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Who does it affect?
A sprained ankle is a very common injury affecting over 20,000 people per day. A sprained ankle can happen to athletes and non-athletes, children and adults. It can happen when you take part in sports and physical fitness activities or simply if you step on an uneven surface, slip or fall.
Why does it happen?
The ligaments of the ankle hold the ankle bones and joint in position and protect the ankle from abnormal movements such as twisting, turning, and rolling of the foot. A ligament is an elastic structure which stretches and contracts within limits. When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the fibres. The injury may cause you to loose footing or fall over and you may not be able to bear weight on the ankle. You may also hear a popping sound and see the inevitable swelling.
The amount of force determines the grade of the sprain which is often graded as below:
- Grade 1 sprain:
Slight stretching and some damage to the fibres (fibrils) of the ligament.
- Grade 2 sprain:
Partial tearing of the ligament. If the ankle joint is examined and moved in certain ways, abnormal looseness (laxity) of the ankle joint occurs.
- Grade 3 sprain:
Complete tear of the ligament, causing gross instability.
The amount of pain depends on the amount of stretching and tearing of the ligament. Instability occurs when there has been complete tearing of the ligament or a complete dislocation of the ankle joint.
Your consultant will be able to easily diagnose a sprained ankle. An x-ray may be required to ensure that you don't have a fractured bone in the ankle or foot, which can exhibit similar symptoms of pain and swelling. The injured ligament may feel tender. If there is no broken bone, your consultant will be able to tell you the grade of your ankle sprain based upon the amount of swelling, pain and bruising.
If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. If this occurs, it is possible that the injury may also cause damage to the ankle joint surface itself. Occasionally it may be necessary for an MRI (magnetic resonance imaging) scan to provide a detailed diagnosis of the injury.
Walking may be difficult because of the swelling and pain. You may need to use crutches if walking causes pain. Usually swelling and pain will last 2-3 days. Depending upon the grade of injury, your consultant may tell you to use removable plastic devices such as castboots or air splints.
Most ankle sprains need only a period of protection to heal. The healing process takes about 4-6 weeks. Your consultant may tell you to incorporate motion early in the healing process to prevent stiffness. Motion may also aid in being able to sense position, location, orientation and movement of the ankle (proprioception). Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately. Even if an ankle has a chronic tear, it can still be highly functional because overlying tendons help with stability and motion.
For a Grade 1 sprain, use R.I.C.E (rest, ice, compression and elevation):
- Rest your ankle by not walking on it.
- Ice should be immediately applied. It keeps the swelling down. It can be used for 20 minutes to 30 minutes, three or four times daily. Combine ice with wrapping to decrease swelling, pain and dysfunction.
- Compression dressings, bandages or ace-wraps immobilize and support the injured ankle.
- Elevate your ankle above your heart level for 48 hours.
For a Grade 2 sprain, the RICE guidelines can also be used. Allow more time for healing to occur. You may also use a device to immobilize or splint the ankle.
A Grade 3 sprain can be associated with permanent instability. Surgery is rarely needed. A short leg cast or a cast-brace may be used for 2-3 weeks.
Rehabilitation is used to help to decrease pain and swelling and to prevent chronic ankle problems. Ultrasound and electrical stimulation may also be used as needed to help with pain and swelling. At first, rehabilitation exercises may involve active range of motion or controlled movements of the ankle joint without resistance. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Lower extremity exercises and endurance activities are added as tolerated. Proprioception training is very important, as poor propriception is a major cause of repeat sprain and an unstable ankle joint. Once you are pain-free, other exercises may be added, such as agility drills. The goal is to increase strength and range of motion as balance improves over time.
All ankle sprains recover through three phases:
- Phase 1 includes resting, protecting the ankle and reducing the swelling (1 week)
- Phase 2 includes restoring range of motion, strength and flexibility (1-2 weeks)
- Phase 3 includes gradually returning to activities that do not require turning or twisting the ankle and doing maintenance exercises. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities) such as tennis basketball or football (weeks to months)
Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to control pain and inflammation.
Surgical treatment for ankle sprains is rare and is reserved for injuries that fail to respond to nonsurgical treatment, and for persistent instability after months of rehabilitation and non-surgical treatment. If surgery is required, you will be offered one of the following:
Your consultant will look inside the joint to see if there are any loose fragments of bone or cartilage, or part of the ligament caught in the joint.
Your consultant will repair the torn ligament with stitches or sutures, or use other ligaments and/or tendons found in the foot and around the ankle to repair the damaged ligaments.
Specific surgical methods and associated risks are described in relation to treatments and will be discussed with you on an individual basis.
You will be fit to go home soon after the operation, normally on the same day. Simple analgesia (pain relief) usually controls the pain postoperatively and will be advised on discharge. The foot should be elevated as much as possible for the first 5 days. Gently bend and straighten the ankle joint from day 1.
Rehabilitation after surgery involves time and attention to restore strength and range of motion so you can return to pre-injury function. The length of time you can expect to spend recovering depends upon the extent of injury and the amount of surgery that was done. Rehabilitation may take from weeks to months.