A Patient's Guide to Ankle Sprain and Instability
Introduction
An ankle sprain is a common injury and usually
results when the ankle is twisted, or turned in
(inverted). The term sprain signifies injury
to the soft tissues, usually the ligaments, of the
ankle.
This guide will help you understand
- how an ankle sprain occurs
- how doctors diagnose the condition
- what can be done to treat a sprain
Anatomy
What part of the ankle is involved?
Ligaments are tough bands of tissue that help
connect bones together. Three ligaments make up the lateral ligament
complex on the side of the ankle farthest from the other
ankle. They are the anterior talofibular ligament
(ATFL), the calcaneofibular ligament (CFL), and the
posterior talofibular ligament (PTFL). The common
inversion injury to the ankle usually involves two ligaments, the ATFL and CFL. Normally, the ATFL
keeps the ankle from sliding forward, and the CFL keeps the
ankle from rolling inward on its side.
Related Document: A
Patient's Guide to Ankle Anatomy
Causes
Why do I have this problem?
A ligament is made up of multiple strands of connective tissue, similar to a
nylon rope. A sprain results in stretching or tearing of the
ligaments. Minor sprains only stretch the ligament. A tear
may be either a complete tear of all the strands of the
ligament or a partial tear of only some of the strands. The
ligament is weakened by the injury; how much it is weakened
depends on the degree of the sprain.
The lateral ligaments are by far the most commonly
injured ligaments in a typical inversion injury of the ankle. In an
inversion injury the ankle tilts inward, meaning the bottom
of the foot angles toward the other foot. This forces all
the pressure of your body weight onto the outside edge of
the ankle. As a result, the ligaments on the outside of the
ankle are stretched and possibly torn. A severe form of
ankle sprain, called an ankle syndesmosis injury,
involves damage to other supportive ligaments in the ankle.
This type of injury is sometimes called a high ankle
sprain because it involves the ligaments above the ankle
joint. In an ankle syndesmosis injury, at least one of the
ligaments connecting the tibia and fibula
bones (the lower leg bones) is sprained. Recovering from
even mild injuries of this type takes at least twice as long
as from a typical ankle sprain.
Related Document: A
Patient's Guide to Ankle Syndesmosis
Injuries
Symptoms
What does an ankle sprain feel like?
Initially the ankle is swollen, painful, and may turn
ecchymotic (bruised). The bruising and swelling 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.
The ankle swells as extra fluid continues to leak into the
tissues over the 24 hours following the sprain.
People who have sprained an ankle often end up spraining
the ankle again. If the ankle keeps turning in with
activity, the condition is called ankle instability.
Patients who have ankle instability lose confidence in their
ankle to support them, especially on uneven ground. They
often have swelling around the ankle that doesn't go away.
Pain and swelling in a joint can cause a reflex where the
body turns off the muscles around the joint. This can cause
times when the ankle feels like it is going to give way,
meaning it may have a tendency to twist again very
easily.
People who have had several mild ankle sprains or one
severe sprain are prone to impingement problems in the
ankle. The ligaments that were sprained may become irritated
and thickened, causing them to get pinched near the edge of
the ankle joint.
Related Document: A
Patient's Guide to Ankle Impingement
Problems
Diagnosis
How do doctors diagnose the condition?
The diagnosis of an ankle sprain is usually made by
examination of the ankle and X-rays to make sure that the
ankle is not fractured. A physical examination is used to
determine which ligament has been injured. The doctor will
move your ankle in different positions in order to check the
ligaments and other soft tissues around the ankle. Some
tests place stress directly on the ankle ligaments to see if
the ankle has become unstable and to find out if one or more
ligaments has been partially or completely torn.
If a complete rupture of the ligaments is suspected, your
doctor may order stress X-rays as well. These X-rays
are taken while the ligaments are placed in a stretched
position. The X-ray will show a slight tilt in the ankle
bone if the ligaments have been torn.
Treatment
What can be done for the problem?
Nonsurgical Treatment
Nonsurgical treatment options depend on whether your
problem is an ankle sprain or ankle instability. Ankle
Sprain
The best results after an ankle sprain come when
treatment is started right away. Treatments are used to stop
the swelling, ease pain, and protect how much weight is
placed on the injured ankle. A simple way to remember these
treatments is by the letters in the word RICE. These
stand for rest, ice, compression, and elevation.
- Rest: The injured tissues in the ankle need time to
heal. Crutches will prevent too much weight from being
placed on the ankle.
- Ice: Applying ice can help ease pain and may reduce
swelling.
- Compression: Gentle compression pushes extra swelling
away from the ankle. This is usually accomplished by using
an elastic wrap.
- Elevation: Supporting your ankle above the level of
your heart helps control swelling.
Your doctor may also prescribe medications. Mild pain
relievers help with the discomfort. Anti-inflammatory
medications can help ease pain and swelling and get people
back to activity sooner after an ankle sprain. These
medications include common over-the-counter drugs such as
ibuprofen. But newer anti-inflammatory medicines called
COX-2 inhibitors show promising results and don't
seem to cause as much stomach upset and other intestinal
problems.
As treatment progresses, it is helpful to gradually begin
putting weight through the joint. Casts have fallen out of
favor because soft tissues weaken when they are kept
immobile. But braces that can be worn to support the ankle,
but still allow weight bearing, are the most popular
treatment for helping reduce strain on the healing
tissues.
Healing of the ligaments usually takes about six weeks,
but swelling may be present for several months. Your doctor
may suggest that you work with a physical therapist to help
you regain full range of ankle motion, improve balance, and
maximize strength. Ankle Instability
If the ankle ligaments do not heal adequately, you may
end up with ankle instability. This can cause the ankle to
give way and feel untrustworthy on uneven terrain. If your
ankle ligaments do not heal adequately following an ankle
sprain, your doctor may suggest several things.
Changes in your footwear may be prescribed to help keep
your ankle from turning in. Placing a heel wedge under the
outer half of your heel blocks the ankle from rolling, as
does a flared heel built into your shoe. In extreme cases,
doctors may prescribe a plastic brace, called an
orthosis, to firmly hold your ankle from rocking side
to side. Some patients feel a sense of steadiness from
wearing high-topped shoes. Patients with ankle instability
should avoid wearing high-heeled shoes.
Physical therapy treatments will likely be initiated to
help restore joint range of motion, strength, and joint
stability.
Small nerve sensors inside the ligament are injured when
a ligament is stretched or torn. These nerve sensors give
your brain information about the position of your joints, a
sensation called position sense. For example, nerve
sensors in your arm and hand give you the ability to touch
your nose when your eyes are closed. The ligaments in the
ankle work the same way. They send information to your
nervous system to alert you about the position of your ankle
joint. A physical therapist will help you retrain this
sensation as a way to steady the ankle joint and protect you
from spraining your ankle again.
Many people who have ankle instability have weakness in
the muscles along the outside of the leg and ankle. These
are called the peroneal muscles. Strengthening these
muscles may help control the ankle joint and improve joint
stability.
Surgery
Surgeons will occasionally do procedures right away in
athletes who tear a lateral ankle ligament. In most other
cases of torn ankle ligaments, surgeons will try nonsurgical
treatments before doing reconstructive surgery of the
ligaments. Ligament Tightening Procedure
Chronic ankle instability can happen when the lateral
ankle ligaments are stretched or torn and the ankle keeps
giving way. Surgery can be done to tighten the stretched
ligaments and improve the stability of the ankle. The
surgery usually involves the ATFL and the CFL.
In this procedure, an incision is made in the skin that
lies over the lateral ligaments. Using a scalpel, the
surgeon cuts the ATFL and CFL in half.
Holes are drilled along the lower end of the fibula bone,
the small bone of the lower leg. The two ends of the cut
ligament are overlapped and sewn together. The surgeon uses
the drill holes in the fibula to hold the stitches to the
bone.
A large band of connective tissue crosses the front of
the ankle just below the lateral ligaments. This band,
called the ankle retinaculum, holds the tendons in
place. The surgeon pulls the top edge of the ankle
retinaculum upward and sews it into the fibula. This helps
reinforce the reconstructed ligaments.
The following images show each step of the ligament
tightening procedure
Tendon Graft Procedure
Another type of reconstruction is done using a tendon
graft. If your surgeon feels that the stretched and scarred
ligaments are not strong enough to simply repair in a
ligament tightening procedure, then the ligaments must be
reinforced with a tendon graft.
In this procedure, the surgeon removes a portion of one
of the nearby tendons to use as a tendon graft. The tendon
most commonly used attaches the peroneus brevis muscle to
the outside edge of the small toe. A section of this tendon
is put in place of the torn lateral ligaments.
After making the skin incision, the surgeon drills a hole
in the fibula near the attachment of the original ligament.
A second drill hole is made in the area where the ligament
attaches on the talus (the anklebone).
The tendon graft is then removed (or harvested)
and woven between these holes to recreate the ligament
complex.
After surgery, you will probably be placed in a cast or
brace for about six 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
What will it take to make my ankle healthy again?
Nonsurgical Rehabilitation
Even if you don't need surgery, you may need to follow a
program of rehabilitation and exercise. Doctors recommend
that their patients work with a physical therapist for two
to four weeks. Your therapist can create a program to help
you regain ankle function. It is very important to improve
strength and coordination in the ankle.
Swelling and pain are treated with ice and electrical
stimulation. If swelling in the ankle is severe, therapists
may also apply massage strokes from the ankle toward the
knee with your leg kept in an elevated position. This helps
get the swelling moving out of the ankle and back into
circulation. Your therapist may issue a compression wrap and
instruct you to wrap your ankle and lower limb and to
elevate your leg.
Therapists also apply specialized hands-on treatment
called joint mobilization to improve normal joint
motion. These treatments restore the gliding motion within
the ankle joint where the lower leg meets the talus bone.
This form of treatment speeds healing after an ankle sprain,
and it helps return people and players more quickly to their
activity or sport.
An effective treatment for ankle sprains is disc
training, which uses a circular platform with a small
sphere under it. Patients place their feet on it while they
sit or stand and work the ankle by tilting the disc in
various positions. This form of exercise strengthens the
muscles around the ankle, and it improves joint sense
(mentioned earlier).
When you get full ankle movement, your ankle isn't
swelling, and your strength is improving, you'll be able to
gradually get back to your work and sport activities. An
ankle brace may be issued for athletes who intend to return
quickly to their sport.
After Surgery
Patients usually take part in formal physical therapy
after surgery. Rehabilitation after surgery can be a slow
process. You will probably need to attend therapy sessions
for two to three months, and you should expect full recovery
to take up to six months.
Rehabilitation proceeds cautiously after reconstruction
of the ankle ligaments. Most patients are prescribed an
ankle brace to wear when they are up and about, and they are
strongly advised to follow the recommendations about how
much weight can be borne while standing or walking. You may
be instructed to put little or no weight on your foot when
standing or walking for up to 12 weeks. Your physical
therapist will work with you to make sure you are using
crutches safely and only bearing the recommended amount of
weight on your foot.
The first few physical therapy treatments are designed to
help control pain and swelling from the surgery. Ice and
electrical stimulation treatments may be used during your
first few therapy sessions to help control pain and
swelling. Your therapist may also use massage and other
hands-on treatments to ease muscle spasm and pain.
Treatments are also used to help improve ankle range of
motion without putting too much strain on the healing
ligaments.
After about six weeks you may start doing more active
exercise. Exercises are used to improve the strength in the
peroneal muscles. Your therapist will also help you retrain
position sense in the ankle joint to improve the stability
of the joint.
The physical therapist's goal is to help you keep your
pain under control, improve range of motion, and maximize
strength and control in your ankle. When you are well under
way, regular visits to the therapist's office will end. Your
therapist will continue to be a resource, but you will be in
charge of doing your exercises as part of an ongoing home
program. | 
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