Ankle sprains are among the most frequent injuries affecting individuals of all ages and activity levels, and they are a leading cause of missed athletic participation. These injuries occur when the sturdy ligaments stabilizing the ankle are overstretched or torn. The severity of an ankle sprain depends on the number of ligaments affected and the extent of the damage.
In most cases, ankle sprains respond well to conservative treatments, such as applying ice, elevating the ankle, using over-the-counter pain relievers, and performing basic rehabilitation exercises. However, if swelling or pain persists for several weeks, or if bearing weight on the affected ankle becomes challenging, a medical evaluation may be necessary to rule out a severe sprain or fracture.
When symptoms fail to improve with non-surgical treatments, surgical intervention might be required to repair or reconstruct the damaged ligaments. Without proper care and rehabilitation, severe or untreated ankle sprains can lead to long-term complications, such as chronic pain, arthritis, or ankle instability, increasing the risk of recurrent injuries.
Description
Ligaments are robust, fibrous tissues that play a vital role in connecting bones throughout the body, ensuring stability and proper alignment of joints. In the ankle, multiple ligaments work together to maintain bone positioning and provide the joint stability needed for daily activities like standing, walking, and running.
Approximately 90% of ankle sprains result from an inversion injury, where the foot turns inward, primarily affecting the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) on the outer side of the ankle. Less commonly, medial ankle sprains occur due to eversion injuries, where the foot turns outward, damaging the deltoid ligament on the inner side of the ankle.
An ankle sprain is an injury to one or more of the ligaments that stabilize the ankle.
The severity of a sprain can vary widely, from small tears in the ligament fibers to complete ruptures. When a ligament is completely torn, the ankle may become unstable, which can lead to progressive damage to the bones and cartilage within the joint if not properly addressed.
The lower leg or foot can roll, or invert, leading to a sprain of the ligaments on the outside of the ankle.
Cause
Ankle sprains frequently occur due to a sudden twisting motion of the foot or ankle. In cases of severe ligament tearing, patients may hear or feel a distinctive “pop” at the time of injury. These injuries can happen unexpectedly during various activities, including:
- Walking or exercising on uneven terrain
- Tripping or falling
- Engaging in sports that require sudden directional changes or jumping, such as basketball, tennis, soccer, football, or trail running
Symptoms
The symptoms of a sprained ankle can vary significantly depending on the severity of the injury. Common signs include:
- Pain, which may be present both at rest and during weight-bearing activities or movement
- Swelling around the affected area
- Bruising, which can range from mild to extensive
- Tenderness when the area is touched
- Ankle instability or a sensation that the ankle may give out
In severe cases, the symptoms of a sprain can closely resemble those of a fractured bone, making it essential to seek prompt medical attention to ensure an accurate diagnosis and appropriate treatment.
Bruising and swelling are common signs of a sprained ankle. Symptom severity varies depending on the degree of injury to the ligaments.
Doctor Examination
Physical Examination
Diagnosing an ankle sprain involves a detailed discussion about the injury and a thorough physical examination of the foot and ankle. Due to inflammation and swelling, this process may cause some discomfort. Key steps in the examination include:
- Observation: The doctor will visually assess the injured ankle and compare it to the uninjured one. Swelling and bruising over the affected ligaments are common signs of a sprain.
- Palpation: By gently pressing on specific areas around the ankle, the doctor can pinpoint the ligaments involved based on tenderness in those regions.
- Range of Motion Testing: The doctor may test the ankle’s ability to move in various directions, though stiffness and swelling can limit movement.
- Stability Testing: The ankle may be manipulated in controlled directions to evaluate the joint’s stability and determine if the ligaments have been compromised.
The severity of the sprain can often be gauged by the extent of swelling, bruising, pain, and joint instability. If weight-bearing is difficult or there is tenderness in the bones, additional imaging tests, such as X-rays, may be required to rule out fractures.
To diagnose a sprain, your doctor will gently palpate around the outside of the ankle in the area of the pain (arrow).
Imaging Tests
Diagnosing an ankle sprain primarily relies on clinical evaluation, including the history of the injury, symptoms, and physical examination by a healthcare provider. However, imaging studies such as X-rays or magnetic resonance imaging (MRI) may sometimes be necessary to rule out fractures or damage to nearby tendons and cartilage.
- X-rays: These images capture dense structures like bones. Based on your symptoms and exam findings, your doctor may order X-rays to check for fractures, especially since severe sprains can mimic fractures with similar levels of pain, bruising, and swelling.
- Stress X-rays: In certain cases, stress X-rays may be taken, where the ankle is gently manipulated in controlled directions. These images help determine if the ankle is unstable due to ligament damage.
- MRI Scans: While not routinely needed for diagnosing ankle sprains, an MRI may be recommended in specific cases:
- To assess additional structures like tendons or cartilage.
- If there are indications of a high ankle sprain affecting the ligaments between the tibia and fibula.
- If symptoms persist beyond 6 to 8 weeks despite non-surgical treatments.
Classification of Ankle Sprains
After completing the examination, your doctor will classify the sprain into one of three grades based on the extent of ligament damage. This classification helps guide the treatment plan.
- Grade 1:
- Slight stretching and microscopic tears in the ligament fibers.
- Mild tenderness, bruising, and swelling.
- Typically no pain during weight-bearing.
- No instability detected during the examination.
- Grade 2:
- Partial tearing of the ligament.
- Moderate tenderness, bruising, and swelling.
- Mild pain during weight-bearing.
- Slight instability noted during the examination.
- Grade 3:
- Complete rupture of the ligament.
- Significant tenderness, bruising, and swelling.
- Severe pain during weight-bearing.
- Substantial instability observed during the examination.
A Grade 2 sprain results in partial tearing of the ligament or ligaments. This commonly leads to moderate swelling and bruising above and below the ankle joint.
Treatment
Nonsurgical Treatment
The majority of low ankle sprains, even severe Grade 3 ligament tears, can be effectively managed without surgery when immobilized and rehabilitated properly. Treatment typically follows a structured three-phase program designed to guide recovery, regardless of the severity of the sprain.
- Phase 1:
- Focuses on reducing swelling through rest, ice, and short-term immobilization.
- Early weight-bearing is encouraged as tolerated.
- Grade 2 sprains may require a removable walking boot or aircast brace for support.
- Grade 3 sprains might need a short leg cast or brace for 10 to 14 days.
- Swelling and pain usually subside within 2 to 3 days, though walking may remain challenging. Crutches may be recommended during this time.
- Phase 2:
- Begins early and emphasizes functional rehabilitation.
- Includes range-of-motion exercises, isometric strengthening, and balance training (proprioception exercises).
- Immobilization should be discontinued to prevent joint stiffness.
- Phase 3:
- Focuses on advancing strengthening and balance exercises and gradually resuming pre-injury activities.
- Initially, activities that do not involve sharp turns are recommended, followed by sports or tasks requiring sudden directional changes (e.g., tennis, basketball, or football).
- Early return to work or sports may necessitate ankle taping or bracing.
Recovery time varies, taking as little as 2 weeks for minor sprains and up to 6 to 12 weeks for more severe injuries.
Home Treatments
For mild ankle sprains, simple home remedies are often sufficient.
- The RICE Protocol:
- Rest: Avoid walking on the injured ankle or resuming sports activities.
- Ice: Apply ice immediately to reduce swelling. Use for 20 to 30 minutes, 3 to 4 times daily. Avoid direct contact with the skin.
- Compression: Use bandages, ace wraps, or compression dressings to immobilize and support the ankle while managing swelling.
- Elevation: Raise your ankle above heart level as often as possible during the first 48 hours to help control swelling.
Medications:
Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen are effective for reducing pain and swelling. They are generally more suitable than narcotic pain medications for mild sprains, as they enhance function by addressing both pain and inflammation.
An air stirrup-type ankle brace.
Physical Therapy
Rehabilitation exercises play a critical role during phases 2 and 3 of recovery, helping to restore flexibility, strength, and proprioception (balance) to the injured ankle. A tailored physical therapy program typically includes the following components:
- Early Motion: To minimize stiffness, your doctor or physical therapist may introduce range-of-motion exercises that involve controlled ankle movements without resistance.
- Strengthening Exercises: As pain and swelling subside, exercises are added to strengthen the muscles and tendons (dynamic stabilizers) around the ankle and lower leg. For those experiencing pain during weight-bearing exercises like toe raises, water-based exercises can provide a low-impact alternative. Resistance exercises are gradually incorporated as tolerated.
- Proprioception (Balance) Training: Poor balance increases the risk of recurrent sprains and chronic ankle instability. Balance exercises, such as standing on the injured foot while raising the opposite foot and closing your eyes, are highly effective. Balance boards are often introduced during this phase to enhance stability and control.
- Endurance and Agility Exercises: Once pain-free, advanced exercises, such as agility drills, can be gradually added. Running in progressively smaller figure-eight patterns is particularly beneficial for improving agility, ankle strength, and calf endurance. Over time, these exercises aim to restore strength, range of motion, and balance, reducing the likelihood of future injuries.
Once you are pain-free, resistance exercises may be added to your therapy program to strengthen the muscles around your ankle.
Surgical Treatment
Surgery is rarely required for ankle sprains and is typically considered only in specific circumstances.
Surgical intervention is reserved for cases where nonsurgical treatments fail to provide relief, particularly for individuals who continue to experience chronic ankle instability or pain after months of rehabilitation. Additionally, surgery may be necessary for certain high ankle sprains involving instability of the syndesmosis—the ligaments that connect the tibia and fibula.
In some instances, surgery is recommended when a severe ankle sprain is accompanied by other significant injuries, such as cartilage damage or a ruptured tendon, requiring more extensive repair.
This X-ray shows extreme instability of the ankle.
Types of Surgery
Several surgical options are available for treating severe or chronic ankle sprains:
- Arthroscopy: This minimally invasive procedure uses a small camera, called an arthroscope, to inspect the ankle joint. During the procedure, your doctor can remove loose fragments of bone or cartilage, or any parts of the ligament that may be trapped within the joint.
- Repair/Reconstruction: For torn ligaments, the doctor may use stitches or sutures to repair the damage. In more severe cases, ligament reconstruction may be performed, replacing the damaged ligament with a tissue graft from other ligaments or tendons in the foot or ankle.
Recovery
- Immobilization: After surgery, the ankle typically requires a period of immobilization using a cast or protective boot to safeguard the repaired or reconstructed ligaments. It is crucial to follow your doctor’s guidance on the duration of immobilization, as early movement or weight-bearing could compromise the healing process.
- Rehabilitation: Post-surgery rehabilitation focuses on regaining strength and restoring range of motion to achieve pre-injury functionality. Recovery times vary depending on the severity of the injury and the type of surgery performed but generally range from several weeks to months.
Outcomes
The prognosis for ankle sprains is generally positive. With proper treatment and rehabilitation, most patients can return to their normal activities. The success of recovery depends on:
- The severity (grade) of the sprain.
- The presence of additional injuries.
- Adherence to a rehabilitation program, as incomplete rehabilitation can lead to chronic ankle instability. Strengthening exercises are essential to prevent future injuries.
Chronic Ankle Sprains
After an initial sprain, you may be more prone to recurring injuries if the ligaments do not fully heal. This can occur if you resume activities, including work or sports, before completing the healing and rehabilitation process. Symptoms such as pain and swelling often indicate whether the ligament has healed enough to progress in therapy and activities.
If pain persists for more than 4 to 6 weeks, it may indicate a chronic ankle sprain. Factors that exacerbate a sprained ankle include:
- Walking or running on uneven surfaces.
- Participating in sports requiring sudden directional changes or twisting movements.
- Poor proprioception (balance and joint awareness), a common complication of ankle sprains, which increases the likelihood of repeat injuries.
Recurrent injuries can lead to chronic instability, persistent pain, and damage to the bones and cartilage.
Prevention
Preventing ankle sprains involves maintaining strong muscles, good balance, and flexibility. These tips can help reduce your risk:
- Always warm up properly before physical activities or exercise.
- Incorporate strengthening exercises to improve ankle stability.
- Stay vigilant when walking, running, or working on uneven surfaces.
- Wear footwear that provides adequate support for your chosen activity.