Ankle injuries are extremely common in sports, particularly netball, basketball, soccer, AFL and volleyball. (As you can see, they can occur almost anywhere). Studies estimate that 1 sprain occurs in every 10,000 people every day. In a town like Perth where we are – that is equivalent to 202 people every day or over 73,000 ankle sprains per year. Ankle sprains also account for up to 25% of all sporting injuries! Studies show that 40% of people can be left with persistent instability of the ankle. Considering what a big problem this is, it is high time that we provide you with the best, evidence based guidelines for the treatment and management of ankle sprains.
What is an Ankle Sprain?
Over 90 % of ankle sprains are injuries to the Anterior Talo-fibular Ligament (ATFL for short). This is due to an inversion injury, where the ankle is twisted inwards. There are three major ligaments on the outside of the ankle – the ATFL, the Calcaneofibular ligament and the Posterior Talo-fibular Ligament. Generally – the worse the injury the more of these ligaments are damaged.
We use the term “sprain” to describe an injury of a ligament (remember a ligament connects a bone to another bone). Sometimes the ankle can twist outwards, injuring the ligament on the inside of the ankle. This guide will focus on lateral ligament sprains, but the same rules generally apply.
So What Should You Do?
So you’ve landed on some defender’s foot at netball and twisted your ankle. It hurts….. bad. Your team mates help you limp off the court, then what do you do? Good early management can significantly improve recovery times following ankle injury, so looking after it well now will get you back on the court quicker.
This immediate phase is where the good old RICE protocol (rest, ice, compression, elevation) is the most effective. (It has actually been expanded up to SPRICEMM, but we’ll get to that later). When we say rest, we mean relative rest. Like stop playing netball and go look after your now rapidly swelling ankle. It doesn’t mean hop around for two weeks being afraid to put your foot down. The S and P stand for support and protect. Support means keep the ankle in a nice neutral position (like the 90 degree position it would be in if you were standing on it). This keeps the ligament in a shortened range and will help with the initial healing process. Protect means prevention from further injury (like don’t go back and limp on to the court).
Anytime you have a soft tissue injury, you have bleeding. Bruising from a bad ankle sprain is bleeding from the damaged ligament and other tissue into the surrounding space. You also develop an acute inflammatory response very quickly following the injury. Inflammation is a normal part of healing, as it bring lots of cells and chemicals rushing to the injured area to begin healing. This is normal and helps initiate the healing process. Inflammation also contains lots of chemicals that are irritants to your nerves and pain receptors in the surrounding tissues – this increases your pain levels and makes sure you know that you’ve had an injury. There is an evolutionary theory that this helps to let you know that you have suffered an injury and to adjust your behaviour accordingly (like don’t fight that mammoth as you might have trouble running away).
Along with all this bleeding comes damage and death of the injured cells of the ligament. Bleeding also means a loss of normal blood supply to the surrounding cells. Ice is very beneficial in the very early stages to reduce secondary injury due to hypoxia (lack of oxygen to the cells) caused by disruption of the normal blood supply. Secondary injury can also occur due to enzymatic mechanisms – the damaged and dying cells can release enzymes (chemicals) that damage the surrounding cells.
(For a deeper understanding of how inflammation works and the effects of ice, stay tuned for my upcoming article on the use of ice for soft tissue injuries)
Ice reduces this secondary injury by:
Reducing metabolic requirements of the surrounding cells thus increasing the number of cells that survive. This obviously means less injury and quicker recovery. It was originally thought that ice also can reduce bleeding and reduce total inflammation, but the jury now seems to be out on this. It is still wise to use ice in the early stages to not only reduce the metabolic load but also to provide pain relief – you will generally feel better with some ice on your ankle.
Compression is probably the most effective tool we have at reducing excessive inflammation. Now remember I said that inflammation is normal and important for healing to occur – so we don’t want to completely halt the inflammation process (I don’t actually think it is even possible to completely stop inflammation with these measures). However, excessive inflammation means that too much inflammatory exudate (inflammatory fluid that collects outside of the injured cells) can gather in the interstitial space (between all the other structures). This creates greater pressure within the space between the tissues and can reduce how much other chemicals and cells can get in to the area to help with healing. It’s a bit technical, but changes to the osmotic pressures and perfusion gradients mean that too much pressure from excess inflammation will stop some of the cells and chemicals required for healing even getting to the site of the injury.
Elevation may also be beneficial in reducing swelling, by using gravity to encourage the flow of fluid (and lymph, etc) away from the ankle. The research isn’t strong in this area, but if you’re resting in a neutral ankle position or icing your ankle, it’s not going to hurt to elevate it as well.
The initial bleeding can continue for up to 24 hours, so it is wise to continue icing regularly for at least the first day. There are lots of different protocols out there with varying levels of evidence, so there probably isn’t a perfect amount of time to ice (or have on/off) but keeping ice on regularly will be highly beneficial.
What about anti-inflammatories?
There is conflicting evidence for the use of anti-inflammatory medications in the early stages of injury. We know that excess inflammation can inhibit optimal healing times and we also know that high pain levels make it hard to move on to the next phases of rehabilitation. BUT, we also know that inflammation is a necessary part of the healing process. Most over the counter anti-inflammatory medications are aspirin substrates, (aspirin is a low grade blood thinner) so this type of medication could also potentially increase bleeding in that first day or so.
Generally we would take this on a case-by-case basis. We have to weigh up the benefits of pain relief with the potential for increased bleeding. Remember over the counter anti-inflammatory medications aren’t exactly wonder drugs. I have never come across anyone who has ever sprained their ankle badly, taken 2 nurofen and then their swelling has magically disappeared. Pain relief is usually beneficial (paracetamol, etc) as controlling your pain levels better allows you to complete all your rehabilitation. If in doubt you should always discuss medication with your local pharmacist – they are experts in medications and their advice is completely free!
Anti-inflammatory medication is widely recommended by doctors for acute injuries, so should be considered generally safe to use. In most cases it is probably more helpful than not.
The next step is to work out if there is any serious damage that requires more medical attention. We follow a set of criteria called the Ottawa Rules to determine if you require an x-ray or might have a fracture. There’s a lot to it, but in general if you:
Can’t walk more than a couple of steps, and
are quite sore to touch on any of the bones of the ankle or lateral foot
it would be wise to see a qualified health professional (such as ourselves) quickly to determine if you need an x-ray or might have broken something. Generally I wouldn’t recommend going straight to emergency (unless there is obviously a bone sticking out in the wrong place) as usually you will just sit in a waiting room for 6 hours, get an x-ray then get sent home on crutches without adequate management advice or treatment. It is usually much easier to get to your physio or GP within the next 24 hours (we usually try to ensure we have same day appointments available). If you need any other immediate treatment we can organise that for you. If you’re not sure, there are always after hours GPs that you won’t have to wait 6 hours in an emergency room to see.
While we’re at it, you should remember that whether you heard a “pop” or “crack” has no bearing on whether you have broken a bone or not – studies show it actually makes no difference at all.
The severity of the injury will dictate how long it will take to get back to full activity (including sport). A grade I injury (minor ligament injury) should be back to sport within a week or two (with proper management). Grade II might be 2-4 weeks. Grade III (greater than 50% rupture) could be 6 weeks or more. A complete ligament rupture could be looking at 12 weeks on the bench, and might need input from a surgeon if there is persistent instability.
Keeping some sort of compression on at this stage usually helps to reduce excessive inflammation, and may also make it easier to weight bear. Icing may not be as important after the first day or two, but it does provide pain relief and doesn’t do any harm (and might possibly help to reduce inflammation) so if it feels good with ice – you should keep using ice. Assuming there is no fracture, then this brings us to the next important point:
Functional treatment is far superior to prolonged rest and immobilization!
While RICE is excellent first aid, it was only ever intended to be first aid. It is not an effective complete treatment plan. There is a lot of information on the internet that will tell you that RICE doesn’t work at all, and this is because they are using it as a complete treatment. Once you are out of the initial first aid phase RICE is not enough – you need functional treatment.
This is actually what the M stood for in SPRICEMM – mobilise! You should start weight bearing (trying to walk on the ankle) as soon as it is comfortable to do so. You will not damage it any further by putting weight on the foot. Sometimes we will tape or brace your ankle to stabilise it better – this usually makes it easier to start walking on it sooner. The sooner you start walking and moving normally, the better you start to regain functional capacity and movement; and the quicker you will get back to sport.
In the old days many people were sent home on crutches and told not to put the foot down for 2 weeks. This is actually terrible advice, and leads to slower recovery, potential secondary complications (like complex regional pain syndrome) and increased risk of recurrence. It also tends to rest the ankle ligaments in a lengthened position, meaning the ligament will heal with more laxity and can suffer from ongoing instability.
We also want to begin some gentle movement of the foot and ankle to restore function and encourage normal healing of the tissues. At this stage we will often start some manual treatment to help restore normal mobility of the foot and ankle. You can also do some mobilisation work yourself at home – particularly working on your dorsiflexion mobility (see below). Keep your heel down and try and bend your knee towards the wall (increasing the angle at the ankle)
When you are able it is best to begin exercise to also work on your balance and stability of the ankle. The ankle is critical for good balance and stability of the lower limb, and this is generally impaired following ankle injury. Rehabilitation and restoration of this stability is critical to avoid persistent “weak ankles” and instability.
Appropriate rehabilitation is the key to avoiding persistent ankle pain and instability. We see patients in the clinic all the time who report having a “weak ankle” following a previous ankle injury. This means they continue to suffer from recurrent ankle sprains once they return to sport. It is completely unnecessary to settle for having a weak ankle after injury. All this means is that you never did the right rehabilitation to get the ankle strong again after the initial injury.
There are literally thousands of different exercises that you can do – for the best rehabilitation you should always be assessed by a competent physiotherapist who can identify your exact problems and design the perfect rehabilitation program specifically for you. Here are some safe places to start:
As simple an exercise as standing on one leg is a very good place to start. This will train the reactions you use to correct you balance, and all the little muscles around your ankle. If this is too easy, you can make it harder by closing your eyes (please do it somewhere safe) or by standing on an unstable surface (like a cushion). Strengthening of the eversion muscles (see below) is also important to resist the forces when you twist your ankle inwards.
Neuromuscular rehabilitation takes these static balance tasks and integrates them into functional movements and dynamic retraining. This is the real difference between just being ok to do normal daily activities and being 100% recovered for full sport. This end stage rehabilitation phase is also the most commonly skipped step. Being able to jump, hop, side-step while changing direction and throwing, and looking over your shoulder are all things that you would do all the time while playing sport. So it makes sense that you should actually retrain these movements. (Remember one of the top keys to any rehabilitation is SPECIFICITY of training).
Studies show that our balance and stability reactions can be impaired for up to a year following ankle injury, so it is essential to regain and retrain those stability mechanisms. Failure to do so is the number 1 reason 40% of people can end up with persistent instability or “weak ankles”.
There is an infinite combination of possibilities with this kind of rehabilitation (far beyond the scope of this article). Suffice to say, the retraining should be specific to your sport or activity. Do you do a lot of jumping and landing in your sport? Then you should probably include jumping and landing activities in your rehabilitation. Do you do a lot of changing direction? Then this should also be included.
We can design specific rehabilitation programs to get you back to 100% that are uniquely individual to your requirements and chosen sport. Even if you are one of those people that has “weak ankles” from previous injuries, then this type of strengthening and neuromuscular rehabilitation will be invaluable to get those ankles stable again and get you back to playing.
Take Home Messages:
1. Ice and compression as soon as possible will give you the best possible start to recover as quickly as possible. Try to keep the ankle in a neutral position.
2. Get your ankle assessed to ensure there is no serious damage. Accurate diagnosis will put you on the right path from the beginning.
3. Start weight bearing as soon as you are comfortable to do so. Even partial weight bearing with crutches is better than no weight bearing. Use tape or a brace if you need to reduce pain and stabilise your ankle.
4. Keep the ankle moving. Normal movement will encourage good healing and get you back to activity quicker.
5. Functional rehabilitation is the best approach to complete recovery.
6. Ensure that you complete your rehabilitation to avoid persistent problems. Most people should not have to put up with ongoing ankle issues – as long as the do the right thing.
As always, if you have any questions about this or anything else, we are always happy to hear from you.
Julian is a Director and Senior Physiotherapist at South Perth Physiotherapy. He has spent over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 35,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues. He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries.
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