Classic Ankle Sprain - How To Diagnose, Treat and Avoid Reoccurrence

There are a few things in life that make me consistently sad. Movies where an animal gets hurt make me sad. Closing down the outdoor pool after Labor Day makes me sad.

When patients tell therapists “oh, I just have weak ankles”, we get sad. Ankles don’t do pull-ups. Ankles don’t fuel up on protein powder and creatine. Ankles don’t faint in the sun because they have the vapors. People don’t suffer from ankle pain simply because their ankles are inherently just “weak”.

What is true is that previous incidence of ankle sprain is the biggest risk factor for future occurrence. What does that mean? If you have rolled your ankle once, you are statistically more likely to have a second, third, fourth (you get the picture) ankle injury. Seems kind of cruel and unfair, right?

However, just because something is statistically true doesn’t mean it will actually be true for you. Statistically, as an American woman in my 30s, I will have 1.87 kids. Actually, I have 3 cats and 5 chickens. Statistically, I will spend $1,700 on clothes per year. Actually, I can tell you that I hate, hate, HATE shopping. I signed up for Stitch Fix for a hot 3 months and still found the act of trying on clothes in the comfort of my own home time consuming, annoying, and just a big fat hassle. Statistically, I will live to be 82yrs old. Actually, if you remind me a couple of decades from now, I’ll invite you to my 90th birthday party and we will eat funfetti cake with extra frosting. Statistics are just that- statistics. They are helpful for knowing trends and then, if those trends are adverse, taking steps to avoid them.

So, you’ve had an ankle injury before? Don’t be a statistic. Know what happened, how to treat it, and how to buck the trend. Knowledge is Power, remember?

A Little Ankle Anatomy

First, it is helpful to know a little bit of basic ankle anatomy:

The ankle is considered a mortise-and-tenon joint, which is a woodworking term that describes the type of fit shown below. The “tenon” is comprised of the bones of the shin: the tibia on the inside and the fibula on the outside. These long bones house the “mortise”, or a smaller bone called the talus. The talus is dome shaped, thankfully, which allows for plantarflexion and dorsi-flexion (pointing and flexing, respectively) of the ankle.

The ankle is stabilized by the tendons of many muscles, most notably the posterior tibialis, anterior tibialis, peroneus longus, and peroneus brevis. Ligaments (which connect bone to bone) also provide further stability on the inside and the outside of the ankle as they fan away from our ankle bones.

An ankle can be injured in a variety of different ways, thus causing a variety of different symptoms. However, the most common ankle injury is called an inversion sprain. It occurs when the ankle quickly and unexpectedly rolls to the outside, hence its colloquial term “a rolled ankle”.

The vast majority of all ankle injuries are inversion sprains…but why?

How An Ankle Sprain Happens

turning your ankle — A Turned Ankle – Ouch!

Imagine that you are rushing down the stairs, laundry basket in hand, and you accidentally step on an unexpected object, like a toy. Due to the shape of the bones, the tenon and mortise joint has the most laxity when the ankle is plantarflexed (toe pointed).

And remember those two long bones, the tibia and fibula? Well, the fibula extends further down toward the ground than the tibia. Therefore, as you step onto the toy with a pointed foot, your lose ankle wobbles. Your foot is literally forced to the outside by the relatively longer inner bone. This places a quick and potentially injurious stretch to the tendons and ligaments of the outside of the ankle.

Replace that toy with a hidden tree root during your trail run, a clump of raised grass on the soccer field, or an unexpected rock at the bottom of a curb. The same sequence of events could occur.

The ATFL is the thinnest ligament and thus the most prone to injury during an inversion ankle sprain. However a number of soft tissue structures can be over stretched, including the posterior talofibular ligament (PTFL), the calcaneofibular ligament (CFL), and the peroneal longus and brevis tendons. Ligaments can be partially or completely torn, and an ankle sprain is usually graded as type I, II, or III, depending on the severity of injury. In very severe cases, bones of the ankle can literally “knock” together causing a bone bruise. Tendons can also be stretched so quickly and forcefully that they can tear a small piece of bone off from where they attach. This is called an avulsion fracture.

All of this can result in swelling, bruising, and difficulty walking or performing your favorite hobby without pain. Scary, right?

Ankle Sprain Treatment

Once you know you have injured your ankle, and that you DON’T want to become a statistic, the next step is to get treated. The most common treatment techniques that physical therapists use to speed recovery and reduce pain caused by inversion sprains are:

Joint and soft tissue mobilization. An inversion sprain can cause small displacements of certain bones in the foot, most notably the fibula and the navicular bone. Restoring normal movement and positioning of these joints with hands on treatment can be extremely helpful in reducing pain and restoring normal movement patterns. Additionally, skilled manual therapy to the overstretched soft tissue can reduce inflammation and speed the healing process.
Taping. Certain taping techniques can be very beneficial in reducing pain after an inversion sprain, and I am not talking about the big bulky techniques that require $5 worth of athletic tape per attempt. The most effective techniques require a few simple strips and can be per-formed on your own if you have a therapist who is able to teach you.
Gentle strength and ROM exercises. It is never advisable to continue pushing through pain; if you are experiencing ankle pain with running, cycling, working out, etc. you need to avoid that activity until you body has healed sufficiently. However in most cases, it is equally un-advisable to immobilize your ankle and do NOTHING. This will cause joint stiffness, muscle atrophy, and apprehension of movement that will make your return-to-normalcy much longer and more cumbersome. If you can do a certain range of motion pain free, you should do it! A skilled physical therapist can help you find strengthening and range of motion exercises that are appropriate and beneficial for your specific injury.

Ankle Sprain Prevention

The next step? You guessed it…PREVENTION! Don’t buy into that “you just have weak ankles” nonsense. You don’t have a weak ankles, you have non-rehabilitated ankles. The most common interventions we teach our patients in order to avoid re-occurrence of ankle sprain include:

Balance Training. Studies show that unconscious proprioceptive deficits occur after acute ankle sprains. English translation? One’s ability to maintain their balance on an injured leg suffers greatly after an ankle roll. Why does this matter? Keep in mind that an inversion sprain is basically a quick loss of balance, resulting in a twisted ankle. Having increased difficulty maintaining one’s balance can result in another ankle sprain, and then another, and then another. That’s why previous incidence of ankle sprain is the highest predictor of future sprain. Disrupt the cycle! Balance training must be pain free and progressive, meaning that it should get harder as your ability improves. If you sprained your ankle 1 month ago, you shouldn’t be doing the same exercise that you did the day after you injured it. Consult with your physical therapist to build a program that is specific to you.
Hip Strengthening. Hip strength is a HUGE component of balance. Small muscles in your hip work to fine tune the placement of your lower leg in space, keeping it aligned as it should be. When you step on that toy, that tree root, or that unexpected rock these hip muscles react to correct your center of balance thus preventing a wobbly foot and potential ankle roll. These muscles can be trained to be quicker, stronger, and more reactive. Therefore balance, like strength, can be improved through training. When patients tell me “I have bad balance” what I really hear is “I have poor reactive hip strength”.
Core Strengthening. Core strengthening compliments balance and ankle injury prevention just like hip strength does. In fancy PT terms we lump this training together and call it “lum-bopelvic control”.

Of course there are other ways that one can injure their ankle, and thus other ways that ankle pain must be diagnosed, treated, and prevented. Stay tuned for our next blog post “I Didn’t Sprain My Ankle, So Why Does It Still Hurt?”