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Ankle Sprains

Image - Photo of Mark C. Drakos, MD
Mark C. Drakos, MD
Assistant Attending Orthopedic Surgeon, Hospital for Special Surgery
Instructor of Orthopaedic Surgery, Weill Cornell Medical College

Sprained ankles are the most common athletic injury and the number one reason people go to see an orthopedist. There are an estimated 30,000 ankle sprains per day in the United States alone. They are more prevalent in certain sports – such as basketball, where in one study they accounted for 13% of all musculoskeletal injuries. (High ankle sprains, which affect a different set of ligaments, are less common.) Despite such a high frequency of injury, conventional wisdom has led most physicians to recommend various forms of conservative treatment, with the adage “all these injuries get better.”

More recently, however, studies of these injuries have shown that 10% to 40% of them result in persistent symptoms after the initial injury. These studies show that this can be due to a number of problems, including:

  • Torn or dislocated tendons
  • Underlying cartilage damage
  • Recurring (chronic) ankle sprains

It is not clear how many cases of chronic ankle sprain result from a single, initial ankle sprain. However, many doctors report that damage to the nerve receptors around the ankle and the weakening of the lateral (outside) ankle ligaments are likely to cause additional ankle sprains.

Types of Ankle Sprains

There are two different basic classifications of ankle sprains: Anatomic (the level severity of damage to tissues in the ankle) and functional (the level an injury affects a patient’s ability to walk or put weight on the ankle).

Anatomic Classifications

  • Grade I ankle sprain – lateral ligaments are strained (overstretched)
  • Grade II ankle sprain – partial tearing of one or several of these ligaments
  • Grade III ankle sprain – complete rupture (tear) one or more of the lateral ligaments

Functional Classifications

  • Grade I injury – the patient is able to fully weight bear and walk
  • Grade II injury – the patient walks with a noticeable limp
  • Grade III – the patient is unable to walk

These grading systems can also predict timelines for recovery, which range from 1 to 2 weeks (Grade I) to 6 to 8 weeks (Grade III).

Treatments

It is very important to reduce swelling in the immediate post-injury period. This can be accomplished by a compressive wrap, icing for 20 minutes at least twice a day and wearing a CAM walker boot or ankle brace to provide protected weightbearing. This will expedite healing and protect the ankle while it is still vulnerable. More importantly, reducing the swelling will help the ankle ligaments heal in their natural position. If the ankle remains swollen for longer periods, the ligaments may heal in a stretched-out position, which makes them less functional.

The time-tested gold standard in treatment of ankle sprains is non-operative management, which remains a well-accepted and typically successful treatment choice for most patients. Several prospective studies have compared non-operative and operative treatment for Grade III sprains, and have failed to demonstrate a difference in outcomes.

Early functional rehabilitation, therefore, remains the cornerstone of conservative management. This includes:

  • The RICE protocol (Rest, Ice, Compression and Elevation)
  • Early range of motion exercises progressive weightbearing guided by level of pain
  • Physical therapy, which includes proprioceptive training (balance exercises), is also beneficial for some patients. Several studies have shown that patients may develop proprioceptive deficits. This means that the body loses some of its ability to localize the position of the ankle in space and fire the ankle muscles accordingly. What this means is that the muscles that protect the ankle from rolling over may not protect patients as well when they are walking on uneven ground. Functional rehabilitation should focus on identifying and restoring these deficits, as well as overall limb strengthening.

The vast majority of patients who undergo conservative, non-operative management will have an uneventful post-injury course and return to sports and/or routine activity within six weeks. Despite these encouraging data, however, 10% to 40% of patients will go on to develop persistent symptoms, including recurrent sprains and pain.

In athletes with a history of prior sprains, bracing or taping the ankle has been shown to decrease the frequency and severity of ankle sprains.

These above non-operative methods should always be considered the first-line treatment in any patient with recurrent ankle sprains. Improved proprioception and muscle strengthening can be very successful in managing these patients, and current data do not support using surgical treatments unless a full course of physical therapy has failed to bring the patient back to full strength and mobility.

Patients with recurrent sprains can benefit significantly from a guided therapy program focusing on strengthening the peroneal muscles (the muscles on the outside of the calf), which can improve dynamic ankle stability. Patients usually reach a maximum benefit at 6 to12 weeks. Any patient who exhibits recurrent sprains, ankle rolling or other instability after that time or has associated injuries such as swelling, locking or catching may be a candidate for surgery. These patients should be evaluated by an orthopedist to discuss optimal management to decrease the risk for future ankle problems such as arthritis.

 

 

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