Figure 10

Figure 11

Figure 12

An ankle sprain is a common injury and usually occurs when the ankle is twisted (inverted). The term “sprain” signifies injury to the soft tissue, usually the ligaments, of the ankle. (Figure 10: picture of inversion accident)

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Anatomy

A ligament is made up of multiple strands of tissue similar to a nylon rope. A sprain results in tearing of the ligaments. The tear can be a complete tear of all the strands of the ligament or a partial tear; in which only some of the strands of the ligaments are torn. The ligament is weakened by the injury, how much depends on the degree of the tear. The lateral ligaments (those on the outside of the ankle) are by far the most commonly injured ligaments in a typical inversion injury of the ankle.

On the lateral side of the ankle there are three ligaments that make up the lateral ligament complex. These include the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The ATFL keeps the ankle from sliding forward and the CFL keeps the ankle from rolling over on its side.

Symptoms

Initially, the ankle is swollen, painful, and can become ecchymotic (bruised). The bruising and initial swelling (edema) are due to ruptured blood vessels from the tearing of the soft tissues. Most of the initial swelling is actually bleeding into the surrounding tissues. This initial swelling due to bleeding then increases as fluid leaks into the tissues as well over the next 24 hours. (Figure 11: picture of bruising on lateral ankle)

Diagnosis

The diagnosis of an ankle sprain is usually made by physical examination of the ankle with x-rays to make sure that none of the bones of the ankle are fractured. If your doctor suspects that there is a complete rupture of the ligaments, he or she may order stress x-rays, as well. These x-rays are taken while someone twists or “stresses” the ligaments. Also an MRI of the injured ankle will give the surgeon the ability to evaluate the ankle ligaments as well as the surrounding tendons.

Treatment begins by:

• Controlling swelling
• Controlling pain
• Controlling weight bearing

Elevation will help control the swelling as well as gentle compression and ice. Mild pain relievers will help with the pain and crutches will prevent weight bearing.

Casts are used in severe cases. As treatment progresses, early weight bearing has been shown to be beneficial. Braces that can be worn to support the ankle but still allow weight bearing is the most popular treatment method today. Healing of the ligaments usually takes about 6 weeks but the swelling may be present for several months. Your doctor might refer you to a physical therapist to help you regain full function of your injured ankle. (See rehabilitation section below)

Ankle Instability

In a small number of cases, the ligaments will not heal to be as strong as normal. This results in an ankle that is unstable and has a tendency to give way or twist again very easily. Ankle instability can lead to an ankle that is sore and painful, sometimes swollen, and untrustworthy on rough terrain. If your ankle ligament does not heal adequately following an ankle sprain, there are several things that may be suggested by your doctor.

A physical therapy program may help strengthen the muscles around the ankle to help make the ankle more stable. The therapy is also necessary to “retrain” the proprioceptive nerves around the ankle that have been torn with the ligament. These nerves are important in telling our brains how to use the muscles to allow the joints to properly function. An ankle brace may also help control some of the instability and prevent the ankle from giving way.

Surgery

If all these simple measures fail, surgery may be suggested to reconstruct the ligaments that have been torn. Surgery involves making an incision on the side of the ankle to allow the surgeon to clearly see the torn tendons/ligaments and perform surgical repair. Occasionally, a neighboring tendon is used to reinforce the repair. Also, the surgeon may use an arthroscope to assist in seeing and repairing the torn ankle ligaments.

After surgery, your lower leg will usually be placed in a cast or brace for about 6 weeks to allow the tendon reconstruction to heal. Following removal of the cast, physical therapy will be required to regain full use of the ankle.

Rehabilitation

Whether you have had an ankle sprain that did not require surgery or whether you are recovering from surgical reconstruction of the ankle ligament, you will probably benefit from physical therapy. Your physical therapist will evaluate your foot and ankle on your first visit to therapy. This will enable your therapist to locate the sore tissue and develop a treatment plan.

The outside (lateral) ligaments of the ankle are hurt most often in an ankle sprain. This is because most ankle sprains are from an inward twisting (an inversion injury). When this happens, the force from the twist may also compress the tissues on the medial, or inside, of the ankle. This can be a source of pain and inflammation on the inside area of the ankle. A grade of I, II, or III is usually given depending on whether you had a slight sprain (grade I), significant tearing and bleeding (grade II), or a complete rupture of the ligament (grade III).

Acute Treatment

Treatment can vary depending on which grade sprain you have. In each case, the first line of treatment is to calm the inflammation and halt the swelling. The PRICE principle can help address each of these needs: Protection, Rest, Ice, Compression, and Elevation.

Rest: A brace or splint will keep the ankle in a safe position, helping you avoid more strain to the sore area. In severe cases, you may require a pair of crutches to limit weight on the foot.

Ice: Cold therapy in the form of ice towels, bags, or wraps can aid on slowing the inflammatory process and in limiting pain. Apply as directed by your therapist.

Compression: An elastic wrap or an air-type brace can compress the sore area, keeping the swelling to a minimum.

Elevation: Keep your ankle elevated above the level of your heart. This will help drain the extra fluid (edema) back into the lymphatic system.

Other treatment choices may be used to further limit pain and inflammation. Examples include contrast baths with hot and cold applications, cold whirlpool, or electric stimulation.

Early Healing Phase

Range of Motion Exercise: As healing gets under way, it is important to begin a series of movement exercises for range of motion (ROM). At first, you’ll work on bending and straightening the ankle. Later, diagonal motions can be used.

Strength Progression: Next, you will begin a strengthening progression for the muscles around the ankle. Emphasis should be placed on the muscles that pull the foot up and out (evertors), up (dorsiflexors), and raise the heel (plantarflexors). Isometric exercises can be used in the early stage of rehabilitation. These are strengthening exercises done with the ankle at different angles, helping you stay away from painful position of the ankle. These exercises are beneficial in reducing the overall pain and swelling. They also help the muscles remember what they are supposed to be doing. (Figure 12: picture of patient with physical therapist)

Early Resistive Exercises: Some types of equipment are helpful in reducing the effects of gravity, allowing you to begin strengthening without causing pain. One example is the sled. It can be set at lower angles at first and then gradually progresses over the course of physical therapy as pain eases. Therapeutic band, pulleys, or isokinetic devices may be used to apply progressive resistance to the muscles around the ankle.

Balanced Resistive Exercises: These exercises are especially important following a ligament injury. Healthy ligaments send information to the central nervous system about the position of a joint. That’s partly why when we close our eyes we know precisely where our limbs are positioned. Once a ligament has been injured, these receptors are unable to receive and send the needed information to the brain. This increases the possibility of injury in the future. Balance exercises help restore this position sense by heightening the sensitivity in the remaining intact receptors. Examples of these types of exercises involve standing and walking on uneven or very soft surfaces, single-leg balance, mini trampoline balance, and
progressive agilities.

Program Progression

More intensive exercises can be chosen as the pain and irritation are controlled. Progressive resistive exercises (PREs) are a group of exercises for the leg and ankle muscles in which the amount of weight being used is carefully increased. Closed-chain exercises are done by fixing the sore-side foot on the ground. This allows the muscles around the ankle to be exercised while easing stress on the ligaments. Examples include partial squat, weight shifting, step ups/downs, single-leg balance, and lunge. These exercises can be used to heighten “motor” control in the ankle muscles. Moving a specific amount of weight but controlling the speed at which it is moved does this. Higher level exercises, like agilities, progressive running and cutting, polymerics, and heavy resistive training can be done to prepare the ankle for specific job or sport demands.

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