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Ankle Sprain

I. Description

II. Causes

III. Symptoms

IV. Diagnosis

V. Treatment

VI. Exercises


Description

A sprained ankle occurs when the ligaments in the foot become stretched beyond their normal capacity in an abnormal position. This can happen when your foot twists, rolls, or turns either from stepping on an uneven surface or stepping down at an angle forcefully. Inversion ankle sprains account for over 80% of ankle sprains, and occur when the foot lands in an inverted position, twisting inward. Eversion ankle sprains occur when the foot lands in an everted position, twisting outward. High ankle sprains (syndesmotic injuries) are so named because their location on the lower leg is above the ankle, involving the syndesmotic ligament. In contrast to common inversion ankle sprains, high ankle sprains are caused when the lower leg and foot twist out.

Ankle sprains are classified into three types, according to severity.

Grades of Sprain

Bones of the ankle and foot
  • Grade I Ankle Sprains are characterized by slight stretching damage to the fibers of the ligament. The tears to the fibers of the ligament are microscopic and treatment typically does not involve casting or splinting.
  • Grade II Ankle Sprains are characterized by a tearing of some, but not all, of the fibers in the ligament. A physical exam of the ankle will reveal abnormal laxity (looseness) of the ankle joint. Treatment typically involves splinting and physical therapy exercises.
  • Grade III Ankle Sprains are characterized by a complete tear of the ligament. A physical exam of the ankle reveals total instability of the ankle joint. Treatment is similar to treatment for Grade II sprains, with longer recovery time. Surgical reconstruction is sometimes necessary with Grade III sprains.


Causes

Ligaments are elastic-like, fibrous connective tissue structures that connect bones to bones, bones to cartilage, and also provide support to organs. They serve to stabilize and hold structures in place and prevent movements in joints that would exceed normal range of motion. When an ankle sprain occurs, the ligaments are overstretched, allowing the ankle bones to move abnormally out of place.

The talus bone (ankle bone) partially dislocates or subluxates, in a forward direction (anteriorly), causing chronic ankle problems and lower extremity bio-mechanical dysfunction. When the talus bone remains in this forward position, the ability to flex the foot upwards (known as dorsiflexion) is limited, because the talus bone is jammed against the front edge of the tibia (shinbone).

The fibula (smaller bone on the outside of the lower leg) also becomes affected by this mal-alignment, losing its motion at the outside of the knee that normally occurs when the foot moves inward and outward. This can cause local pain on the outside of the knee. Typically, ankle sprains occur upon landing on to an uneven surface from running or jumping. Stepping off of a curb or stair abnormally or slipping on ice are also common events that cause ankle sprains.



Symptoms

Symptoms for ankle sprains vary with the severity of the injury, but swelling and tenderness are symptoms common to all three grades of ankle sprain.

Grade I Ankle Sprain Symptoms 
  • Mild tenderness and swelling
  • Minimal impairment in movement; mild pain upon standing or walking
Grade II Ankle Sprain Symptoms
  • Moderate tenderness and swelling
  • Decreased range of motion
  • Mild to moderate bruising
  • Possible instability
Grade III Ankle Sprain Symptoms
  • Significant tenderness and swelling
  • Moderate to severe bruising
  • Severe instability; sometimes delayed after initial injury phase
  • Walking may not be possible


Diagnosis

To determine the grade of ankle sprain present, a physician will perform a physical exam of the area and assess swelling, range of motion, bruising and pain symptoms. Typically an exam will also include questions about the injury and a history of any other ankle injuries. Imaging tests may be required to rule out a broken bone in the foot, which causes similar symptoms. If there is no broken bone, the grade of sprain may sometimes be determined without further testing. The physical exam may be painful as the doctor moves the ankle joint in different directions to see which ligament has been damaged. Orthopedic tests may be performed to determine the location and type of the sprain.

Orthopedic Tests


Anterior Ankle Drawer Test

This test helps determine the stability and involvement of the anterior talofibular ligament (ATFL) in inversion ankle sprains.
  • Patient lies on their back with their feet extending over the edge of the table.
  • Examiner applies one hand to the anterior distal tibia (area of the leg just above the ankle).
  • Examiner then places the other hand so that it cups the heel.
  • While pushing the heel anteriorly (upwards), the examiner applies counterpressure with the top hand.
  • The examiner checks for upward movement in the ankle mortise, which is where the tibia and fibula end (distal area) and join the top of the talus (ankle bone).
If laxity/movement (and often pain) occurs, it is indicative of ATFL ligament sprain.

Inversion Talar Tilt Test

This test, when positive, indicates a combined sprain of the calcaneofibular ligament and the anterior talofibular ligament (ATFL) in the ankle.
  • Patient is seated with the legs over the edge of the table
  • Examiner cups the calcaneus (heel) with one hand and stabilizes the lower portion of the same leg with the other hand.
  • Examiner then provides inversion stress by rolling the calcaneus (heel) inward while the ankle is in a neutral position. If this causes pain, it indicates involvement of the calcaneofibular ligament (CF).
  • Examiner then provides another inversion stress by rolling the calcaneus (heel) inward while the ankle is in the plantar-flexed (toes pointed downward) position. Pain upon this movement indicates involvement of the anterior talofibular ligament (ATL).
The test result is positive if there is pain and excessive laxity (looseness) in the ankle, indicating a combined sprain of the ATFL and CL sprain in the ankle.

Eversion Talar Tilt Test

This test, when positive, indicates a sprain of the deltoid ligament.
  • Patient is seated with the legs over the edge of the table
  • Examiner cups the calcaneus (heel) with one hand and stabilizes the lower portion of the same leg with the other hand.
  • Examiner then provides eversion stress by rolling the calcaneus (heel) outward while the ankle is in a neutral position.
  • Examiner then provides another eversion stress by rolling the calcaneus (heel) outward while the ankle is in the plantar-flexed (toes pointed downward) position.
The test result is positive if there is pain and excessive laxity (looseness) in the ankle, indicative of a deltoid ligament sprain.

Hoffa's Sign

This test assesses the presence of an avulsion fracture of the calcaneus (heel) bone. Avulsion fractures occur when a fragment of bone tears away from the main bone mass due to physical trauma. Fractures need to be ruled out when evaluating an ankle sprain, because if present, fracture management is the first line of treatment that must occur.
  • The patient lies face down with their feet extended over the edge of the table.
  • The examiner feels the Achilles Tendons in both ankles to compare tautness, while also comparing the involved ankle's dorsiflexion (upward flexing ability) with the other ankle's dorsiflexion.
The test result is positive if the involved ankle is abnormally loose, which is indicative of an avulsion fracture of the calcaneus. Additionally, the fracture may have caused bone fragments which may be felt around either malleolus.

Crossed-leg test
 

This test assesses for the presence of a high ankle sprain (Syndesmotic Injury).
  • Patient is seated in a chair and places the involved ankle over the knee of the other leg, letting the weight of the crossed leg apply pressure to the area just above the ankle (proximal fibula).
The test result is positive if there is pain in the area of the ankle resting on the knee (the syndesmotic ligament area), indicative of a high ankle sprain.


Treatment

Treatment for ankle sprains can involve clinical methods as well as at-home measures. If fractures are present, a physician will focus on stabilizing the ankle and reducing swelling and related symptoms. The fracture must be addressed before other orthopedic adjustments to the ankle area can be performed. Typically, most ankle sprains heal to full recovery in about four to six weeks. The course of treatment depends on the type and severity of the ankle sprain, but all ankle injuries incorporate three phases:
  • Phase 1: resting and protecting the ankle, with treatment focusing on reducing the swelling. Typically this phase lasts about 1 week. During this phase, following the R.I.C.E. protocol tips may assist in reducing initial swelling and pain for all types of ankle sprains.

    • Rest the ankle- do not walk on it while swelling persists and immediately after the injury.
    • Ice- apply immediately after the injury and for the days following to help reduce swelling. It can be used for 20 to 30 minutes, three to four times daily, or according to your doctor's instructions. Always keep a layer of fabric between the ice pack and the skin to prevent ice burns.
    • Compression- support and immobilize the injured ankle. Depending on the grade/severity of injury, mild compression sleeves or more supportive lace-up braces to rigid immobilizers may be helpful for protecting your ankle during the healing stages.
    • Elevate the ankle above your heart level as much as possible during the 48 hours following the injury.

  • Phase 2: restoring range of motion, strength and flexibility. This can last one to two weeks, or more.
  • Phase 3: gradually resuming physical activities while temporarily avoiding anything that twists or turns the ankle, and continuing with balance and range-of-motion exercises.

At Home Treatments for All Grades of Ankle Sprain


While some treatments depend on the severity of sprain, all ankle sprains may benefit from some basic care, particularly immediately after the injury.
  • Ankle Ice Packs- Cold therapy is most helpful when applied immediately after the injury has occurred and for the first three days (until swelling is gone). Cold therapy may be useful in helping to reduce symptoms of swelling and inflammation. Apply an ice pack to the affected ankle for 20 to 30 minutes, three to four times daily. Always keep a layer of fabric between the ice pack and the skin to prevent ice burns. Ice packs that are incorporate compression are another convenient option.
  • Ankle Pain Gels- These topical analgesics may help stimulate circulation and may temporarily reduce pain.
  • Ankle Heat Therapy- After swelling is gone, heat therapy may be useful in soothing sore tissues and can provide comforting warmth.
  • Foot Massager- Sometimes a sprained ankle can create tension in the surrounding muscles of the foot; not just the ankle area. This roller's massaging properties provide relaxing massage sensations, much like reflexology, to the bottom of the foot. This may provide soothing relaxation to tired feet.
  • Orthotics- Using a heel cup or insole may be beneficial in stabilizing the heel, possibly preventing excessive pronation, which refers to the natural side-to-side movement of the foot during walking or running. Overpronation refers to excessive inward movement, while underpronation refers to excessive outward movement of the heel. A weakened ankle can result in reduced contact between the sole of the foot and the ground, weakening neuromuscular signals to the brain. Insoles can help provide a surface that conforms to the bottom of the foot and thereby reinforce the signals that aid in balance and motion.
  • Foot Rests- These ergonomically designed foot rests offer a comfortable, slightly elevated surface to help reduce pressure on your ankle while seated. Footrests can also help align your pelvis, and encourage better posture while sitting.



Treatments By Grade of Ankle Sprain


Some treatments vary by the severity of the sprain, particularly types of braces and supports and rest time. Grade I and II ankle sprains usually heal without clinical treatments with proper home care and rehabilitation, while grade III sprains require medical attention to rule out possible fractures.

At-Home Treatments for Grade I Ankle Sprains
  • Follow the R.I.C.E. Protocol above. For a Grade I ankle sprain, usually 1-3 days of rest is adequate (or until swelling is gone). However, some walking and weight-bearing is recommended (as tolerable) as soon as possible, and should be gradually increased as healing progresses, to maintain range of motion and reduce radical scar tissue from forming.
  • Grade I ankle sprain braces- Mild compression may help reduce symptoms and may assist in the recovery process.
  • Balance Exercises should be incorporated into the healing process as soon as any swelling is gone. See below for specific exercises that you can perform on a balance board.

At-Home Treatments for Grade II Ankle Sprains
  • Apply the R.I.C.E. Protocol listed above immediately following the injury
  • Grade II ankle sprains should involve rest immediately following the injury, but, as soon as weight bearing is tolerable, walking and range of motion exercises should be incorporated in the healing process to maintain range of motion and reduce radical scar tissue from forming.
  • Grade II ankle sprain braces- Moderate compression may help reduce symptoms, stabilize, and provide comforting support for the ankle during recovery.
  • Balance Exercises and other types of range of motion exercises are vital for preventing permanent weakness in the ankle which can lead to chronic (on-going) ankle sprain.


At-Home Treatments for Grade III Ankle Sprains


Treatment for a Grade III ankle sprain focuses on immediately applying ice, compression and elevating the injured ankle, followed by medical care. Early evaluation is critical to rule out fractures and to determine the appropriate rehabilitation.
  • Apply the R.I.C.E. Protocol listed above immediately following the injury
  • Crutches may be needed to help keep weight off the ankle immediately following the injury
  • Grade III ankle sprain braces- Grade III ankle sprains require support to protect and compress the ankle. Use of an ankle orthosis (a boot that restricts ankle range of motion) after surgery, or a brace that restricts range of motion may help to reduce swelling and protect the ankle from movements during early recovery stages. After two to four weeks, switch to a moderate support ankle brace that allows more movement but still protects the ankle. 
  • Grade III sprains require more rest and a longer period of compression and support. Use care when beginning to reincorporate weight bearing movement, and follow your doctor's instructions regarding how and when to perform rehabilitative exercises on your injured ankle.


Professional Treatment for Ankle Sprains


Often ankle sprains heal with time and proper rest and physical therapy, without major clinical treatments. Surgery is rarely necessary for ankle sprains. Sometimes an ankle sprain can induce chronic instability, though the ankle may still be quite functional due to supporting ligaments that are not damaged. However, it may predispose the ankle for future sprains. If this occurs, the condition is known as a chronic ankle sprain. Persistent instability from a chronic ankle sprain may require surgical treatment. Surgery may also be recommended if the physician suspects a bone fragment to be the cause of the pain and persistent problems.

Typically, surgery options for ankle repairs include:
  • Arthroscopy-a pencil-thin device equipped with a camera lens and light is surgically inserted into the ankle area through a tiny incision. Surgical instruments are passed through the arthroscope to remove fragments of damaged cartilage.
  • Reconstruction- the torn ligament is repaired with stitches or suture, or portions of other ligaments and/or tendons found in the foot and around the ankle may be used to repair the damaged ligaments.

Rehabilitation after surgery can take a long time, from weeks to months. Recovery involves time and commitment to following a physical therapy routine to restore strength and range of motion to the ankle.

Orthopedic Adjustments

Once fractures have been ruled out, an orthopedic adjustment of the talus (ankle) bone may help encourage proper biomechanics which may assist the healing process. Below are two typical orthopedic adjustments of the ankle.

Antero-Medial Talus Adjustment

A professional may perform this adjustment for inversion ankle sprains (the most common type of sprain wherein the ankle rolls inward). Indications for the adjustment include limited dorsiflexion of the foot (upward flexion), a decreased or abnormally shallow anterior talar fossa (the gap or depression in the front top surface of the ankle), and a varus forefoot (angle of forefoot deviates inwardly).
  • Patient lies face-down with the affected leg flexed at a-90 degree angle
  • Examiner stands facing the patient's knees, on the opposite side of the affected leg
  • Examiner places knee closest to the head across the lower hamstrings of both knees, applying equal pressure
  • Using the hand closest to the head, the examiner grasps the lateral ankle, with the middle finger on the mid talar fossa as the contact finger, and places the thumb around the Achilles tendon.
  • The hand toward the feet is used for stabilization, and supports the contact finger and thumb while lifting the inside of the foot
  • After applying the stabilization hand, the examiner lifts the ankle toward the ceiling, and thrusts the talus straight back toward the heel.
  • The examiner then checks both feet for more even dorsiflexion, changes in depth of anterior talar fossa, and changes in forefoot varus.

Antero-Lateral Talus Adjustment

A professional may perform this adjustment for eversion ankle sprains (sprains wherein the ankle rolls outward). Indications for this adjustment include limited dorsiflexion (upward flexing) of the foot, a decreased or abnormally shallow anterior talar fossa (the gap or depression in the front top surface of the ankle), and a valgus forefoot (angle of forefoot deviates outwardly).
  • Patient lies prone with the affected leg flexed at a-90 degree angle
  • Examiner stands facing the knees of the patient on the same side of the involved leg.
  • Examiner then places their knee closest to the patient's head across the hamstrings of only the involved leg.
  • With the hand that is closest to the patient's head, the examiner grasps the medial ankle with the middle finger on the mid talar fossa, and places the thumb around the Achilles Tendon.
  • The hand toward the feet is used for stabilization and supports the contact finger with its middle finger. The thumb can go either over the cuboid bone or around the Achilles tendon.
  • The examiner then thrusts the talus straight back toward the heel.
  • The examiner then compares the feet for more even dorsiflexion, changes in depth of anterior talar fossa, and changes in forefoot valgus.


Exercises

Even during the healing stages of an ankle injury (once initial swelling, acute pain, and any fractures have been resolved) and beyond, performing ankle exercises that focus on range of motion and balance may help strengthen the ankle and may possibly reduce risk of future injury.  Always check with your doctor before beginning any exercise program, and always listen to your body, stopping anything that causes pain. Incorporate as many or as few of the following exercises as you prefer, or rotate from one set to another periodically.

Balance Board Training


Balance board training should be performed for all grades of sprain to revitalize the damaged proprioceptors. Proprioceptors are sensory receptors on nerve endings found in muscles, tendons, joints, and the inner ear. They can detect the body's movements and position in space (sense of balance and force), signaling the body to move accordingly.

You will need:
  • Balance boards (or wobble boards) may help improve ankle stability by providing an unstable surface to train the ankle on. The instability forces the musculoskeletal system in the foot and body to respond and adjust to remain balanced.
OR
  • Balance pad Check with your doctor before performing balance/wobble board exercises. Care should be taken while training on the unstable surface of a balance/wobble board. For those who are less secure with their balance, a balance pad may be more suitable.
Exercises
  • Balance board rocks: Place both feet on the board, about shoulder width apart. Hold the back of a chair for support if needed. Rock the board back and forth, and side to side, for up to 3 minutes as your ability allows.
  • Seated balance board range of motion exercise: Sit in a chair and place a balance board under your feet. Rotate the board slowly in both directions. Keep your ankles pointing in the same direction while you move, and try to focus on only rotating your ankles and keeping your hips still.
  • Balance board edge exercise: Stand on the balance board, feet shoulder width apart. Rotate the board around so that the edge of the board is in contact with the floor at all times. Try this exercise for 2 to 3 minutes.
  • Balance board sustain exercise: Balance on the board for as long as you can without the edges touching the floor for 2 minutes or as ability allows.
  • Balance board rotation exercise: Rotate the balance board in a circle but without allowing the edge of the board to touch the floor. Perform for 2 minutes or as ability allows.
  • Balance board with half squats: While balancing on the board, perform 10 (if ability allows) slow, controlled half-squats.


Exercises for Ankle Dorsiflexion

Dorsiflexion is the ability to flex the ankle upward; it is the movement that decreases the angle between the top of the foot and the shin (plantarflexion is the movement that increases the angle). Limited ankle dorsiflexion is a typical result of poor ankle joint mobility, and not only can limit specialized athletic movements, but can also limit the movements of everyday life. If the ankles are stiff, the stress of motion tends to move onto the next possible joint. The knees often overcompensate for ankle stiffness by over-bending. Poor ankle dorsiflexion can even lead to involvement from the hip and lower back, which can lead to alignment problems. Incorporating ankle range of motion exercises and ankle balance exercises may help improve ankle dorsiflexion.

Dorsiflexion wall exercise
:
  • Stand a few inches away from a wall and place one foot behind you.
  • Bend the front leg, and try to touch the wall the your knee by dorsiflexing your ankle.
  • As soon as your knee touches the wall, bring it back to the starting position and repeat this movement 5 times, for each ankle.
  • After 5 repetitions for each ankle have been performed, move back an inch to two inches and repeat the same movement. Try to go as far back as you can while still keeping your heels on the ground, all the while keeping the weight on your heels, and off of your toes. Perform 5 repetitions for each ankle.
Dorsiflexion wall exercise with tennis ball:
  • Perform the same wall dorsiflexion exercise above, but use a tennis ball to massage the calf area.
  • When you dorsiflex your ankle, roll the tennis ball over your calf, beginning just below the calf muscle and working upwards toward the back of your knee.
  • Be gentle at first as the area may be tender. The massage coupled with the dorsiflexion may help to break up tension that may be limiting your ankle dorsiflexion.
Raised Dorsiflexion
  • Stand with your heels down and your toes (both feet) up against a raised platform, several inches high. The foot is now in a dorsiflexed position.
  • Then increase your amount of dorsiflexion, using both ankles at once, and release. Repeat the dorsiflexing and releasing action, for 1-2 minutes or as able.
Ankle range of motion and strength exercises
  • Alphabet writing: This can be performed while seated in a chair, or, while lying down. Point your toes and "write" the alphabet in the air with big, circular motions. For variety, try doing this exercise in cursive, uppercase, and lowercase letters.
  • Tip-Toe raises: Stand on the tips of your toes, and then slowly lower back down. Keep the movements slow and controlled and try to make the efforts equal on both the raising and lowering action.
  • Toe and Heel Walking:Alternate walking for one minute on your tip toes, and then switch to walking on your heels. Walking on your heels encourages dorsiflexion while walking on your toes encourages plantarflexion.


Stretching the ankle

Performing regular stretching on the ankle and calf area may help reduce tension in the ankle and potentially improve your ankle mobility. Specific products designed to make this easier can be useful tools to incorporate into your exercise routine.

Helpful products:
  • Resistance Bands
  • Resistance Tubes
  • Stretch rope
  • Stretch rockers- single or double- provide a fun and innovative way to get a full stretch on your ankles and calves.
  • Stretcher board- Featuring two sizes, this is a helpful tool for encouraging limber calves and Achilles Tendons, and may help promote overall ankle stability and function.
  • More Products for Ankle Exercise
Ankle stretches
  • Achilles stretch: While seated or lying down, take a stretch band, resistance tube, or stretch rope and loop it around your toes. Hold the other ends, pulling your toes upwards, feeling the stretch in the back of the ankle. Keep your heels on the floor. Perform this 3-4 times a day for several minutes.
  • Alternatively, perform the same stretch above but this time move the stretch band to the middle of the foot. Keep your heels on the floor. This stretch is similar but should be felt more in the back of the leg and ankle.
  • Seated dorsiflexion stretch: Loop the stretch band around the middle of the foot and attach/tie the other ends of the stretch band to a sturdy object. Flex your ankle back and forth while keeping the heels on the ground. Hold the upward flex (dorsiflexion) for a few seconds with each flex.



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