, change of direction and then more sport-specific drills.
Typically the time needed to return to normal activity depends upon the severity of the sprain and for this we use a grading system:
- Grade I: Minimal disruption of fibers with minimal swelling
- Grade II: Partial disruption of fibres with moderate swelling
- Grade III: Complete rupture of ligament with significant swelling
The average time to return to sport or full weight-bearing status is six weeks for a Grade I sprain, 6-12 weeks for a Grade II sprain, and up to three months for a Grade III sprain. A Grade III may be managed conservatively or surgically and is discussed should this event occur.
The goal of treatment and rehabilitation is to prevent chronic ankle instability. Ankle injuries with some degree of instability have a 35% chance of at least one re-sprain within the first three years (2.) The main predictive factor for risk of recurrence and chronic instability is the severity of the original injury (1,2,4.)
1. Hertel J, Anatomy F. Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. J Athl Train2002;37:364–75
2. Lynch SA, Renström PA. Treatment of acute lateral ankle ligament rupture in the athlete. Conservative versus surgical treatment. Sports Med 1999;27:61–71.
3. Verhagen EA, van Mechelen W,de Vente W. The effect of preventive measures on the incidence of ankle sprains. Clin J Sport Med 2000;10:291–6
4. Delahunt E, Coughlan GF, Caulfield B, et al. Inclusion criteria when investigating insufficiencies in chronic ankle instability. Med Sci Sports Exerc 2010;42:2106–21