Ankle sprains are common, making up 25% of all sports-related injuries.
At Motus Health and Performance, our Physios and Exercise Physiologists assess and treat ankle sprains frequently in those who run, play Soccer, AFL, Netball, Rugby, Touch Footy, and Tennis, and also those unlucky to injure on an uneven surface such as the edge of a footpath. We can be the first line of assessment for ankle injuries, without a referral. Early assessment is vital to decide if scans and immobilisation are necessary and to begin the recovery process. All ankle injuries are different, and the rehabilitation depends heavily on the type of injury and specific activity you are aiming to return to. This blog post will outline the anatomy of the ankle, the types of ankle sprains, and the typical treatment plan. If any of your questions aren’t answered here, please reach out to our team.
The Ankle Anatomy
The Ankle joint connects the shin to the foot. Functionally, we call this a hinge joint as it permits opening and closing (Dorsiflexion and Plantarflexion), which is the “lift and push off” of our walk and run. The way the two shin bones extend down the outside of the Talus bone creates the inside and outside borders of the ankle joint, allowing us to turn the foot inwards (invert) and outwards (evert).
Ligaments in the ankle are strong fibrous bands that create stability between the bones.
On the inside, we have the medial ligament (Deltoid) that consists of 4 bands forming a triangle, to connect the medial Malleolus to the Navicular, Calcaneus and Talus. This prevents excessive eversion of the foot.
On the outside we have 3 separate ligaments: the Anterior and Posterior Talofibular ligaments, and the Calcaneofibular ligament. These guide ankle motion and resistance against excessive inversion and internal rotation stress.
We categorise these two groups as the ‘low ankle’ ligaments.
The ‘high ankle’ ligaments (the Syndesmosis) are the bands that connect the Tibia and Fibular to each other, just higher than the ankle joint itself. The AITFL runs on the front side of the two bones, the PITFL runs on the back side of the two bones, and the Interosseous Membrane runs down the length in between the two bones.
What are the Types of Ankle Sprain?
Around 90% of ankle sprains involve an inversion injury, where the foot turns inwards. This can cause injury to the lateral or outside ankle ligaments (ATFL and CFL).
Less commonly, eversion injuries can occur, where the foot turns outwards. This can injure the deltoid ligament on the medial or inside of the ankle.
High ankle sprains account for approximately 25% of all sprains in contact sports. These often occur with higher force, in sporting situations where the ankle is forced into a twist or rotation, injuring the syndesmosis.
Common causes of ankle sprains
Often the mechanism of injury is a roll or twist to the joint, as we outlined above. What can cause this?
- Uneven surfaces such as grass, sand, trails, stairs, edges of footpaths, gutters
- Body weight force of falling down, slipping or tripping
- External forces such as pressure from another player
- Changes of direction with declaration, acceleration, or cutting / stepping
- Jumping and landing
What are the Grades of Ligament Damage and the Associated Symptoms?
Physiotherapy assessment will help to indicate the grade of ankle sprain. It is the grade of injury, and return to activity goals of the individual that will govern the recovery treatment, so this is an important step.
The grade is based on what percentage of the ligament is injured. The following explains the classification system and typical signs and symptoms we see with each.
- Slight stretching and microscopic tearing of the ligament fibres
- Mild tenderness, bruising and swelling around the ankle joint
- Typically little pain with weight-bearing and walking
- No true instability with physiotherapy assessment
- Partial tearing of the ligament fibres
- Moderate tenderness, bruising and swelling around the ankle
- Mild to moderate pain with weight-bearing
- Low to moderate grade instability with physiotherapy assessment
- Full tear / separation of the ligament fibres
- Significant tenderness, bruising and swelling around the ankle
- Often increased pain with weight-bearing
- High grade instability with physiotherapy assessment
How should we treat ankle sprains?
Almost all ankle sprains can be managed successfully without surgical intervention and with the appropriate dedication to physiotherapy treatment, particularly in cases where the sprain is isolated to the lower ligaments (‘low ankle sprain’). Early assessment and guided physiotherapy treatment is known as the best line of management. Typically, the treatment should follow three main phases.
Protection and Optimal Loading
- In some cases, a period of immobilisation is indicated as the first response to protect the ankle from further injury. This can involve a boot, or supporting taping
- Relative rest and inflammation control is next, and important to manage pain and associated symptoms of stiffness caused by the swelling
- Early weight bearing is vital to avoid disuse that typically results in weakness, atrophy, decreased proprioception and reduced confidence
Strength Accumulation and Exposure to Challenges of Proprioception
- Arguably the most important, and unfortunately most poorly executed part of the rehabilitation phase
- Here, a physiotherapy program should be progressive and inline with objective achievement of markers including swelling clearance, regain of full range of motion, and adequate joint stability
- Targeted rehabilitation drills should be prescribed to increase muscle strength of the calf and achilles complex, tibialis anterior, peroneals and plantar fascia
- This is not always linear, and may require sustained work to achieve performance markers
- Treatment is used throughout this phase to promote recovery
Return to function with training / activity exposure before unrestricted return to play
- Here, the plan levels up with a structured exposure to the situations and environments that will challenge the ankle the most. Often these are where the ankle was injured in the first place
- All accelerating, decelerating, change of direction, skills, and fitness elements of your sport and activity should be successfully demonstrated here
- We ensure physical performance is inline with the individual’s confidence to lower the chance of re-injury, and ensure return to performance at the same level as before.
Is there a role for surgery in ankle sprains?
As a general rule, surgery is reserved for the cases where the level of instability caused by the sprain fails to respond to nonsurgical treatment. Persistent symptoms, or recurrent sprains are examples of when surgery may be indicated.
In severe sprains, where the injury is not isolated to the ligaments only, and cartilage, tendons or muscles are also affected, surgery may be the intervention that will best restore stability and allow an individual return to their desired level of activity.
In these cases, the grading classification will be done with the assistance of investigative scan. A thorough plan should be agreed upon to ensure the individual is aware of exactly what is involved. The details of the surgery, required time of immobilisation, post operative restrictions to activity and sport should be well known. Similarly to non-surgical management, a detailed return to function timeline and program will be formed on an individual basis.
When should we Scan an Ankle Sprain?
Physiotherapists can gain a lot of information to clinically diagnose your sprain with how the injury occured, level of pain, swelling, stiffness and ability or lack of, to weight bare and function. We decide to scan if symptoms and impact to function are severe enough, and to diagnose involvement of bone and tendon injury. We have a systemised assessment that includes:
- Bony tenderness along the distal edge of the tibia or fibular and tip of the malleoli
- Bony tenderness at the base of the 5th Metatarsal
- Bony tenderness at the navicular
- Inability to bear weight both immediately after injury and for 4 steps during the initial assessment
We use physical tests that move the ankle joint and look for stability / resistance provided by the injured ankle, as well as strength of the surrounding muscles to resist ankle inversion and eversion.
How long does an ankle sprain take to heal?
In a complete ligament tear, healing occurs in three phases:
1. Haemorrhage with inflammation, where a blood clot is formed, subsequently resorbed and replaced with a heavy cellular infiltrate. After this, a vascular response takes place in the gap between the injured ligament ends.
2. Matrix and cellular proliferation, defined as production of ‘scar tissue’, where dense cellular collagenous connective tissue is made, and over time becomes well aligned.
3. Remodelling and maturation, where the scar matures and strengthens to play a role similar to that of the original ligament.
Evidence suggests that this healing process occurs over a number of weeks.
As a general guide, we see healing for each of the grades in the following times:
Grade 1: 1-2 Weeks
Grade 2: 2-6 Weeks
Grade 3: 4-8 Weeks
Involvement of the high ankle ligaments can elongate this healing time.
How soon can I return to sport after an ankle sprain?
Return to sport post ankle sprain must consider tissue healing time, and completion of an individualised progressive program. At Motus, we clear for sport once objective criteria has been met with regard to symmetry between sides, and performance of the ankle on movement, strength, plyometric and fitness testing. All elements of your work, activity or sport must be completed without symptoms or hesitation to indicate lower chance of reinjury and optimal level of performance when you do return.
Should I tape my ankle after sprain?
There are varying opinions when it comes to this topic, however we feel it depends on the prognosis, severity and type of the injury. There are many techniques, uses and benefits of sports tape which comes in various different shapes, sizes, textures and strengths. Rigid sports tape and Dynamic tape are the most common form of tape. We mostly use rigid here at Motus Health and Performance. If you’d like more information on this topic, we have outlined our view in this article When To Use Sports Tape
We also offer taping only sessions in clinic if this is something you need help with. Whether you’ve got a match coming up, or just need a bit of support for everyday life activities, we’ve got you!
Why you should see a Physio for an ankle sprain
Treated poorly, an ankle sprain of any grade has a high likelihood of re-injury. Evidence based advice immediate post injury will set up the first phase of recovery well. Friends and family become injury experts when you ask about an ankle sprain, and although they care, their advice will not always be specific to your actual injury. Seeing a Physio will allow referral for a scan and immobilisation if indicated, and the appropriate level of rehabilitation prescribed. Treatment is used to manage the pain, swelling and stiffness, allowing you to continue with work and other activities. We lead and support you through the return to running, and ultimately sport because we know what’s needed to get you back, and how important it is to all of us to spend less time on the sidelines. Contact us today to get an initial ankle sprain assessment so we can get you back doing what you love sooner!
We run a unique, 6 level return to running program at Motus H&P, on field with our clients recovering from injury or surgery so we can coach correct technique, and so you’re not toughing it out alone, but with another clients with the same objectives as you.
As the last step, we ensure you’re across a thorough warm up, and prevention program to continue with post physiotherapy treatment and prevent reoccurring injury.