Ankle sprains are an extremely common injury that are experienced in both the general population as well as in sporting environments. Typically it is the lateral (outside) ligaments that get affected. One ankle sprain occurs per 10,000 people every day and between 15-45% of all sports related injuries can be attributed to ankle sprains (1).
Astonishingly only 50% of people who experience an ankle sprain seek medical attention despite the potential for this type of injury to affect day to day activity and sporting participation (2).
Ankle sprains range from mild sprains that will likely resolve within a few weeks to more severe ligament tears or ruptures and can involve bone bruising and tendon damage too, and anything in between.
What Happens When You Sprain Your Ankle?
There are many ligaments in the ankle and the image below shows the most common ones that are affected. The anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), posterior talofibular ligament (PTFL) are the three most commonly injured ligaments because where they are situated. When you “roll” your ankle the foot gets forced into a pointed and/or turned in position which stresses these ligaments and can result in injury.
When you damage a ligament, i.e. tear it, it initiates an inflammatory process. Initially the ligament bleeds and we see lots of swelling and sometimes bruising along the outside of the foot. Then lots of chemical and cellular processes happen stimulating the repair as the body produces scar tissue. Often though, in the aftermath of an ankle sprain we are left with:
– Restricted movement
– Reduced proprioception (your body’s awareness of where it is in space)
– Anxiety and reduced confidence
– Limited participation in sport
– Time off work
How Does This Injury Happen?
Common ways that ankle sprains occur are mis-stepping off a curb, falling downstairs, landing awkwardly from a jump or even over balancing if you’re wearing high heels!
In essence, your foot is forced into a position described as plantarflexion and inversion – medical speak for your foot was pointing down and turning in at the same time whilst being put under pressure. This puts stress through the ligaments on the outside of the ankle causing possible tearing, and in more extreme cases total rupture of the ligaments.
What Should You Do If You Think You’ve Sprained Your Ankle?
First things first, you need an accurate diagnosis of the injury. It is not altogether uncommon for fractures (broken bones) to occur when you “roll” your ankle, so it needs to be certain that there aren’t any fractures. Depending on the situation you may or may not need investigative imaging to conclude this. An X-ray will normally be administered at A+E if your symptoms are in line with a possible fracture, and this is usually sufficient to highlight the presence of a fracture.
If you are unable to fully weight bear on the ankle and the time of the injury is followed by immediate swelling it is advisable to attend A+E so you can be assessed this way. If you are able to weight bear, there is delayed swelling and there isn’t any bony tenderness then its unlikely you have suffered a fracture, however, by visiting a clinician they can fully assess you and make a decision on whether you ought to have an x-ray or not.
Once a firm diagnosis of a ligament sprain is concluded you need to start managing things correctly.
This leads us to the Do’s and Don’ts list:
The “Do” List
It’s Time To Give Yourself PEACE & LOVE
In a world of acronyms for managing injuries let us introduce you to the latest one; PEACE & LOVE. Standing for Protection, Elevation, Avoid Anti-inflammatories, Compress Educate and Load Optimise Vascularisation Exercise. The most contemporary principles that clinicians have to guide us in assisting the treatment of soft tissue injuries, such as those caused in an ankle sprain highlight the complexity of what are considered common and simple injuries by many.
Whilst PEACE & LOVE guides clinician’s thinking in relation to how they help you recover, there are still elements that can be applied by you and indeed some of the classic principles by the more commonly known RICE and PRICE acronyms. We discuss the concepts of this below.
Whilst swelling after a soft tissue injury is pretty inevitable, and necessary for recovery, its important to get it under control and reduced it as soon as possible.
Persistent swelling can bring its own problems. You may be familiar with the Rest Ice Compression Elevation (RICE) concept. This was promoted, historically, to manage swelling for most acute injuries. However, a study that was published in 2017 (3) found that there was no presently published literature supporting the use of this principle. Whilst there are some studies with suggestions that RICE provides benefit, the research is limited and so it is important not to rely solely on this method to manage swelling.
A more pragmatic approach, perhaps, is to employ a ‘PRICE’ plus early rehab approach. The ‘P’ in the PRICE acronym stands for protection. In the case of more severe ankle sprains, being put into a protective boot for up to 10 days may prevent further injury, aid swelling drainage and modulate pain.
Less serious sprains will benefit from taping or ankle supports for a period of 4-6 weeks. In fact, the study suggested that being immobilised for long periods was linked with poorer prognoses and so use of protective boots should be limited to short term use before progressing to utilising a support (ankle supports/tape).
In cases where a protective boot isn’t warranted supports and tape should still be encouraged in early management of an ankle sprain.
If you are sensible and deploy protection measures such as bracing/supports, incorporate some of the RICE principles ALONGSIDE early rehab and make sure you modify your activity levels you should be able to control and resolve the swelling within a few weeks depending on the extent of the injury.
*** Should I take Anti-inflammatories (NSAIDs) – based on the work by Vuurberg et al, 2017 they had the following recommendation; “NSAIDs may be used by patients who have incurred an acute ankle sprain for the primary purpose of reducing pain and swelling. However, care should be taken in NSAID usage as it is associated with complications … and may suppress or delay the natural healing process.”***
So they can be an adjunct to pain relief, but you may be better off with holding from them if your pain levels are manageable. It is strongly recommended you discuss medication with your GP or a pharmacist to be fully informed of the options you have.
As with most things in life exercise is our route to success. Whilst there are other things that a physiotherapist can do such as massage, joint mobilisations, taping etc the real golden ticket is exercise. Hands on therapy can facilitate the benefits of exercise (2) but progressive loading through rehabilitation is key.
It is also important to consider what counts as exercise too. Broadly speaking you can consider this in two ways; rehabilitation – specific strengthening and balance exercises prescribed to you by a clinician – and functional – day to day ambulation and walking. Even standing and walking to the kitchen to make a cup of tea puts load through the ankle and helps to stimulate tissue repair. The key is to find the right balance.
A common question asked to physiotherapists is, “how far can I walk on a sprained ankle?” The answer is grey and varies person to person and on the injury, however incorporating walking into your recovery is a great idea. Often the answer is to start off with smaller distances and duration and monitor to see if the ankle responds i.e. swells or becomes more painful. Based on this you can then build a progressive walking programme for yourself. If you can walk 10 minutes without pain or swelling increasing you know you can then try 15 or 20 minutes. If you do get an increase in pain or swelling, that is your ankle telling you it can’t quite cope with that so we need to give it longer before asking the ankle to perform in that way. Crutches and braces can be useful short term adjuncts when necessary.
Exercise is especially beneficial in preventing the recurrence of sprains, reducing the chances of getting instability and increasing the speed of recovery. Exercise should be prescribed in a progressive way taking into account the stage of healing, extent of pain and damage, and base line strength, range of movement and proprioception
Along with swelling reduction, restoring full ankle range of movement is very important for long term outcome and avoiding secondary problems further down the line. A full resolution of movement and swelling are often indicators used to progress rehabilitation. Exercise is an important method by which to build strength and restore ankle proprioception too.
Proprioception is your body’s awareness of where it is in space without you having to look. So for example, if you close your eyes right now whilst you are reading this, you’ll be able to describe the position that your legs are in, that your head is tipped down or facing forwards and that your left elbow is bent and your fingers are in a relaxed fist. When you lose proprioception around the ankle you are more likely to experience a second sprain because you aren’t receiving the same level of information about the joint position as before the injury.
Whilst there may be times when surgery is required after suffering an ankle sprain, current evidence would suggest that it is best to be reserved in the recommendation of surgery. Whilst there may be times where surgery is opted for in earlier time frames (such as in elite sport), conservative measures are still the primary option for treating ankle sprain injuries. The good news is that IF you do need ankle surgery, the post-surgical outcomes are often very good (as long as you rehab after). (2)
The ‘Don’t’ list
Assume All Is Well
As mentioned previously, ankle sprains often lead to persistent problems and ankle instability if not treated properly. In cases where the injury is mild, with minimal swelling and sustained by those who are better conditioned then a couple of weeks of modified activity may be enough to allow full recovery and return to life/sport.
However, in more significant cases an ankle sprain needs some TLC and nurturing to try and prevent long lasting effects. Just thinking that time passing, and resting is enough to recover is not the case in majority of situations. By not treating an ankle sprain correctly you stand a greater chance of joining the 70% of individuals suffering recurrent sprains (3). Don’t assume, be proactive and make sure!
Rely On Frozen Peas
Whilst they may be great in their mushed-up form on the side of some battered haddock and chips, or in a salad if you’re feeling whimsical, they aren’t going to fix your sprained ankle. From a cryotherapy (icing) point of view they do not stay cold enough for long enough to elicit a physiological effect to impact swelling. As we’ve discussed earlier, ice can be a part of swelling management, but it needs to be something that stays consistently ice cold for 10-12 minutes and ideally that can be applied with compression.
Try To Run It Off
Anywhere between 1.5 up to 5 times body weight of force goes through each leg per step when running. If you’ve rolled your ankle and are then asking it to withstand significant forces you are likely to do one of three things, increase pain, increase swelling or risk rolling the ankle again. Acknowledge that you have an injury and deal with it appropriately
Hopefully this blog post has given you some insight on to things to do to take control of managing your ankle sprain and some things not to do as well. A key message here is that an ankle sprain, albeit common, is not to be taken lightly just because it happens a lot. It can, and in most cases does, lead to future complications if not dealt with properly. But equally important is the message that if you do the right things and treat it well it WILL get better and you stand a better chance of avoiding it happening again.
- Verhagen EA, van Mechelen W, de Vente W. The effect of preventive measures on the incidence of ankle sprains. Clin J Sport Med. 2000;10(4):291-6
- Vuurberg G, Hoorntje A, Wink LM, van der Doelen BFW, van den Bekerom MP, Dekker R, van Dijk CN, Krips R, Loogman MCM, Ridderikhof ML, Smithuis FF, Stufkens SAS, Verhagen EALM, de Bie RA, Kerkhoffs GMMJ. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018 Aug;52(15):956.3
- T J Hubbard, E.A. Wikstrom. Ankle sprain: pathophysiology, predisposing factors, and management strategies. 2010. Open Access Journal of Sports Medicine