Ankle injuries are among the most common injuries in sport.  Ankle sprain is the most common injury in virtually all epidemiological studies. Being the first part of the kinetic chain to withstand the impact of running, twisting, pushing off and landing, the ankle and foot must, within fractions of a second, distribute the impact higher up the chain in complex flexion, extension, eversion and inversion movements of the talo-crural joint and supination and pronation at the mid-foot. The faster the movement, the more important is the balancing act and proprioceptive function of the ankle.

How it happenes

Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions. A great force is transmitted upon landing. You can sprain your ankle if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range in an abnormal position.

If there is a severe in-turning or out-turning of the foot relative to the ankle, the forces cause the ligaments to stretch beyond their normal length. If the force is too strong, the ligaments can tear. You may lose your balance when your foot is placed unevenly on the ground. You may fall and be unable to stand on that foot. When excessive force is applied to the ankle’s soft tissue structures, you may even hear a “pop”. Pain and swelling result.

Grade 1 sprain:

Slight stretching and some damage to the fibers (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. If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs.

Diagnosis

Diagnosis of the injury is determined by examination of the location of the bruising (ecchymosis), swelling, and tenderness. It is also necessary to perform stress testing of the ligaments to determine whether the ligament has been torn. Stress testing of the ligaments is done by pushing on the ankle and attempting to determine if there is any abnormal motion at the joint which would indicate that a ligament has been torn. In addition, x-rays are often performed to check for the possibility of a chipped bone or fracture.

When performing a stress test of the ligaments, a posteriorly directed force is applied to the front of the tibia (shin bone). If the ankle ligaments are completely torn, the tibia will visibly shift backwards at the ankle joint. When the force is removed, the tibia will snap back into its proper position at the ankle joint. When this abnormal motion occurs, the anterior talo-fibular ligament (ATFL) has been torn.

Most ankle sprains need only a period of protection to heal. The healing process takes about four weeks to six weeks. The doctor 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. The doctor 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 two weeks to three weeks.

All ankle sprains recover through three phases:

• Phase 1 includes resting, protecting the ankle and reducing the swelling (one week).
• Phase 2 includes restoring range of motion, strength and flexibility (one week to two 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).

What is the best way to use ice?
Putting ice on your ankle can be very helpful, but you also need to be careful. The cold can damage nerves if the ice is left in place too long.

Ice can be left on your ankle for up to 20 minutes at a time. When your skin feels numb, it’s time to remove the ice. Use ice treatments every 2 to 4 hours for the first 3 days after your injury. Ice treatments can consist of ice packs, ice slush baths or ice massages.

To use ice packs, partly fill a plastic bag with crushed ice. Wrap a thin, wet cloth around your injury. Place the ice pack over this and then wrap an elastic bandage around the ice pack to hold it in place.

For ice slush baths, fill a large bucket with water and ice. Place your ankle in the bucket until the skin gets numb.

Ice massages can work well for small areas. Freeze water in 4- to 8-ounce styrofoam (coffee) cups. Tear the top part of the cup away from the ice. Hold the covered end and slowly rub the ice over the sprained area with a circular motion. Don’t hold the ice on one spot for more than 30 seconds.

Rehabilitation

Adequate rehabilitation is often overlooked by the athlete and subsequently places them at increased risk for re-injury. The overall goals of rehabilitation for an ankle sprain are: decrease swelling, decrease pain, increase range of motion, return to normal gait and function and regain lost strength. Modalities commonly used by athletic trainers in the initial care of ankle sprains include ice, cold whirlpool and electric stimulation. As symptoms improve, athletic trainers will include the use of ultrasound, moist hot packs and warm whirlpool. The use of these modalities is an important factor in the high performance athlete returning to play faster than the recreational athlete. To regain strength and motion, athletic trainers often add stretching activities such as calf stretching and range of motion exercises. Calf raises, rubber tubing exercises and balancing are other forms of exercise one would commonly see in an ankle sprain rehabilitation program. The athlete may be able to return to practice and competition prior to a complete recovery. If this is the case, continuing to strength the muscles surrounding the ankle while improving balance are essential tasks to avoid re-injury.

Prevention

The best way to prevent ankle sprains is to maintain good strength, muscle balance and flexibility.

• Warm-up before doing exercises and vigorous activities
• Pay attention to walking, running or working surfaces
• Wear good shoes
• Pay attention to your body’s warning signs to slow down when you feel pain or fatigue