Your top 10 questions about ankle sprains

Answered by an orthopaedic foot and ankle surgeon

By Dr. Jeremy M Saller, MD

1) What is a sprained ankle?

Your ankle is the joint that connects the bones of your foot to your leg. Ligaments are tough bands of tissue in your body that connect one bone to another bone. In your ankle joint, there are ligaments on both sides of this important joint. The ankle ligaments on the outside (lateral ligaments) are weaker than the ligaments on the inside. The most common type of ankle sprain is an inversion injury which is when the foot rolls inward underneath the leg. This results in an injury to the lateral ligaments on the outside of the ankle. Ankle sprains are a common injury that can occur in people of all ages and can occur with many everyday activities. It is estimated that about 2 million ankle sprains occur in the United States per year. This type of injury often happens when you walk on an uneven surface, trip over something, or when rolling the ankle during running or cutting activities during sports.

2) What is the anatomy of the ankle joint?

The ankle joint is made up of three bones. At the top of the ankle joint there is the larger tibia bone and the smaller fibula bone. The bottom of the ankle joint consists of a dome shaped bone called the talus. Both the tibia and the fibula have a malleolus. Malleolus means “small hammer or mallet” in Latin. The plural form of malleolus is malleoli. The lower end of the fibula is called the lateral malleolus. The inside (medial) portion of the lower end of the tibia is called the medial malleolus. The malleoli of the ankle bones provide bony structural support to the ankle. The ligaments of the ankle provide additional soft tissue support to the ankle.

On the outside (lateral) of the ankle, there are three ligaments.

Anterior Talofibular Ligament: This is the ligament that is most commonly injured in a sprained ankle.

Calcaneofibular Ligament: This is the second most common ligament injured in a ankle sprain. This ligament is usually injured when the foot is inverted and dorsiflexed (the foot is pointing up toward the knee).

Posterior Talofibular Ligament: This is the least common ligament injured on the lateral side of the ankle. If the posterior talofibular ligaments are torn, it is usually torn along with the other two ligaments in a more serious injury.

On the inside (medial) of the ankle, there is one large, strong fan shaped ligament called the deltoid ligament.

Other important ligaments near the ankle include the syndesmosis ligaments. These are ligaments that attach between the fibula and tibia bone just above the ankle joint. These ligaments are involved in a “high ankle sprain”. There are 3 ligaments that make up the syndesmosis.

Anterior inferior tibiofibular ligament (AITFL): This ligament runs between the fibula and tibia on the front of the bones (anterior)

Posterior inferior tibiofibular ligament (PITFL): This ligament runs between the fibula and tibia on the back (posterior)

Interosseous ligament (IO): This ligament runs down the middle of the fibula and tibia at the lower leg.

3) How is the severity of the sprain classified?

The types of ankle sprains are classified based on the severity of the injury of the torn ligament as grade 1, grade 2, or grade 3.

Grade 1: In a grade 1 injury, the ligament is stretched but not torn. The outside of the ankle will usually be sore and painful and slightly swollen. In most cases, you will be able to walk and bear weight.

Grade 2: In a grade 2 injury, the ligament is partially torn. This type of injury will cause more severe pain and swelling which will last longer after the injury. It will often be difficult to bear weight on the ankle secondary to the pain. Bruising over the lateral ankle is also usually present. This occurs due to internal bleeding around the damaged ligament.

Grade 3: In grade 3 injuries, the ligament is completely torn. There will be severe pain, significant swelling, and bruising. Because the ligament is completely torn, you will ankle with be unstable and you won’t be able to bear any weight on the ankle. Complete tears will take longer to heal and have a much higher risk of chronic ankle instability if not treated appropriately.

4) What are the symptoms of ankle sprains?

Common symptoms are pain, swelling, and bruising at the affected area of the ankle. In cases of severe swelling, the foot and toes may be cold and numb due to lack of blood flow. Pain is usually worse when putting any weight on the ankle.

5) What other common injuries are seen when you twist or roll your ankle?

Ankle fractures (broken bone) can occur from the same type of twisting injury that occurs with a lateral ankle sprain. The most common ankle bone fracture is a lateral malleolus fracture which occurred when the lower end of the outside ankle bone (the fibula) is broken. In more severe injuries, the inside of the ankle joint (the medial malleolus) can be broken as well. This is called bimalleolar ankle fracture. Another serious ankle injury occurs when the lateral malleolus breaks along with ligament on the inside of the ankle (deltoid ligament).

Inversion injuries also can cause a fracture of the base of the fifth metatarsal. The fifth metatarsal is the foot bone on the outside of the foot. In these cases, the swelling, bruising, and tenderness will be located over this part of the injured foot.

Soft tissues other than the ankle ligaments can be damaged from an ankle sprain. The peroneal tendons are two tendons that run on the outside of your leg behind the lateral malleolus. These tendons can often be injured in ankle inversion injuries. Minor injuries the tendons can heal on their own. More severe tears of the tendons often require surgical repair.

In severe ankle sprains, the ankle joint cartilage can be damaged. The most common place for this to happen is the dome of the talus bone. This is called an osteochondral dissecans lesion. Mild osteochondral “cracks” can be treated without surgery. In more severe cases in which the cartilage is partially or fully separated from the underlying bone, surgery is often necessary.

6) How do you know when to seek medical attention for an ankle sprain?

Minor sprains may not need immediate medical attention. More serious injuries such as grade 2 and 3 ankle sprains, and ankle or foot fractures are usually associated with severe pain when bearing weight. If you can’t bear weight on the foot or ankle, you should seek medical attention in order to get the proper treatment. Attempting to just “walk off” a more serious injury can result in further injury to the ankle.

7) How does a doctor diagnose an ankle sprain?

The history (what you tell the doctor) of the rolled ankle along with the physical examination findings of tenderness, swelling, and bruising over the ankle ligaments is enough to make the diagnosis of an inversion ankle sprain. Often, ankle x-rays will be taken to make sure the bones are not fractured. In more severe cases, your primary care physician, urgent care physician, or emergency room physician may refer you to an orthopaedic surgeon. The orthopaedic surgeon will perform a physical exam and review the x-rays. Although an MRI is often not needed to the make the diagnosis, in cases of a severe injury or an injury that fails to heal in an appropriate time period, your orthopaedic surgeon may order an MRI in order evaluate all the bony and soft tissue structures around the ankle in greater detail.

8) How is an ankle sprain treated?

Most ankle sprains, even severe sprains, do not require surgical treatment if addressed appropriately. The treatment that is recommended is based on the grade of the sprain. For all grades of ankle sprains, the first thing to do is to follow the R.I.C.E. protocol.

Rest – try not to walk on the ankle until it is comfortable to do so

Ice – ice will help constrict the small blood vessels around the ankle to help control swelling. When using ice, place a cloth over the ankle and place the ice pack over the cloth, limit the ice bag application to 20 to 25 minutes at one time

Compression – a compressive elastic bandage around the ankle with help control swelling and provide a little bit of support

Elevation – elevating the ankle above the heart for the first 48 hours will help limit the amount of swelling by allowing blood to flow back to your heart more easily

For Grade 2 ankle sprains, a support ankle brace is often needed to provide support to the damaged ligaments

For Grade 3 ankle sprains, a walking boot for several weeks is often recommended to provide additional support and immobilization to the ankle. Because there is a much higher risk of ankle instability with this grade, early immobilization is often necessary to prevent the ligaments from becoming over stretched. Grade 3 injuries also often require a longer period of rehabilitation.

Nonsteroidal anti-inflammatory medications such as Ibuprofen or Naproxen can help you manage the pain and swelling in the early period.

For grade 2 and grade 3 ankle sprains, physical therapy can be very helpful in the recovery process. The physical therapist will help you regain your ankle mobility, strength, and balance which will help decrease the risk of another injury down the road. Physical therapy is often done for in initial period of 4 to 8 weeks.

There are three phases of recovery in an ankle rehabilitation program:

Phase 1: This involves resting the ankle and reducing the swelling (following the R.I.C.E. protocol) to protect the ligaments

Phase 2: This involves early rehabilitation or physical therapy to help restore ankle range of motion and strength.

Phase 3: This involves more specific strengthening exercises and proprioception training. Proprioception is your ability to “know” where your foot is positioned without looking at it. This normal function is altered after an ankle sprain and must be restored by appropriate balance training. Restoring proprioception around the ankle will decrease the risk of future ankle sprains. In this phase, more sports specific or work specific rehabilitation is done.

Once you have completed your physical therapy program, it is a good idea to continue doing maintenance exercises to keep your ankle strong and flexible to prevent future injuries.

9) How long does it take an ankle sprain to heal?

The recovery time for ankle sprains is dependent on the severity of the injury. Mild sprains (grade 1) can heal in 2 to 3 weeks. Moderate sprains (grade 2) usually take about 4 to 6 weeks to heal. Severe ankle sprains can take 3 to 6 months to completely heal.

10) What can happen if my ankle sprain doesn’t heal properly?

If your ankle ligaments do not heal properly, they can become permanently stretched to the point where they do not provide enough support to the ankle joint. This can result in frequent ankle sprains and/or frequent swelling and pain around the ligaments. How do you know if you have developed ankle instability? Below are some signs to look out for:

1) frequent recurrent moderate or severe ankle sprains

2) a continued feeling of instability when walking

3) problems with instability or pain when walking on uneven ground

4) persistent weakness in the ankle

5) frequent severe swelling after normal activities such as walking or light exercise

6) chronic pain in the ankle

If you are experiencing the above problems, it is best to see an orthopaedic surgeon to be properly evaluated. He or she will perform a physical exam in order to determine the degree of instability of your ankle. New current x-rays will often be done to make sure that there is not a missed fracture or an abnormal space at the area of the joint where the ligaments attach. Often in cases of instability, the x-rays will be normal. The diagnosis will be made by putting together your history (your story about the symptoms you are having), the physical exam findings, and advanced imaging tests such as an MRI. The MRI can show the damaged ligaments and any other surrounding structures that may be damaged.

For cases of instability that have persisted for over 3 months and haven’t improved from conservative treatments such as bracing, physical therapy, and home exercise regimens, surgery is often needed. The orthopedic surgeon will surgically tighten the damaged ligaments in order to allow them to work properly. After the surgery, you will need more physical therapy in order to regain full range of motion in the ankle and strengthen those weak muscles around the ankle.

I hope this article gives you a nice overview of ankle sprains and how to best manage the injury, and when to seek medical attention. I wish you all the best.

Sources:

2020. FootCareMD – American Orthopaedic Foot and Ankle Society: “Ankle Sprain”. https://www.footcaremd.org/conditions-treatments/ankle/ankle-sprain.

Nicola Maffulli, MD. 2008. “Management of Acute and Chronic Ankle Instability.” Journal of the American Academy of Orthopaedic Surgeon 608-615.

2016. OrthoInfo – American Academy of Orthopaedic Surgeons: “Sprained Ankle”. https://orthoinfo.aaos.org/en/diseases–conditions/sprained-ankle/.

2020. WebMD.com “Sprained Ankle”. February 25. https://www.webmd.com/pain-management/ankle-sprain.

The content of this article including text, images, and graphics is for general informational purposes only. It is not intended to substitute for professional medical advice, including a medical diagnosis and treatment plan.

If you need medical evaluation and you live in South Carolina near Columbia, Irmo, Lexington, or the surrounding regions, you can book an appointment with Dr. Jeremy M Saller, MD at https://www.midorthoneuro.com/doc-saller.php or call 803-256-4107 to book an appointment.