24/7 Emergency Cases: 8133 2020
After Clinic Hours Appointment Booking: 9622 1555

Ankle Sprain

What is an ankle sprain?

An ankle sprain refers to tearing of the ligaments of the ankle. The most common ankle sprain occurs on the lateral or outside part of the ankle. This is an extremely common injury which affects many people during a wide variety of activities. It can happen in the setting of an ankle fracture (i.e. when the bones of the ankle also break). Most commonly, however, it occurs in isolation.

An ankle sprain is an injury to one or more ligaments in the ankle, usually on the outside of the ankle. Ligaments are bands of tissue – like rubber bands – that connect one bone to another and bind the joints together. In the ankle joint, ligaments provide stability by limiting side-to-side movement.

Some ankle sprains are much worse than others. The severity of an ankle sprain depends on whether the ligament is stretched, partially torn, or completely torn, as well as on the number of ligaments involved. Ankle sprains are not the same as strains, which affect muscles rather than ligaments.

The most common site of sprains is the ankle. An ankle sprain can happen when you fall, when you suddenly twist your ankle too far, or when you force the joint out of its normal position (for example, when you land awkwardly on your foot after jumping). Most ankle sprains happen during sports activities or when walking or running on an uneven surface.

The signs of an ankle sprain can include:

  • pain or tenderness
  • swelling
  • bruising
  • coldness or numbness in the foot
  • inability to walk or bear weight on the joint
  • stiffness

The severity of an ankle sprain depends on how badly the ligaments are stretched or torn. If the sprain is mild, there may not be much pain or swelling, and the ligaments may only be stretched. If the sprain is severe, one of more ligaments may be torn, and the join may be severely swollen. A severe sprain can also be extremely painful.

What are the symptoms an ankle sprain?

Patients report pain after having twisted an ankle. This usually occurs due to an inversion injury, which means the foot rolls underneath the ankle or leg. It commonly occurs during sports. Patients will complain of pain on the outside of their ankle and various degrees of swelling and bleeding under the skin (i.e. bruising). Technically, this bruising is referred to as ecchymosis. Depending on the severity of the sprain, a person may or may not be able to put weight on the foot. 

Sprained ankles often result from a fall, a sudden twist, or a blow that forces the ankle joint out of its normal position. Ankle sprains commonly occur while participating in sports, wearing inappropriate shoes, or walking or running on an uneven surface.

Sometimes ankle sprains occur because of a person is born with weak ankles. Previous ankle or foot injuries can also weaken the ankle and lead to sprains.

What are the risk factors for an ankle sprain?

As noted above, these injuries occur when the ankle is twisted underneath the leg, called inversion. Risk factors are those activities, such as basketball and jumping sports, in which an athlete can come down on and turn the ankle or step on an opponent’s foot.

Some people are predisposed to ankle sprains. In people with a hind foot varies, which means that the general nature or posture of the heels is slightly turned toward the inside, these injuries are more common. This is because it is easier to turn on the ankle.

In those who have had a severe sprain in the past, it is also easier to turn the ankle and cause a new sprain. Therefore, one of the risk factors of spraining the ankle is having instability. Those who have weak muscles, especially those called the peroneals which run along the outside of the ankle, may be more predisposed. 

Anatomy

There are multiple ligaments in the ankle. Ligaments in general are those structures that connect bone-to-bone. Tendons, on the other hand, connect muscle-to-bone and allow those muscles to exert their force. In the case of an ankle sprain, there are several commonly sprained ligaments. The two most important are the following:

1.The ATFL or anterior talofibular ligament, which connects the talus to the fibula on the outside of the ankle.
  
2.The CFL or calcaneofibular ligament, which connects the fibula to the calcaneus below.  

3. Finally, there is a third ligament which is not as commonly torn. It runs more in the back of the ankle and is called the PTFL or posterior talofibular ligament. These must be differentiated from the so-called high ankle sprain ligaments, which are completely different and located higher up the leg.

How is an ankle sprain diagnosed?

Symptoms
The symptoms of ankle sprains may include:

  • Pain or soreness
  • Swelling
  • Bruising
  • Difficulty walking
  • Stiffness in the joint

These symptoms may vary in intensity, depending on the severity of the sprain. Sometimes pain and swelling are absent in people with previous ankle sprains. Instead, they may simply feel the ankle is wobbly and unsteady when they walk. Even if there is no pain or swelling with a sprained ankle, treatment is crucial. Any ankle sprain – whether it’s your first or your fifth – requires prompt medical attention.

Ankle sprains can be diagnosed fairly easily given that they are common injuries. The location of pain on the outside of the ankle with tenderness and swelling in a patient who has an ankle with inversion is very suggestive. In these patients, normal X-rays also suggest that the bone has not been broken and instead the ankle ligaments have been torn or sprained.

It is very important, however, not to simply regard any injury as an ankle sprain because other injuries can occur as well. For example, the peroneal tendons mentioned above can be torn. There can also be fractures in other bones around the ankle including the fifth metatarsal and the anterior process of the calcaneus. In very severe cases, an MRI may be warranted to rule out other problems in the ankle such as damage to the cartilage. An MRI typically is not necessary to diagnose a sprain. 

Diagnosis
In evaluating your injury, the foot and ankle surgeon will obtain a thorough history of your symptoms and examine your foot. X-rays or other advanced imaging studies may be ordered to help determine the severity of the injury.

What are treatment options?

Surgery is not required in the vast majority of ankle sprains. Even in severe sprains, these ligaments will heal without surgery. The grade of the sprain will dictate treatment. Sprains are traditionally classified into several grades. Perhaps more important, however, is the patient’s ability to bear weight. Those that can bear weight even after the injury are likely to return very quickly to play. Those who cannot walk may need to be immobilized.

In general, treatment in the first 48 to 72 hours consists of resting the ankle, icing 20 minutes every two to three hours, compressing with an ACE wrap, and elevating, which means positioning the leg and ankle so that the toes are above the level of patient’s nose. Those patients who cannot bear weight are better treated in a removable walking boot until they can comfortably bear weight.

Physical therapy is a mainstay. Patients should learn to strengthen the muscles around the ankle, particularly the peroneals. An ankle brace can be used in an athlete until a therapist believes that the ankle is strong enough to return to play without it. Surgery is rarely indicated but may be needed in a patient who has cartilage damage or other related injuries. Ligaments are only repaired or strengthened in cases of chronic instability in which the ligaments have healed but not in a strong fashion.

Non-surgical Treatment

When you have an ankle sprain, rehabilitation is crucial—and it starts the moment your treatment begins. Your foot and ankle surgeon may recommend one or more of the following treatment options:

  • Rest. Stay off the injured ankle. Walking may cause further injury.
  • Ice. Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
  • Compression. An elastic wrap may be recommended to control swelling.
  • Elevation. The ankle should be raised slightly above the level of your heart to reduce swelling.
  • Early physical therapy. Your doctor will start you on a rehabilitation program as soon as possible to promote healing and increase your range of motion. This includes doing prescribed exercises.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation. In some cases, prescription pain medications are needed to provide adequate relief.

When Is Surgery Needed?


In more severe cases, surgery may be required to adequately treat an ankle sprain. Surgery often involves repairing the damaged ligament or ligaments. The foot and ankle surgeon will select the surgical procedure best suited for your case based on the type and severity of your injury as well as your activity level.

After surgery, rehabilitation is extremely important. Completing your rehabilitation program is crucial to a successful outcome. Be sure to continue to see your foot and ankle surgeon during this period to ensure that your ankle heals properly and function is restored.

How long is recovery?

Recovery depends on the severity of the injury. As noted above, for those minor injuries, people can return to their activities in sports within several days. For very severe sprains, it may take longer and up to several weeks. It should be noted that high ankle sprains take considerably longer to heal.

Outcomes for ankle sprains are generally quite good. Most patients heal from an ankle sprain and are able to get back to their normal lives, sports and activities. Some people, however, who do not properly rehab their ankle and have a rather severe sprain may go on to have ankle instability. Chronic instability occurs in patients repeatedly spraining the ankle. Such repeated episodes can be dangerous because they can lead to damage within the ankle. These patients should be identified and considered for repair. 

Potential Complications

Surgery is rarely needed. As noted above, however, an improperly rehabbed ankle may end up having chronic instability. It is important to address this with either therapy or surgery before further damage occurs to the ankle.

Frequently Asked Questions

What is a high ankle sprain and is that different from a regular ankle sprain?

A high ankle sprain refers to tearing of the ligaments that connect the tibia to the fibula (this connection is also called the syndesmosis). These are different and much less common than the standard lateral ankle sprains, meaning those that occur on the side of the ankle. 

Do ankle sprains ever need to be repaired acutely?

Ankle sprains rarely, if ever, needed to be treated with surgery. The vast majority simply need to be treated with rest, ice, compression and elevation followed by physical therapy and temporary bracing. 

I have sprained my ankle many times. Should I be concerned?

Yes. The more you sprain an ankle, the greater the chance that problems will develop. For example, turning the ankle can lead to damage to the cartilage inside the ankle joint. You should see your doctor if this is occurring.

Why Prompt Medical Attention Is Needed


There are four key reasons why an ankle sprain should be promptly evaluated and treated by a foot and ankle surgeon:

  • An untreated ankle sprain may lead to chronic ankle instability, a condition marked by persistent discomfort and a “giving way” of the ankle. Weakness in the leg may also develop.
  • A more severe ankle injury may have occurred along with the sprain. This might include a serious bone fracture that, if left untreated, could lead to troubling complications.
  • An ankle sprain may be accompanied by a foot injury that causes discomfort but has gone unnoticed thus far.
  • Rehabilitation of a sprained ankle needs to begin right away. If rehabilitation is delayed, the injury may be less likely to heal properly. 

How are ankle sprains diagnosed?

Your doctor will usually be able to tell if you have a sprain by asking you some questions about how the injury occurred and by examining your ankle. You doctor may also want to take an X-ray of your ankle to make sure that it’s not fractured or broken.

How can ankle sprains be treated?

Many doctors suggest using the RICE approach–Rest, Ice, Compression, Elevation–for treating ankle sprains (see the box below).

RICE approach

Rest–You may need to rest your ankle, either completely or partly, depending on how serious your sprain is. Use crutches for as long as it hurts you to stand on your foot.

Ice–Using ice packs, ice slush baths or ice massages can decrease the swelling, pain, bruising and muscle spasms. Keep using ice for up to 3 days after the injury.

Compression–Wrapping your ankle may be the best way to avoid swelling and bruising. You’ll probably need to keep your ankle wrapped for 1 or 2 days after the injury and perhaps for up to a week or more.

Elevation–Raising your ankle to or above the level of your heart will help prevent the swelling from getting worse and will help reduce bruising. Try to keep your ankle elevated for about 2 to 3 hours a day if possible.

Will I need to wear a brace?

This will depend on how serious your sprain is, if you have other ankle injuries and how your doctor thinks your sprain should be treated. You may need to wear a brace or padded plaster, plastic or fiberglass splint for 10 days to 6 weeks. A brace or splint keeps the bones and injured ligaments from moving, which provides protection, reduces pain and speeds healing.

How long before I can use my ankle?

This depends on how serious your sprain is. If your sprain is mild, your doctor may suggest that you start trying to use your ankle again fairly soon–from 1 to 3 days after your injury.

Special exercises are sometimes needed to regain strength and to help reduce the chance of ongoing problems. Your ankle may need to be supported by taping or bracing to help protect it from re-injury.

What about medicine for pain?

If you need medicine to ease the pain, try acetaminophen (brand name: Tylenol) or ibuprofen (brand names: Advil, Motrin, Nuprin).

What is the best way to use ice?

Putting ice on your ankle can be very helpful, but you also need to be careful. The cold can damage nerves if the ice is left in place too long.

Ice can be left on your ankle for up to 20 minutes at a time. When your skin feels numb, it’s time to remove the ice. Use ice treatments every 2 to 4 hours for the first 3 days after your injury. Ice treatments can consist of ice packs, ice slush baths or ice massages.

To use ice packs, partly fill a plastic bag with crushed ice. Wrap a thin, wet cloth around your injury. Place the ice pack over this and then wrap an elastic bandage around the ice pack to hold it in place.

For ice slush baths, fill a large bucket with water and ice. Place your ankle in the bucket until the skin gets numb.

Ice massages can work well for small areas. Freeze water in 4- to 8-ounce Styrofoam (coffee) cups. Tear the top part of the cup away from the ice. Hold the covered end and slowly rub the ice over the sprained area with a circular motion. Don’t hold the ice on one spot for more than 30 seconds.

How do I wrap a sprained ankle?

Start by cutting out a horseshoe-shaped pad from 1 x 4- to 3 x 8-inch-thick felt. Put this pad around the outside of your ankle joint on both sides of your foot, with the open end facing up.

Then wrap an elastic bandage, such as an Ace bandage, in a basket-weave “figure-eight” pattern. Leave your heel exposed. Reinforce your wrap with 21 x 2-inch adhesive tape over the elastic bandage.

Ask your doctor to show you how to do this. The ankle shouldn’t be wrapped so tightly that the blood flow is cut off.

How soon can I exercise or play sports?

If you’re an athlete, you’ll probably be able to return to your sport in several weeks, depending on how serious your injury is and what sport you’re involved in. When participating in sports, you may need to keep your ankle braced or wrapped for support and protection.

Bicycling, swimming or even running are usually okay to return to right away if they don’t cause pain during or after exercise. But you’ll still need to avoid pivoting and twisting movements for 2 to 3 weeks.

How can I prevent reinjury?

When your doctor feels you’re ready to exercise again, you can help prevent further sprains and setbacks by wearing a semi-rigid ankle brace when you exercise for another 1 to 2 months.

Special wraps that use hook and loop fasteners, or air-filled or laced braces may also help prevent re-injury. Wearing high-top tennis shoes may also help prevent ankle sprains if your shoes are laced snugly and if you also tape your ankle with a wide, nonelastic adhesive tape. Elastic tape or braces are usually not helpful because the elastic gives too much around the joint.

Once your sprain has completely healed, a program of ankle exercises will also help prevent re-injury by making the muscles stronger, which provides protection to the ligaments. Try the following exercises:

Ankle Circles

Sit on the floor with your legs stretched out in front of you. Move your ankle from side to side, up and down and around in circles. Do 5 to 10 circles in each direction at least 3 times per day.

Alphabet Letters

Using your big toe as a “pencil,” try to write the letters of the alphabet in the air. Do the entire alphabet 2 or 3 times.

Toe Raises

Pull your toes back toward you while keeping your knee as straight as you can. Hold for 15 seconds. Do this 10 times.

Heel Raises

Point your toes away from you while keeping your knee as straight as you can. Hold for 15 seconds. Do this 10 times.

In and Out

Turn your foot inward until you can’t turn it anymore and hold for 15 seconds. Straighten your leg again. Turn it outward until you can’t turn it anymore and hold for 15 seconds. Do this 10 times in both directions.

Resisted In and Out

Sit on a chair with your leg straight in front of you. Tie a large elastic exercise band together at one end to make a knot. Wrap the end of the band around the chair leg and the other end around the bottom of your injured foot. Keep your heel on the ground and slide your foot outward and hold for 10 seconds. Put your foot in front of you again. Slide your foot inward and hold for 10 seconds. Repeat at least 10 times each direction 2 or 3 times per day.

Step Up

Put your injured foot on the first step of a staircase and your uninjured foot on the ground. Slowly straighten the knee of you injured leg while lifting your uninjured foot off the ground. Slowly put your uninjured foot back on the ground. Do this 3 to 5 times at least 3 times per day.

Sitting and Standing Heel Raises

Sit in a chair with your injured foot on the ground. Slowly raise the heel of you injured foot while keeping your toes on the ground. Return the heel to the floor. Repeat 10 times at least 2 or 3 times per day. As you get stronger, you can stand on your injured foot instead of sitting in a chair and raise the heel. Your injured foot should always stay on the ground.

Balance Exercises
Stand and place a chair next to your uninjured leg to balance you. At first, stand on the injured foot for 30 seconds. You can slowly increase this to up to 3 minutes at a time. Repeat at least 3 time a day. To increase the difficulty, repeat with your eyes closed.

To Recap:

Ankle Sprain

Ankle sprains are some of the most common sports injuries, often recurring again and again. In most cases the ankle is rolled outwards, resulting in damage to the ligaments on the outside of the ankle.

It is important to get the correct treatment as soon as possible after injury and then follow a full rehabilitation program to get back to full fitness and ensure the injury does not recur.

Symptoms

Symptoms may vary from being very mild to very severe. With a mild sprain the athlete will likely be able to continue with training or competition. A very sever injury will result in hospital treatment and take longer to heal than a broken ankle.

The injury usually occurs from a sudden trauma, twisting or turning over of the ankle. Pain will be felt in the ankle joint itself although will specifically be felt on the outside of the ankle when pressing in on the damaged ligaments. Swelling or bruising may be present but not always in the more mild cases. Pain can also be felt on the inside of the ankle from compression of bones and soft tissue.

Sprains are graded 1,2 or 3 depending on severity and a professional therapist will carry out a full diagnosis and assessment which will include range of motion tests and resisted movement tests to determine the structures injured and extent of the damage.

How bad is my sprained ankle?

Recovery time will depend on how bad the injury is.

Grade 1
 

symptoms will cause only mild pain with little or no instability. There may be some joint stiffness with difficulty walking or running but the athlete is likely to be able to play on. Some stretching or perhaps minor tearing of the lateral ankle ligaments may have happened resulting in mild swelling around the bone on the outside of the ankle.

Grade 2 

symptoms will result in moderate to severe pain with difficulty walking. The athlete is unlikely to be able to play on and will limp. Minor bruising may be evident along with swelling and stiffness in the ankle joint. There is likely to be some instability of the joint resulting from moderate tearing of some of the ligament fibres.

Grade 3 sprains  

usually results in a total or almost complete rupture of a ligament. Severe pain will be felt initially with lots of swelling and extensive bruising. The athlete will experience gross instability of the joint.

Explained

The most common is an inversion sprain or lateral ligament sprain where the ankle turns over so the sole of the foot faces inwards, damaging the ligaments and other soft tissues on the outside of the ankle.

The most common damage sustained in a sprained ankle is to the anterior talofibular ligament. This ligament, as the name suggests, connects the talus with the fibula bone. If the sprain is severe there might also be damage to the calcaneofibular ligament which connects the calcaneus or heel bone to the fibula further back towards the heel. This ligament only becomes injured in more severe injuries.

In addition to the ligament damage there may also be damage to tendons, bone and other joint tissues. If possible an X-ray should be done, as small fractures or avulsion fractures where a tendon or ligament pulls a small piece of bone away can occur. Osteochondral lesions which are tears of the cartilage lining the top of the talus bone are also complications of moderate to severe injuries.

Severely sprained ankles may result in complete ruptures of the ligaments along with dislocation and fractures of the ankle bones.

Treatment 
 
Immediately first aid aims to reduce the swelling by RICE (Rest, Ice, Compression, and Elevation) as soon as possible.
 
Cold therapy or ice should be applied for 10 to 15 minutes every hour for the first 24 to 48 hours. Often pitch side therapists will bind the ankle tightly in a compression bandage as soon as the injury has occurred to restrict swelling, although this must be done with caution for only 10 minutes at a time to prevent starving the area of blood resulting in further injury. 
 
Following the initial acute stage of a sprained ankle exercises should begin as soon as pain allows maintaining mobility and building strength and co-ordination or proprioception in the ankle. A full rehabilitation program should be undertaken which should include wobble board exercises. 
 
A sports injury specialist will assess the injury, make an accurate diagnosis and identify any complications. A doctor may prescribe anti-inflammatory medication (e.g. ibuprofen) to help with pain and swelling. Swelling can be reduced by using compression devices or applying ankle wraps and taping techniques.
 
Specialist cryotherapy devices which apply cold and compression automatically are used widely by professional sports teams. Use of electrotherapy such as ultrasound and laser treatment can reduce pain, swelling and inflammation. Cross friction massage after the initial acute stage may help reduce scar tissue development.

For Enquiries or Appointment bookings, email us at info@iog.com.sg or you may also call us at 9622 1555