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Family Health Magazine
ACTIVE LIVING

Ankle Sprains
Treatment, rehabilitation and prevention

Ankle sprains are high on the list of injuries that occur during physical activity. You might sprain an ankle when you are active at a sport, but it’s as likely to happen when you least expect it. The cause might be something as simple as stepping in a small hole or slipping off the edge of a curb. Even when the activity is on flat ground and proper footwear is providing protection, unexpected twists can cause the ankle to turn. Sprains usually occur when the foot rolls inwards.

The diagram shows how the ankle joint is constructed. There are many ligaments (bands of flexible connecting tissue) that stabilize and support the joint. These ligaments are the most common tissues injured in an ankle sprain. The ones usually damaged are those along the outside of the ankle from the fibula to the calcaneus (heelbone) and talus bones. Occasionally the ligaments that support the ankle along the inside are involved, but this is less common.

Types of Sprains

Ankle sprains are graded as first, second or third degree depending how severely the ligaments are damaged and how loose the ankle feels when examined.

First degree ankle sprains are the most common. The ligament towards the front of the ankle is mildly stretched with a few tiny tears in the tissue. There may be slight damage to the other ligaments. Most of the pain and swelling is over the front part at the outside of the ankle. These injuries often heal well with minimal treatment. Full activity is usually possible within a couple of weeks.

Second degree sprains usually include more ligament tissue tearing. There is bleeding into the tissues and the ankle will bruise within a few days of the accident. These injuries often take two to three weeks longer to heal.

Third degree sprains involve a complete tear in the ligaments. Torn ligaments cause immediate pain. Occasionally there is a tearing or 'popping' sensation along the outside of the ankle. Very quickly afterwards there is bleeding (bruising) and swelling. Healing may take several months and the joint may be unstable and loose after the injury.

Early Treatment

Every sprained ankle should be treated on the spot using the basic first aid management of R.I.C.E. This early care will reduce pain, swelling and bleeding. For most first and second degree sprains, the R.I.C.E. treatment should be continued for 48 to 72 hours.

If you have any difficulty bearing weight (try taking a step or two), if there is a large amount of swelling or persistent pain, and certainly if there is any loss of feeling or strength in your foot, you should have it checked by a doctor. The limb may need to be x-rayed to rule out a possible fracture. A doctor may also be able to suggest further treatment, including physiotherapy and anti-inflammatory medications, to reduce the length of time you are disabled. After seeing a doctor for assessment, follow the recommended treatment. If there is no improvement in the ankle within five to seven days, see the doctor again.

Physicians follow guidelines for assessing ankles and determining whether an x-ray is needed. These are called the Ottawa Ankle Rules as the research to develop them was done in hospital emergency departments in Ottawa. In deciding whether or not an x-ray is needed, a doctor will assess your ability to bear weight and the amount of swelling and tenderness at certain points around your foot and ankle. Applying the 'rules' makes it easier for a doctor to make the correct decision about the necessity of an x-ray.

Rehabilitation

It is important to do exercises to recover the mobility in the ankle joint and the strength in the muscles around the ankle. With a mild ankle injury, after the first three days, you can begin stretching exercises to reduce stiffness and muscle spasm.

The first exercises are simple range of motion. They can be done by drawing the alphabet in the air using your big toe and moving only at the ankle to make the letters. This puts the ankle through a full range of motion in all the different directions. As it feels more comfortable, you can put progressively more weight on the ankle and finally increasing to your regular activities.

Strengthening exercises can be done using stretchy tubing such as surgical tubing, an old bicycle inner tube, or an old pair of stretchy panty hose. You should also do flexibility and stretching, and balancing exercises shown.

If you go to physiotherapy, various techniques may be used to reduce the discomfort and swelling. The physiotherapist will show you exercises which help recover the mobility, balance and strength around the ankle joint.

Although the ankle may feel like it is completely healed, the tissues will take several extra weeks to get back to normal. During this time you must protect the ankle from further injury. This protection can be done through taping or the use of a protective brace. Your doctor or physiotherapist should be able to recommend the best protection for you.

Ankle sprains seldom create long-term complications. If, however, the joint continues to be painful, is swollen, or feels loose and unstable, it should be seen by a doctor. There may be severe ligament damage, an unusual fracture, nerve injury or poor stability. Your family doctor will assess the seriousness of the injury and outline a treatment program so that you can return to all of your activities without any problems from the ankle sprain.

Prevention

Often ankle sprains happen without warning and can be difficult to prevent. However, wearing the proper footwear for an activity will prevent many sprains. Taping or bracing joints which have been sprained previously will keep them more stable during sports. Getting the ankle back in shape properly after a sprain is important to prevent re-injury. Take care of your ankles. Do what you can to prevent ankle sprains.

Balance Exercise
To recover a sense of balance, stand on one foot with your eyes closed and try to balance as long as possible. Repeat this four to five times. As your ankle feels stronger, vary the exercise by moving your arms around, and then by moving the raised leg backwards and forwards.

Stretching Exercise
The stretch shown in the photo should be done leaning against the wall until there is tightness felt in the back of the calf. This should be held for 15 to 20 seconds and repeated four to five times. It should be done with the leg straight and then with the knee slightly bent.

Stretchy Tubing Exercises
For each exercise in the diagrams, the tubing should be wrapped around the base of your toes. For each movement, pull against the resistance of the tubing in the direction described for one to two seconds. Return slowly to the starting position over four seconds. Each exercise should be done in three sets of 15 repetitions with a few minutes separating each set. Once the ankle is more mobile and comfortable, these can be done daily until the strength in the injured ankle is the same as the normal ankle.