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Ettore Vulcano, MD Orthopaedic Surgery Assistant Professor | Orthopaedics Icahn School of Medicine at Mount Sinai, New York

Ankle Sprain

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A sprained ankle is one of the most common musculoskeletal injuries. It occurs when the ankle rolls inward leading to tearing of some or all of the ligaments on the outside of the ankle. Risk factors for suffering an ankle sprain include: a history of previous ankle sprains, playing high-risk sports (basketball, volleyball, soccer, etc), and overly loose joints. The severity of an ankle sprain will determine the length of the recovery time.  Initial treatment includes: rest, activity modification, ice, elevation, and compression. Physical therapy that focuses on range of motion and strengthening can be helpful once the initial pain and swelling has settled.

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Clinical Presentation:  Ankle Sprain

Patients with a sprained ankle typically describe an episode where they roll their ankle to the inside (Figure 1), which creates tearing of the ligaments on the outside aspect of the ankle (Figure 2). Patients typically have significant pain and swelling (Figure 3), and usually limp. However, quite often those who have sprained their ankle are still able to bear some weight.  This is in contrast to patients who have suffered an ankle fracture which makes weight bearing extremely difficult or impossible. With the ankle swollen over the outside (lateral) aspect, there is often associated redness due to the increased blood flow to this area.

Figure 1
  Figure 2
Figure 3

Physical Examination: Sprained Ankle

Physical examination will reveal swelling over the outer aspect of the ankle and tenderness over the outer front aspect of the ankle (Figure 4). Unlike ankle fractures, there is usually no major tenderness over the posterior outside aspect of the ankle. Usually there is no tenderness on the inside of the ankle (medially). It is important to assess for other areas of tenderness and potential injury, as the same mechanism that creates an ankle sprain can also lead to other injuries (ex. fracture of the anterior process of the calcaneustalar osteochondral injury).

Figure 4: Main area of Tenderness

Imaging Studies: Sprained Ankle

In the emergency room, x-rays are often taken, however, they are not always indicated. In a patient with an ankle sprain, x-rays will not identify any bony abnormalities and the ankle joint will be well located. If there is no tenderness posteriorly, and the patient is able to take 4 steps, then according to the Ottawa ankle rules, the patient does not require x-rays.

Ankle Sprain Classifications

Ankle sprains are typically classified as mild, moderate, and severe. It is often difficult to tell exactly which category the ankle sprain is.

  1. mild ankle sprain involves partial tearing of the anterior talofibular ligament -the first ligament to be stretched when the ankle rolls inwards. In a mild ankle sprain this ligament has tearing of some of the fibers and may be even stretched, but it is intact. Mild ankle sprains will take 4-7 days to achieve most of the recovery.
  2. moderate ankle sprain involves a significant tearing of the anterior talofibular ligament and some tearing of the calcaneofibular ligament. Moderate ankle sprains often takes 7-14 days to mostly recover.
  3. severe ankle sprain involves disruption of all of the major ligaments on the lateral aspect of the ankle, specifically the anterior talofibular ligament and the calcaneofibular (and much less commonly the posterior talofibular ligament). A severe ankle sprain is a major injury that may take 4-6 weeks, or even longer, to largely recover. Furthermore, in approximately 8-10% of patients suffering a severe ankle sprain, there will be associated injuries to the ankle joint (ex. an osteochondral injury to the talar dome) that may lead to residual symptoms.

Treatment: Sprained Ankle

The basic treatment of an ankle sprain is the R.I.C.E. approach (Rest, Ice, Compression, Elevation):

  • Rest and Activity Modification: Time is usually the best treatment for a typical ankle sprain. The body just takes time to heal the injured tissue. Resting the injured ankle by limiting activity during the initial healing period is helpful.
  • Ice: Applying ice to the injured ankle helps decrease swelling and improves pain control. Ice should be applied 10 minutes on and 10-15 minutes off repeatedly. Ice helps limit the blood flow to the injured ankle. Normally, increasing the blood flow to an area is a good thing. However, after an ankle sprain, excessive local blood flow leads to too much swelling during the acute phase of the injury
  • Compression: Compression helps decrease the swelling. This can be achieved with a compression wrap, such as an Ace bandage.
  • Elevation:  Elevating the ankle (ex. placing two pillows under the leg while lying) helps to decrease swelling. Having the ankle down (ex. while standing) will tend to increase swelling and pain in the ankle.
  • Anti-inflammatory medications (NSAIDs): Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as ibuprofen can be helpful in decreasing pain following an ankle sprain.  NSAIDs lessen pain by decreasing the inflammatory response to the injury. However, there is some evidence that suggest that anti-inflammatories may have an adverse effect on ligament healing.

Subacute Phase

Once the symptoms associated with the initial ankle sprain have started to improve, patients will benefit from exercises designed to improve their:

Surgery is not indicated for the treatment of ankle sprains. The exception would be if there is a displaced cartilage and bone fragment in the ankle joint due to an osteochondral injury to the talus (lower bone of the ankle joint).Patients who have recurrent ankle sprains due to ankle instability may be candidates for an ankle ligament stabilization procedure.

Source footEducation.com