Ankle sprains are one of the most common musculoskeletal injuries and account for around 15-20% of most sports-related injuries. While they’re particularly prevalent during exercise and sports, ankle sprains can also happen when simply walking down the street or stepping on something left lying around the house!
Ankle sprains are often underestimated and up to 50% go untreated, which can result in chronic issues in the joint down the track.
Here, we explore some common questions about ankle sprains, best practice sprained ankle treatment, and outline the key factors you need to be aware of when returning to sport after an ankle injury.
How Does a Typical Ankle Sprain Occur?
The typical mechanism of ankle injuries is an ‘inversion’ sprain which is your classic rolled ankle but can also occur with an external rotation of the ankle, which can cause a ‘high ankle’ sprain.
An inversion sprain (low ankle sprain) happens when the ankle rolls inwards and flexes forwards and usually results in swelling and bruising on the outside of the foot and around the ball of the ankle joint. Often it is sore to walk on straight away and this may last for a few days. The majority of ankle sprains do not require an X-ray or Ultrasound but an assessment by a physiotherapist will be able to tell you if further investigation is required.
Low ankle sprains involve two main ligaments: the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) and are categorised into three grades, with less severe sprains graded lower.
It is possible for the ligaments to pull off a small part of bone during the injury, otherwise known as an avulsion fracture, and these small fractures are usually managed conservatively. The amount of bruising and swelling does not necessarily correlate to a higher grade sprain and therefore a proper assessment can help give you an accurate diagnosis and prognosis for return to sport.
Risk factors for ankle sprains include:
- Hyper or hypomobility of the ankle.
- Poor calf strength.
- Poor balance or proprioception.
- Sports involving high speed cutting and stepping movements.
- Previous history of ankle sprains.
Ankle sprains also have the highest re-injury rate of any lower limb injuries. You have twice the risk of ankle injury in the 12 months following ankle sprain, which can lead to ongoing recurrent sprains and a higher risk of chronic injury. This demonstrates the importance of correct management after acute injury.
Ankle sprains that affect the inside of the ankle and the high ankle are less common but often take longer to rehabilitate. Your physio will guide you as to whether any of these ligaments have been affected by your injury.
What is the Initial Sprained Ankle Treatment Method?
Initially, within 24-48 hours, it is recommended that the POLICE approach is utilised. This is an updated version of the RICE technique with the aim to reduce pain and swelling and optimise the healing process. This involves:
- Protecting the injured area, either by stopping sport or utilising crutches or a brace if required.
- Optimal Loading of the ankle, i.e avoiding complete rest and performing the right amount of weight bearing through the ankle to allow for optimal healing.
- Icing the outside of the ankle.
- Compressing the ankle joint to reduce swelling around the injury site.
- Elevating the leg and ankle.
The ankle should then be assessed for the grade of injury and an appropriate sprained ankle treatment plan put in place. This assessment would usually involve swelling reduction techniques, restoring movement in the ankle joint, strengthening the muscles that cross the ankle joint to provide better stability and balance exercises to restore the body’s proprioception or knowledge of where the ankle is during movement to prevent recurring injury.
Do I Need an X-Ray After My Ankle Sprain?
Most ankle sprains do not require an X-ray to rule out injury. Physiotherapists are trained to assess and determine the likelihood of a fracture being present and can refer for an X-ray if deemed necessary.
This assessment includes determining the ability to walk away from the injury along with palpation of key spots in the foot and ankle to help increase or decrease the likelihood of a more serious injury being present.
What Are the Key Indicators for Return to Sport After an Ankle Sprain?
A recent consensus of health professionals experienced in sprain ankle treatment has developed the PAASS criteria. This involves a set of assessment items which should be assessed prior to return to sport. These assessments include:
- Pain, both during sport and over the last 24 hours.
- Ankle impairments, including range of motion, muscle strength, endurance and power.
- Athlete perception or perceived ankle confidence/reassurance and stability, inclusive of psychological readiness to return to sport.
- Sensorimotor control and proprioception, including dynamic postural control and balance.
- Sport related and functional performance, such as hopping, jumping and agility; sport-specific activities, and the ability to complete a full training session.
Most of the above indicators are best assessed by an accredited physiotherapist and highlights the importance of injury assessment prior to return to sport.
Why is My Sprained Ankle Still Sore 3 Months After Injury?
There are a number of reasons why the ankle joint can continue to cause issues months after an ankle sprain and are often associated with mismanagement of the initial injury. This could be due to not seeking treatment for the injury, a small fracture in the bone which was not identified, returning to sport too soon after injury or involvement of the ligaments on the inner side of the ankle or in the high ankle.
Chronic ankle sprains are those that are still causing pain, recurrent swelling or instability (feelings of “giving way”) greater than 3 months post injury and can occur in up to 40% of acute injuries. These chronic presentations will usually have reduced ankle range of movement, reduced strength in the lower leg muscles, reduced postural control along with altered movement patterns and are usually present as these impairments were not addressed during the initial phase of ankle injury.
How to Prevent an Ankle Injury from Becoming Chronically Unstable
Preventing an ankle injury from becoming chronically unstable requires a comprehensive approach that addresses both the acute injury and the underlying factors that may contribute to instability. Here are some key strategies to consider:
- Restore ROM and strength to baseline levels.
- Consider prophylactic taping or bracing of the ankle during sporting activities.
- Incorporate proprioceptive balance (neuromuscular training) exercises into a regular program.
- Rehabilitate sports specific movements prior to return to sport.
Seek Advice from Coast Sport Physiotherapy
Although ankle sprains are often shrugged off as ‘just a rolled ankle’ and often go undiagnosed and untreated, the rate of chronic ankle sprains is high in both the athletic and general population. If you’re unsure or you are still experiencing pain more than two days post injury, consider an appointment with your physiotherapist.
Our accredited Physiotherapists and Exercise Physiologists are highly experienced in ankle sprain injuries and sprained ankle treatment. We can devise a carefully tailored program to get you back to sport safely, quickly and effectively.
Book an appointment with us to find out more and get back to doing what you love.
Halabchi, F et al. (2020) Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World Journal of Orthopaedics. 11 (12): 534-558.
Martin, RL et al. (2021) Ankle stability and movement coordination impairments: Lateral ankle sprain revisions. JOSP; 51: (4)
Smith, MD et al. (2021) Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework—an international multidisciplinary consensus. Br J Sports Med; 55: 1270-1276.