Ankle sprains are the most common athletic injury, with an estimated 30,000 injuries per day in the United States alone. They are most prevalent in sports such as basketball, as one study found ankle sprains accounted for 13% of all musculoskeletal injuries. Despite such a high frequency, conventional wisdom has resulted in most physicians recommending various forms of conservative management with the adage that “all these injuries get better”. More recently, however, careful assessment of these injuries has revealed that 10-40% result in persistent symptoms after acute injury. Studies have determined that this can be due to a number of different problems including tendon tear or dislocation, underlying cartilage damage and recurrent ankle sprains. While the exact incidence of chronic ankle sprains as a result of an initial ankle sprain remains unknown, many authors have reported that injury to the nerve receptors around the ankle and weakening of the lateral ankle ligaments are likely causes.
When discussing ankle sprains, there are both anatomic and functional classifications:
- Grade I represents a stretching of the lateral ligaments
- The patient is able to fully bear weight and walk
- Grade II is a partial tearing of one or several of these ligaments
- The patient walks with a noticeable limp
- Grade III represents complete rupture of the lateral ligaments
- The patient is unable to walk
These grading systems can also predict timelines for recovery which range from 1-2 weeks (Grade I) to 6-8 weeks (Grade III).
The time tested gold standard in treatment of ankle sprains remains non-operative management, which is 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 outcome.
Early functional rehabilitation, therefore, continues to be the cornerstone of conservative management. This consists of: the RICE protocol (Rest, Ice, Compression and Elevation), early range of motion, progressive weight bearing guided by symptom tolerance, and physical therapy which includes proprioceptive training. 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 protected weight bearing with a CAM walker boot or ankle brace. This will expedite healing and protect the ankle while it is still vulnerable. More importantly, reducing the swelling will help the ankle ligaments assume their natural position.
If the ankle remains swollen for longer periods, the ligaments may heal in a stretched out position making them less functional. Physical therapy is also of benefit in selected 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 this form of management will have an uneventful post-injury course and return to sport and/or routine activity within 6 weeks. However, 10-40% of patients will go on to develop persistent symptoms including recurrent sprains and pain. In athletes with a history of prior sprains, bracing and taping have been shown to decrease the frequency and severity of ankle sprains. It should be noted that this rehabilitative program should always be considered the first-line treatment in any patient with recurrent ankle sprains as well. Improved proprioception and muscle strengthening can be very successful in managing these patients, and current data does not support surgical management unless one has failed a course of physical therapy. Patients with recurrent sprains can benefit significantly from a guided therapy program focusing on peroneal strengthening which can improve dynamic ankle stability. Patients usually reach a maximum benefit at 6-12 weeks. Any patient who exhibits recurrent sprains or episodes of giving way after that time or has associated injuries such as swelling, locking or catching may be a candidate for surgery. Such patients should be evaluated by an orthopedist to discuss optimal management to decrease the risk for future ankle problems such as arthritis.
Dr. Mark Drakos is an orthopedic surgeon specializing in disorders of the foot and ankle as well as sports-related injuries. Dr. Drakos is the author of more than 50 peer-reviewed articles, book chapters and presentations involving orthopedics. He has directly provided care for high school, collegiate, professional, and Olympic athletes.