Ankle Sprain and Rehabilitation

An ankle sprain occurs when the ligaments of the ankle are undergone a force that stretches them beyond their capabilities and tear. Ligaments of the ankle are tough bands of tissue that provide support to hold the ankle bones together and prevent excessive movement. The lateral (outer) part of the ankle is made up of three ligaments the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). The deltoid ligament supports the entire medial (inner) aspect of the ankle. There is an interosseous ligament, which is tissues that runs between the entire length of the tibia and fibula. Most ankle sprains occur on the lateral aspect of the ankle, affecting the ATFL ligament. Anyone can experience an ankle sprain at any age.
 
There are three different types of ankle sprains:

1. Inversion ankle sprain
   - Usually involves inversion + plantar flexion + rotation
   - Damages the lateral ligaments of the ankle
   - Peroneal muscle and tendon strains (lateral muscles of the leg)
   - Peroneal nerve injury may also occur in serious cases
2. Eversion ankle sprain
   - Rare
   - Most events are severe
   - Damages medial ligaments of the ankle
3. Diastasis/syndesmosis
   - Damage to the distal talofibular ligaments
   - There can be ankle instability
   - Often associated with a fracture

 
There are 3 grades to a sprain:

1. Grade one
   - No bruising, mild swelling and tenderness
   - Mild to no limp, can raise up on toes
   - No joint laxity, pain at end range of motion
   - 1-2 weeks recovery
2. Grade 2
   - Bruising on one side of foot, more extensive swelling
   - Less localised tenderness, i.e. both sides of ankle
   - Visible limp and unable to raise up on toes
   - Slight laxity and pain with most movements
   - 4-8 weeks recovery
3. Grade 3
   - Bruising and swelling both sides of foot.
   - Tenderness on both sides
   - Unable to weight bear
   - Large amount of laxity
   - 2-6-month recovery

Phase 1 - Acute management of ankle sprain (within 24-72 hours of injury):

• RICE protocol – rest, ice (20 min on, 1 hour off), compression, elevation
• Move ankle through pain free active range of motion as soon as possible
• Watch for significant swelling or changes to ankle which means major damage has occurred
• Weight bear when tolerable, use crutches if it is too painful to load the ankle

 
Phase 2 - Post-acute phase management (Recovery time will vary depending on severity):

• Provide support around the ankle when needed.
• Continue to move the ankle through pain free range of motion
• Strengthen muscles that invert (turn foot inwards) and everters (turn the foot outwards), this depends on the type of sprain. This can be achieved with a resistance band.
• Single leg stance with eye close to improve proprioception (perception/awareness of the position and movement of the body). This can be made more difficult with an unstable surface such as a foam matt or folded pillow.
• Ankle manipulations (done by an allied health practitioner) to promote movement and healing within the joint of the ankle.
• Use massage ball to release tight muscles that have compensated because of the injury.
• Increase weight bearing; use pain and swelling as a to guide the intensity
• Heel/calf raises to increase strength and stability of the ankle

  
Phase 3 – Return to play when all of the above is achieve:

• Begin running with focus on agility and side stepping.
• Jump rope/hopping with increase the intensity of bearing weight onto the ankle.
• Return to sports specific drills.
• Return to play if there is no discomfort during the sports specific training.

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Josh Hallinan
Chiropractor
Available for Appointment Tuesday & Thursday at Health Associates

Vuurberg G, Hoorntje A, Wink LM, et al Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline British Journal of Sports Medicine 2018;52:956.
 
Kerkhoffs GM, van den Bekerom M, Elders LAM, et al Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline British Journal of Sports Medicine 2012;46:854-860.
 
Walls RJ, Ross KA, Fraser EJ, et al. Football injuries of the ankle: A review of injury mechanisms, diagnosis and management. World J Orthop. 2016;7(1):8–19. Published 2016 Jan 18. doi:10.5312/wjo.v7.i1.8
 
Wolfe, Michael W. "Management of ankle sprains." American family physician 63.1 (2001).
 

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