Ankle Sprains

Contents:

1. Symptoms of ankle sprains
2. What exactly is a sprained ankle?
3. Severe ankle sprains
4. Different grades of ankle sprains
5. Treating ankle sprains
6. Surgical procedures used to treat ankle sprains

In my opinion – a doctor of the Polish Football Association PZPN – ankle joint sprains are an underestimated injury which, if badly treated or left untreated, could lead to serious consequences for professional athletes: instability, recurring sprains, and, after a few years, irreparable degenerative changes to the ankle joint.

Correct, immediate action is key – on the pitch or on the court – as well as subsequent conservative or surgical treatment. Thanks to new surgical techniques, e.g. internal bracing, we are able to immediately restore stability to the ankle joint and shorten the time it takes to get back to training to a minimum. If you have sprained your ankle, feel free to book an appointment for a full assessment. I recommend you read the article so that your ankle joint regains full function even after serious injury. 

Ankle sprains are the most common injury to the lower limb, and not just among athletes. It can happen to anyone during normal everyday activities. Even though ankle sprains seem trivial, they can cause many problems. What is more, once the ankle is sprained, it is more likely to suffer from injury in the future. 

Even though the sprain may not appear serious at first, if it is untreated or not treated correctly it can lead to ankle joint instability and cause many more problems in the future. This is why it is important to get the right treatment as soon as possible. Below you will find the most important information about the ankle joint, including the symptoms of ankle sprains, treatment and rehabilitation options and advice about how to prevent further damage.

Symptoms of ankle sprains

People with ankle sprains often suffer from symptoms which can be mild or severe. Slight ankle sprains do not usually cause the patient much trouble and athletes are even able to continue with training or competitions. However, severe damage can warrant hospitalisation. To avoid many problems and further injury it is important to not make light of the symptoms. You must see an orthopaedist or sports doctor as soon as possible. 

Most often ankle sprains are accompanied by pain around the ankle which is more intense while walking, when there is more pressure on the strained ligament. Other symptoms include swelling and bruising which are just as common but do not appear in every case.

Ankle sprains are classified according to a 3-point scale, depending on the extent of damage to the tissue.  Treatment depends on the grade of the injury. 

What exactly is a sprained ankle?

The ankle joint is made up of joint surfaces, which are: the distal end of the tibia and fibula and the talus bone. There is also the joint capsule, which is strengthened by ligaments: medially by the deltoid ligament, and laterally by the anterior talofibular ligament, the posterior talofibular ligament and the calcaneofibular ligament. The joint capsule holds the bones together, creating the correct conditions for the joint to work, preventing the neighbouring tissues from getting in between the bones and holding the joint fluid.

A sprained ankle is basically a strained or ruptured joint ligament with damage to the joint capsule. 

• The most common kind of this injury is an inversion sprain, which causes excessive mobility in the ankle joint. The sole of the foot rotates medially, which damages the outer ligaments of the ankle joint. 

• However eversion ankle sprains occur much less often, and can be accompanied by breakages. The sole of the foot rotates laterally causing damage to the deltoid ligament. 

The ligament that is most often damaged is the ATFL – the anterior talofibular ligament, located around the lateral malleolus. The ATFL is the main ligament that stabilises the ankle joint. So the important ligament is damaged most often, and its injuries are sometimes underestimated. As the name suggests, the ligament is attached to the anterior side of the ankle and runs medially to the front. The insertion is at the front end of the side surface of the talus bone. 

If the injury is serious, the CFL – calcaneofibular ligament can also be damaged. It joins the heel bone to the fibula. This ligament isn’t damaged as often, only as a result of heavier loads. Naturally, it carries a lighter load, is stronger and more flexible.

Severe ankle sprains

Injury to the ligaments can also be accompanied by damaged to the tendons, bones, and other soft tissues. This is why it it important to get the best diagnosis soon after the injury. An orthopaedist assesses if it is necessary to do an x-ray (to get a clear picture of the bones of the ankle joint), or if it is enough to do an ultrasound. An x-ray allows us to uncover other small ruptures or bone breakages. A severely sprained ankle with a damaged ligament can cause instability in the ankle and may need to be treated surgically.

Different grades of ankle sprains

The time it takes to recover from an ankle sprain depends on the degree of damage, which is described in three degrees depending on its severity.

First degree – characteristics:

• Strained or minimally ruptured ankle joint ligament
• Minimal or lack of stability of the ankle joint
• Mild pain
• Possible slight swelling around the ankle
• Occasionally the ankle joint can stiffen up making it difficult to bend, e.g. when walking

Second degree – characteristics:

• Moderately torn ligament tissues
• Joint instability 
• Pain ranging from moderate to severe which makes it impossible to walk
• Swelling and stiffness in the ankle joint
• Small bruises may also appear (haematomas)

Third degree – characteristics:

• Completely torn ligament tissues
• Complete joint instability
• Severe pain 
• Severe swelling
• Usually extensive bruising (haematomas)

Treating ankle sprains

Treating a sprained ankle involves both first aid and long-lasting rehabilitation of the ankle joint in order to strengthen it and prevent further injuries. The course of treatment is usually as follows: the pain and swelling is reduced in order to begin exercises and restore full mobility and stability to the ankle joint. 

Immediate first aid:

To alleviate pain and decrease swelling, there are four steps to be taken, i.e. the RICE procedure: Rest, Ice, Compression, Elevation.

• Rest It is recommended that you take a break from physical activity and if necessary use orthopaedic crutches, especially in the first days. With time you can gradually start putting weight on the joint and begin rehabilitation. 
• Ice You should put ice on the injured area immediately after the injury. You can use a special ice spray (from the correct distance, wiping the skin after each time), or just place the ankle under a running cold tap (for a dozen or so minutes). For the first 48 hours after the injury it is recommended that you compress ice to the area 3-4 times a day for 20 minutes. Using ice and compression will help alleviate the pain, decrease swelling and haematomas and stimulate blood flow. Use a thin piece of material between the ice (or cool gel ice packs) and the skin to prevent it from freezing. 
• Compression Immediately after cooling, you should tightly wrap an elastic bandage around the ankle, from the toes to the middle of the calf. The bandage should be comfortable and not cut of circulation to the foot and ankle. Using a tight bandage decreases swelling and haematomas. It also decreases joint mobility, so that the damage doesn’t get any worse.
• Elevation Try to keep the leg higher than the heart as often as possible. Lifting the leg decreases swelling and haematomas in the calf.

After the first painful post-injury phase, you can start using other methods that help restore function to the damaged joint. Exercises such as straightening the ankle joint help to move the joint and reduce swelling. You also need to stretch your calves.

Other treatment methods (often surgical) and specific rehabilitation will be necessary in the case of more serious sprains, including tendon rupture and bone breakages.

Rehabilitation

Rehabilitation is essential to heal a sprained ankle as well as possible – to restore full function as quickly as possible and strengthen it to prevent further injury. The rehabilitation plan must be tailored to meet the needs of the patient. It depends on the degree of injury, the patient's age and their level of activeness. A full rehabilitation plan includes the following: reducing pain and swelling, improving the flexibility and strength of the joint, restoring motor coordination (including proprioceptive deep sensation) and finally returning to normal physical and sporting activity. 

Preventing further injury

The best way to prevent ankle sprains is to stay fit, flexible and maintain muscle balance. Above all: 

• Always remember to do warm-up exercises before training
• Be careful when walking and running and try to avoid uneven surfaces
• At the beginning when you return to sport, use an ankle brace, tape, or an elastic bandage.

How do you restore function after a sprain?

• Minimal immobility 

Immobilising the ankle joint can cause serious problems in the future. The ankle joint regenerates much quicker when it is placed in a semi-rigid cast or stabiliser. I always very carefully assess whether immobilisation is even necessary and if so for how long. To help me do this I use ultrasound and MRI scans and I am in regular contact with the physiotherapist. An important issue is time. If the joint is immobilised for too long this can cause stiffness and make it susceptible to further injury.

• Exercises 

Even if you feel moderate pain when walking, you should do exercises that restore function to the joint a few times a day. Some simple exercises will help you maintain good joint mobility and will improve reconstruction of the damaged ligaments by slightly stretching and strengthening them. We try to get you to be able to begin exercising on moving platforms as soon as possible, e.g. wobble boards, which allow you to consciously rebuild a feeling of stability in the joint.

Strengthening the Achilles tendon

You can begin stretching the Achilles tendon shortly after spraining your ankle. Perform the exercises in the following way: sit or lie on the floor, take a towel and wrap it around your toes. Pull on the towel, pushing the toes upwards. You will feel stretching at the back of the calf. Do this exercise for a few minutes 3-4 times a day.

Writing in the air

In a seated or lying position try to ‘write’ the letters of the alphabet in the air with your toes. Do the letters as big as possible, making exact turns with the ankle. When ‘writing’ you can be creative – changing the font and the size of the letters. 

Stretching exercises

The next step, after moving the ligaments around, is to stretch and strengthen the surrounding muscles. By doing this, you can both strengthen the ankle joint and prevent further injuries. Examples of exercises:

• Standing on your toes – stand on the stairs or on another raised surface keeping the heel on the edge.  Try to stand almost on the edge of your toes and then return to the starting position, all the while keeping your heel at the edge.  Repeat this 10-20 times, even 4 times a day.

• Walking on your toes and heels – try walking for a minute on your toes, and then on your heels. Do alternate exercises: heel-toe, heel-toe, and try to do these exercises for 10 minutes 4 times a day.

• Your physiotherapist will teach you more exercises that you can do at home. E.g. you will be taught exercises using special rubber bands. 

Activeness!

When the pain and swelling goes away, you can start walking faster and then jogging. Athletes can start more intensive and specialised exercises. The key is to gradually increase the load. When you are returning to sport, training should be short and less intense. It is advised for the sports doctor to work with the trainer.

What should I do if the pain doesn’t go away?

The most common cause of chronic pain after a sprained ankle is incorrect diagnosis (assessment of the degree of damage) and incomplete or incorrect rehabilitation. It can also be caused by a lack of the proper procedures and exercises at physiotherapy as well as returning to appropriately intense training too quickly (or too slowly!). That is why it is worth being under the supervision of an orthopaedic sports doctor so that nothing is neglected and you return to maximal form!

Surgical procedures used to treat ankle sprains

Reconstructive surgery is thankfully performed very rarely on patients who have a sprained ankle. Surgical treatment is used to treat recurring ankle sprains and chronic pain. It specifically applies to people who have had a complete rupture or an incorrectly treated strained ligament. The developments made in orthopaedics in recent years have created a minimally-invasive option – arthroscopy. 

Ankle arthroscopy is performed when, e.g. as a result of a sprained ankle there is damaged not only to the ligament, but also to the synovial membrane, articular cartilage, or when loose fragments of articular cartilage ‘swim around’ inside the joint and they need to be removed. Arthroscopy, which is a minimally-invasive endoscopic procedure, allows us to safely repair most of the internal joint structures. We insert an elongated camera and instruments into the joint through two incisions at the front of the ankle that are a few millimetres long. This procedure is often performed on athletes and in the case of relatively young patients (usually younger than 60 years old) who are trying to regain full function and ankle joint performance. Before the procedure I conduct a full diagnosis to have an exact plan of the course of the procedure. You can learn more about the procedure itself in the operations section – click here.

• Damaged tendons and ligaments in the ankle joint can also be treated with other methods. The best effects can be achieved thanks to Orthokine ® therapy and platelet-rich plasma therapy.