Another common condition that we see in the urgent care and clinic is the ankle sprain. Sometimes there can be some worry about whether there is an ankle fracture by the patient and the doctor. Here is some general information about ankle pain that might be helpful if you have or know someone who has ankle pain.
Ankle sprains include stretch injuries, partial ruptures or even a complete ruptures of at least on ligament of the ankle. Ligaments provide stability and help direct the motion of the ankle. If the ankle starts to move in a direction that causes too much stretch and puts the ligaments at risk of injury, there are sensors built into the ligament that help provide a reflex to move the ankle back to a safe position. This happens without conscious effort of the patient. These stretch receptors within the ligament can become damaged with a prior ankle sprain. If this happens, they might not work properly to protect the ankle from future sprains.
How bad is the sprain?/Grading: There are three classes of ankle sprains that help describe how bad the sprain is by loss of function and clinical signs. Grade 1 is less severe and results from mild stretching of the ligament with microscopic tears. There is no joint instability on exam. Grade 2 sprains are more severe and involve the complete tear of a ligament. There is usually mild to moderate joint instability on exam with reduced range of motion and loss of function. Walking with a grade 2 ankle sprain is painful. Grade 3 ankle sprains involve a complete tear of a ligament, and there is significant mechanical instability. Patients are usually unable to walk with these sprains.
Lateral ankle sprain: The most common injury to the ankle is when the ankle is plantar-flexed (toes pointed down) and the ankle rolls inward. This causes damage to the lateral ligament complex of the ankle (anterior talofibular ligament [ATF], calcaneofibular ligament [CFL] and posterior talofibular ligament [PTF]). The ATF is the first or only ligament that is injured in almost all ankle sprains. If the ankle injury is more severe, the TF and CFL might become injured, which can result in ankle joint instability. Very strong forces to the ankle may result in injuries to all three ligaments. These are less common injuries, but are more debilitating and are often associated with ankle nerve injury.
Medial ankle sprain: The strongest ligament of the ankle is the medial deltoid ligament complex. If the ankle rolls outward in a forced motion, it can cause damage to this structure but usually this type of motion causes an avulsion fracture of the medial malleolus.
High Ankle Sprain: 1-11% of all ankle sprains are this type and are more common with contact sports. This sprain is caused by the toes pointing upwards and rolling the ankle outwards. This can cause a sprain that includes the interosseous membrane as well as the ATF, PTF and transverse tibiofibular ligaments. These ligaments are critical to ankle stability.
Physical exam of the ankle: We look at the ankle and look for several signs on examination which may include: Swelling, bruising, palpating the fibula, the Achilles tendon, the edge or tip of the lateral malleolus, the posterior edge or tip of the medial malleolus, the base of the 5th metatarsal and the navicular bone. We use a set of rules called the “Ottawa ankle Rules” to determine the need for an ankle x-ray.
Treatment: For lateral ankle sprains, the treatment goal is to limit inflammation and swelling to maintain range of motion to the ankle. This is usually done via early treatment with RICE (rest, ice, compression and elevation) for the first 2-3 days.
1) Rest is done by limiting any standing or walking and using crutches until the patient can walk normally.
2) Ice is applied (or cold water emersion) for 15-20 minutes every 2-3 hours during the first 2 days or until the swelling has improved.
3) The sprained ankle should be elevated above the level of the heart to reduce swelling.
4) Compression with a gel splint or elastic bandage such as an ACE wrap or SAM splint is helpful to minimize swelling and reduce further injury.
5) Ibuprofen, Aleve or Tylenol can be used to reduce pain.
Rehabilitation/Physical Therapy: For ankle sprains, I feel that early rehabilitation with range of motion exercises can be very helpful for retuning to activity and preventing chronic instability. In most patients with mild to moderate sprains, rehab should begin as soon as the initial pain and swelling have decreased to allow them to perform simple exercises. The program will take several weeks in order for the ankle to become stronger and limit the chance of re-injury.
Indications for referral to an ankle surgeon include:
1) Ankle fracture
2) Dislocation or subluxation
3) Syndesmosis injury
4) Tendon rupture
5) Wound that goes into the ankle joint
6) Uncertain diagnosis
Prevention of ankle sprains: Some possible options for prevention of ankle sprains include:
1) External ankle supports (lace up, high-top shoes, taping, etc)
2) Stretching and strengthening
3) Proprioceptive ankle training using a wobble board
4) Appropriate shoes/boots for the planned activity – ie. Hiking boots for a hike on uneven terrain.
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO