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We have all done it before. At some point, we have “rolled” our ankle while doing an activity consisting of either playing some backyard basketball, running in the woods, or stepping on something awkwardly.
Ankle sprains are the most common type of injury to affect active and athletic individuals, outranking ACL injuries.
The human foot and ankle is a unique body part in that it has to demonstrate a perfect balance of mobility and stability.
The foot and ankle are structures that allow us to be stable as one of the only mammals to walk upright while also being able to feel the surface below us and adapt to the underlying terrain.
It is no wonder that injury to this area can result in significant impairment, often contributing to continued dysfunction down the line if not appropriately addressed.
In this article, we will discuss ankle instability, the mechanisms of injury, treatment, and prevention.
An ankle sprain is a tear in the ligaments of the ankle.
Ankle sprains are one of the most common injuries amongst active and athletic individuals. Ankle sprains can result in limitations during daily life activity as well as removal from sports participation.
More commonly occurring in females, most individuals who experience one episode of an ankle sprain are likely to have a reoccurrence.
Studies have found that anywhere from 30-70% of individuals with a history of an ankle sprain are likely to have another episode as well as pain and ankle dysfunction lasting up to a year after the injury.
The term “sprain” is often taken lightly as a common misconception is that sprains are not that serious since some sprains can be considered low grade.
The most common symptoms of an ankle sprain are:
When you sprain your ankle ligaments are torn.
The lateral ligaments most commonly torn are:
The medial ligament most commonly torn is the deltoid ligament.
Ligaments commonly torn in high ankle sprains are:
After an ankle sprain, you should immediately get off your feet and apply ice to keep the swelling down.
Once the swelling is under control, consult your primary care doctor or physical therapist to diagnose the severity of the ankle sprain and treatment options if needed.
The time it takes to recover and heal from an ankle sprain depends on the severity of the sprain and what treatment options are implemented.
Generally speaking, it takes ligaments at least six weeks to heal.
Muscle strength, range of motion, proprioception, and return to sport will vary from individual to individual.
Sprains are usually characterized in a grading system, which can sometimes be very subjective.
Grade 1 sprains involve the stretching and small tears in the ligaments. Full ligament healing occurs within 2-3 weeks, but it will take up to 6 weeks for full scar tissue maturation.
Grade 2 sprains involve larger tears in the ligaments compared to grade 1 sprain, but they are not a complete tear.
Full ligament healing occurs within 4-6 weeks.
Generally, this type of sprain rehabilitation is needed.
A grade 3 ankle sprain involves the complete rupture or tear of the ligament(s).
These types of sprains can also fracture bones or causes high ankle fractures.
Rehab times for grade 3 ankle sprains are 6-12 weeks but is highly variable depending on the specific injury.
A small tear can be considered 10% of the fibers torn, and a moderate tear can range anywhere from 50-75% fibers torn. It is tough to conclude that a ligament torn at 50% is more deficient that one at 75%.
Even though it may seem common sense that more fibers damaged would necessarily result in weaker tissue integrity, the remaining intact fibers can sometimes scar down and be surprisingly stable.
This is the difference between an incomplete tear and a complete tear.
Lateral ankle sprains are usually more common than medial ankle sprains because the ankle and foot are more mobile with movements inward. There is more movement of the foot inward into inversion than there is moving outward into eversion.
Try moving your foot in and then out while keeping your knee straight, and you will notice the difference. More mobility means sacrificing stability.
Therefore the outside of the ankle is more prone to injury than the inside.
Lateral ankle sprains usually result mostly from non-contact mechanisms where there is poor communication of sensory receptors resulting in weak muscle firing patterns.
In other words, the person’s central nervous system is unable to send the proper message to the muscles to stabilize the foot in response to the external force.
The ligaments affected most commonly in a lateral ankle sprain are displayed above.
Physical therapists and rehab practitioners will use specific mechanical stress movements, which are provocative special tests to determine the integrity of the ligaments and assess for pain.
The tests are performed on both legs to appreciate the individual’s average level of joint mobility.
Studies have revealed that individuals with more joint laxity have a diminished ability with motion perception meaning they cannot respond with proper control of their foot and ankle to unstable surfaces or external forces such as something pushing them off balance.
Studies also have revealed that individuals with a history of ankle sprains also have the same deficits in motion perception performance compared to individuals that have no history of ankle sprains.
Medial ankle sprains usually occur from some trauma resulting in positioning the foot in a downward and outward movement such as catching the toes into the ground.
Think about the “horse-collar tackle” in football where a player pulls another one down from the back of their shoulder pads. The foot can get caught underneath the player and result in a medial ankle sprain.
Ankle locks in martial arts and jujitsu or MMA are the same mechanisms of injury. The individual is forcing the foot into a downward and outward movement to stress the inside of the ankle, producing an “ankle lock,” usually causing the other individual to tap out or result in a broken ankle.
Usually, due to the rotational forces with this type of ankle sprain, fractures can occur, often requiring surgical repair.
Considering the medial ankle is more stable than the lateral, injury to the medial side is more detrimental.
Sometimes it is not the amount of force applied but rather the direction and angle of the force applied that can result in an injury.
The muscles on the outside of the ankle that work to bring the foot outward and upward are called Peroneals.
They run along the fibula bone, which at the top is where the peroneal nerve can be found. You can find it by locating the boney prominence on the outside of your knee.
If you push hard enough, you can hit the nerve and cause a shocking, tingling sensation down into your foot.
The peroneal nerve innervates the muscles that allow you to bring the foot upward and outward.
Individuals with diabetes that have severe neuropathy (disease of the nerve) can have what is referred to as “drop foot.” The condition results in damage to the nerves of the lower legs, resulting in damage to the peroneal nerve in particular.
A little fun fact is that during riots or mobs, law enforcement will often hit the side of the leg at this spot to shock the peroneal nerve and cause the leg to give out.
It also is a target for striking with kicks during combat sports. Contact and non-contact injuries to the lower leg, including very involved ankle sprains, can result in trauma to the nerve from impact, swelling, or muscle aggravation.
Symptoms can usually result in the sensation of tingling, pins and needles on the outside of the lower leg and foot or notable weakness with attempting to lift the foot.
Peroneal muscles displayed in the above image.
This image shows the pathology involving trauma to the peroneal nerve. Superficial nerves usually result in the sensory input, and deep nerves result in motor function.
So what is done for the treatment and prevention of future sprains?
As mentioned before, the occurrence of one ankle sprain increases the risk for future sprains. Most commonly, people do not seek treatment after an ankle sprain.
It is widespread practice to ice, rest and resume activity once feeling better but this is where the problem resides.
Individuals tend to return back to activity prematurely or without executing the proper measures to restore normal function.
After the trauma that occurs from an ankle sprain, the nerve fibers that function for control and proprioception of the foot and ankle become damaged.
Proprioception is almost like our sixth sense. It is how we are aware of where our body is in relation to everything else. When you stand close to something, you generally have an idea of how close you are to that object.
Ever “feel” someone coming up behind you? It’s almost like our innate “spidey sense,” for all you Marvel fans out there. Restoring the function of these sensory nerves is essential for a return to normal function.
Let’s break down the type of treatments rendered for ankle sprains.
The most popular go-to method. Ice is only useful for the first 24-48 hours after an initial injury and only has the most benefit to control excessive swelling.
Swelling has to be controlled so that movement can be restored and /or imaging can be done to determine if there are fractures or tears.
Too much swelling can impede mobility, range of motion and the ability to view imaging results.
Inflammation is not bad! Inflammation is the body’s way of bringing the proper nutrients to the area to heal and repair.
A constant flow of these nutrients is vital towards the appropriate healing process so using excessive ice and cold therapy is not as beneficial as it was once believed.
Using ice excessively is an older treatment methodology, and throughout the years with more research, treatment philosophies have changed. The goal is not to close the floodgates, but rather control the flow through the floodgates.
Active movements use of warm modalities, and muscle activation techniques have been found to yield better results towards recovery.
Think about a sponge filled with water. The best way to remove the water is to squeeze it. The same principle applies to muscle activation in providing the pump required to push fluid out of the area.
Most physicians will either brace or issue a boot to protect the foot if pain or tissue damage is excessive. This is in an attempt to de-stress the area and allow for healing without frequent aggravation.
The boot allows for protection while providing the individual with the ability to be still mobile.
Taping techniques are also used to help support the foot and ankle and promote proper mechanics with walking and standing.
Following sprains, joint mechanics can become altered. With lateral ankle sprains, when the foot moves inward during the injury, the fibula tends to glide down, resulting in shifting of the joints.
This limits the ability to execute dorsiflexion or the ability to raise the foot correctly.
Taping helps to support the ankle joint towards the correct alignment and acts as an adjunct to the exercises used to engage the muscles to restore normal mechanics.
Rocktape has become increasingly popular amongst athletes, probably often overused and misunderstood. This type of tape works differently than supportive tape in that it has an elastic property and is used more as a sensory feedback technique.
Taping methods with this type of tape are used to mimic and inhibit muscle function to promote a feedback mechanism to the individual to either initiate movement or limit movement.
This is best applied when a patient is challenged with re-learning how to complete specific movements or avoid painful ranges during rehab.
Surgery is usually not performed for lateral ankle sprains as it has been found that the risk outweighs the benefit.
Surgeons have found that most of the ligaments tend to scar down, and the re-education of muscle function is sufficient enough towards restoring function.
The muscle strength and neuromuscular control are the primary gatekeepers towards preventing injury, as deficient activation was the mechanism of injury in the first place.
Surgery is only done if there are complete tears of the majority of the ligaments, and extreme laxity is present.
For medial ankle sprains or sprains resulting in fractures, surgery may be required depending on the severity and type of fracture or tissue damage.
Ankle braces are often used after rehab or surgery when return to play of a sport, or athletic engagement resumes. The brace is usually a lightweight, lace-up tie model that can fit into a shoe and be worn during activity.
Ankle braces provide extra stability as a secondary defense against re-injury.
No studies have revealed that braces of this type have any adverse effects on muscle function in terms of providing too much support. Muscle function remains the same with brace wearing.
Although it will vary depending on the severity of the sprain and the individual, ankle braces should be worn for 2-6 weeks or more if recommended by your physical therapist.
Physical therapy plays a significant role in restoring the normal function of the foot and ankle to return individuals to their prior level of function with reduced risk of re-injury.
Studies have demonstrated that balance and dynamic stability training exercises help to improve poor movement patterns and re-educate proper stability.
Basic exercises to engage the muscles, such as the isolated band exercises seen above are staple components to build a foundation of proper muscle function.
Once essential muscle function improves, progressions to balance training on compliant surfaces, dynamic surfaces and balance drills with various stimuli help to reintegrate the proper central nervous system response to stressors and resistance.
According to healthline.com, the 15 best ankle sprain exercises are:
About The Author:
Michael St. George, PT, DPT (@icore_stgeorge on Instagram) is a physical therapist who works for Excel Physical Therapy and Fitness, which is a private practice that is based around the greater Philadelphia region and suburbs. He is FMS, SFMA, Y Balance, and Motor Control Test Certified with eight years of experience in outpatient orthopedics and sports medicine. His training consists of experience working with physicians and surgeons from the Rothman Institute and therapists in his field specializing in various manual techniques and advanced treatment procedures.