Ankle sprains are undoubtedly one of the most common injuries we see as physiotherapists. The vast majority of active people will have experienced an ankle sprain during their lifetime and, unfortunately, sprains have a nasty habit of recurring if not managed well in the first instance.
Understanding Ankle Sprains
Lateral ankle sprains are injuries involving the ligaments on the outside of our ankles. Ligaments are the tissues that connect our bones together and are critically important to the stability of joints, including the ankle joint.
There are 3 ligaments that provide this stability to the outside of our ankles, but the one that is most commonly injured is the anterior talofibular ligament or ‘ATFL’. A sprain occurs when the ligament is over-stretched with possible associated tearing of the fibres, depending on severity. This typically occurs in the ankle when we roll our foot inwards with our toes pointing down.
Ankle sprains are very common injuries for athletes playing sport, but can affect anyone. Often, the environment will play a role in a lateral ankle sprain. For example, it is not unusual for clients to report running on an uneven surface (e.g., a divot in the grass), or stepping onto an object on the floor (e.g., a ball or toy) as the cause of their injury. Sometimes the foot may also get caught, either in the ground, or underneath another player (e.g., in contact sports), causing the ligaments to become rapidly stretched. In some cases, there is no obvious external factor, just a misplacement of the foot when walking, running or jumping.
Signs and Symptoms of an Acute Lateral Ankle Sprain
The signs and symptoms of an acute lateral ankle sprain will vary largely depending on the severity of the sprain itself. However, some common indicators of an ankle sprain include:
- The mechanism of injury was an inwards roll of the ankle.
- Immediate pain and swelling, followed by bruising soon afterwards.
- The individual reports that they heard or felt a ‘pop’ or ‘crack’ on the outside of their ankle.
- Difficulty or avoidance of weight bearing due to pain and instability.
Physio Assessment of Ankle Sprains
If a lateral ankle sprain is suspected, it is important that the individual undergoes a physiotherapy assessment. A physiotherapist will be able to determine which ligaments are involved and whether something more serious, such as a fracture, is present.
The physiotherapist will run through a battery of tests to determine whether an x-ray is appropriate to rule a fracture out. A physio assessment will also include:
- Ligament laxity testing to help determine the grade and severity of tear.
- Ankle range of motion and strength testing.
- Assessment of ability to weight bear
- swelling, and bruising.
- Palpation of ligaments and surrounding structures.
- Functional testing, such as a single leg balance test, to determine level of ankle stability.
Physiotherapy Treatment of Ankle Injuries
Management of a lateral ankle sprain will depend on the severity and irritability of the injury and be guided by the findings of the physiotherapy assessment. Below you will find some common physiotherapy management strategies when treating a lateral ankle sprain.
RICE – Rest, Ice, Elevation, Compression
Immediately after a lateral ankle sprain, the RICE protocol can be initiated to limit swelling, reduce pain, and protect the ligaments and joint. RICE may be continued throughout treatment, particularly if pain and swelling persists.
Progressive Weight-Bearing
Good quality research has found that immobilisation of the foot and ankle (i.e., keeping them completely still) results in less favourable outcomes for lateral ankle sprains. As a result, it is important to gradually increase movement and the amount of weight bearing through the ankle, guided by a physiotherapist.
A physiotherapist will be able to advise you regarding what level of activity is suitable at any given stage of recovery. The physio may recommend equipment, such as crutches, in the early phase, but this will depend on the specific situation and injury.
Braces and Taping (Functional Supports)
Braces and taping can be used for protection of the ligament and joint and these allow for progressive weight bearing by supporting these same structures. A physiotherapist will determine whether bracing or taping is more appropriate based on the severity and irritability of the individual’s injury. Braces and tapes can also be used as a preventative strategy, particularly for individuals playing sport or who suffer from chronic ankle instability.
Exercise Therapy
Exercise therapy is associated with a quicker recovery time and better outcomes, such as a quicker return to sport or work, following an ankle sprain.
Furthermore, good quality research has proven that exercise therapy can help reduce the recurrence of lateral sprains and reduce lasting instability post-injury. This is a critical point that should not be underestimated, as it is common for patients to experience recurrent ankle sprains if the initial treatment program doesn’t provide a sufficient exercise rehabilitation component.
Exercises should generally be targeted at improving neuromuscular strength and proprioception. This will typically mean a range of balance, strength, flexibility and co-ordination exercises. The physiotherapist will design an individualised progressive exercise program guided by the assessment findings and the client’s personal needs.
Manual Therapy
In the management of lateral ankle sprains, manual joint mobilisation has been proven to be of benefit. It facilitates a short-term increase in ankle range of motion, and a decrease in ankle pain. Other manual therapies that can be used include soft tissue therapy and dry needling. Both forms may help improve tissue flexibility and manage pain.
The Importance of Physiotherapy
Physiotherapy plays a critical role in the prevention and management of lateral ankle sprains. There are several modifiable risk factors linked to ankle sprains, including reduced ankle range of motion, proprioception (our spatial awareness), and postural control/balance.
A physiotherapist will identify these deficits (and others) in a physical assessment and put in a place a custom management plan to address them. A well-designed program can help to prevent lateral ankle sprains from occurring and improve athletic performance.
Physiotherapists can also offer information and assistance when it comes to preventative taping and bracing of the ankle, which will improve stability and reduce the risk of injury (or re-injury).
Preventing Chronic Ankle Problems
Chronic ankle instability is when pain, swelling, and instability remain for at least 12 months after the initial ankle sprain. It is estimated that up to 40% of individuals develop chronic ankle instability after a lateral ankle sprain. This can result in recurrent ankle sprains leading to more time spent away from sport or work and increases the likelihood of joint degenerative changes (e.g., arthritis) over time due to repeated trauma.
Factors related to the development of chronic ankle instability include the duration of pain, ability to perform functional tasks, such as jumping and landing, level of sports participation, and strength / postural control. A good physiotherapist will be vigilant regarding these risk factors and customise treatment to prevent chronic ankle instability and its associated consequences from ensuing.
So, as always, seek treatment early, get the right advice from a physio, and we’ll help you on your way back to 100%.
References
- Vuurberg, G., Hoorntje, A., Wink, L. M., Van der Doelen, B. F. W., Van den Bekerom, M. P., Dekker, R., Van Dijk, C. N., Krips, R., Loogman, M. C. M., Ridderikhof, M. L., Smithuis, F. F., Stufkens, S. A. S., Verhagen, E. A. L. M., De Bie, R. A., Kerkhoffs, G. M. M. J. (2018). ‘Diagnosis, treatment, and prevention of ankle sprains: update of an evidence-based clinical guideline’. British Journal of Sports Medicine, 52, 956-970