Ankle injuries commonly occur when you twist or roll over on your ankle while walking or running.
Ankle sprains usually affect the outside of the ankle and are referred to as an inversion injury.
Inversion Ankle Sprains
Inversion ankle sprains account for 90% of ankle injuries. These injuries happen for 2 main reasons:
1. During normal gait, the foot moves from supination to pronation (rolling in of the foot) and back to supination as your foot leaves the ground; a necessary and natural process to enable you to effectively absorb shock.
When this process is interrupted (for example when you walk on uneven surfaces, or you play a sport that involves a large amount of jumping, quick direction changes or twisting of your foot), your foot can roll and twist outwards causing the ligaments on the outside of your ankle to stretch or tear. This is a common cause of acute ankle injuries and even lateral ankle sprains.
2. The ligaments in the lateral ankle are smaller, weaker and more prone to stretching whereas the Deltoid ligament in the medial compartment is much larger, stronger and thicker.
Medial ankle sprains are generally sports related injuries and commonly occur during impact.
The Ankle Joint
Only two movements occur at the ankle, and they are plantar flexion (the movement of the foot downwards known as pointing your toes) and dorsiflexion (the movement of the foot towards the shin bone or lower leg).
The Ankle Joint consists of the three bones, they are the tibia (shin bone), fibula (smaller bone of the lower leg – paralleling the tibia) and the talus (a small bone sitting beneath and between the tibia and fibula).
The joint immediately under the ankle joint, formed by the calcaneus (heel bone) and talus is the talocalcaneal joint (or sub talar joint), and produces inversion (ankle rolling outwards) and eversion (ankle rolling inwards) forms part of the ankle complex.
These bones are held in place with interconnecting ligaments to maintain structural integrity. To enable mobility and adaptability muscles provide the means for which movement can occur.
The ankle ligaments are split into two different groups, the medial ankle and lateral ankle. The medial ankle consists of the strong deltoid ligament. This is a strong fibrous ligament that connects the medial malleolus (inside ankle bone) to the calcaneus (heel bone), talus and navicular.
The lateral ankle, on the other hand, is made up of three much smaller ligaments, these being:
a. Anterior Talofibular Ligament (ATFL)
Connects the front of the lateral malleolus (outside ankle bone) to the talus.
b. Posterior Talofibular Ligaments (PTFL)
Connects the back of the lateral malleolus (lower section of the fibula) to the talus.
c. Calcaneofibular Ligament (CFL)
Connects the bottom section of the lateral malleolus (lower section of the fibula) to the calcaneus.
The ankle joint attaches the lower leg to the foot, so it is important for the ankle to be able to adapt to the environment. When this transition goes wrong an ankle sprain can occur.
Types of Ankle Sprains
Inversion Ankle Sprains
Inversion ankle sprains are a common and debilitating ankle injury that occur when the foot rolls over and causes injury to the outside of the ankle. Common causes may include:
- High intensity activities that involve lateral movement or jumping such as basketball, tennis, football or netball
- Walking or running on uneven ground
- Rolling your ankle while wearing high heels
Eversion Ankle Sprains
Eversion ankle sprains are much less common ankle injuries and involve the deltoid ligament. Common causes of an eversion ankle sprain would be high contact sport such as football, a fall from a height, or even an accident causing impact on the lower leg.
Treatment of a Sprained Ankle: RICE
First aid post ankle sprain is important for recovery. These steps are important to manage a sprained ankle, they include:
Pain is your body’s signal that something is wrong. When the ankle is hurt, it is important to stop your activity, rest as much as possible for the first 48 hours. The “no pain, no gain” philosophy at this stage of recovery is very damaging and increases the likelihood of further damage to the ankle
Ice is a tried-and-true tool for reducing pain and swelling. Applying ice has been shown to reduce the inflammatory response to the ankle sprain and can reduce the pain associated with the injured ankle. Ice is applied for 15-20 minutes every two to three hours during the first 24 to 48 hours after your injury. An ice pack or frozen peas are commonly used.
Compression involves wrapping the ankle sprain in an elastic bandage to prevent too much swelling in the joint. The compression needs to be tight enough to prevent the fluid from pooling around the foot and ankle so as to prevent joint stiffness.
If the foot turns blue, and you start to experience numbness, cold and tingling in the foot release the compression bandage.
Once ICE and a compression bandage has been applied to the ankle sprain it is then advisable to lay down and place the foot above the heart to mange any further fluid build up.
This reduces pain, throbbing and swelling to the affected foot and ankle.
Taping and bracing are a great way to manage chronic ankle instability. Some popular tapes used include:
Athletic tape is specifically designed to restrict movement and protect your joints from injury. The tape doesn’t stretch and therefore stabilises an injured ankle and prevents further injury by limiting most of the movement at the ankle.
In general, the athletic tape should only be worn for a limited time, as it can restrict circulation and impede neurological feedback.
Kinesio tape is stretchy and moveable. This type of tape is best for when you require more range of motion in your ankle but need some extra support. Kinesio tape might be best for you if:
1. You’re returning to sport or physical activity after an ankle injury.
2. You have unstable ankles
Severity of Ankle Sprains
Ankle sprains are ranked in severity. This ranking notes how much the ligaments or tendons have been affected. More severe ankle sprains will have further changes evident on ultra sound and xray, plus further joint range of motion during testing. The following classes of ankle injuries are:
a. Grade I – With Grade I ankle sprains the ligaments and tendons have been stretched beyond their normal limits. Grade I ankle sprains generally present with mild swelling, tenderness and limited loss of function. The symptoms are often present for only 2 -8 days. Treatment usually involves the application of ice and rest. If early return to activity is required after an acute ankle injury a course of dry needling will help reduce inflammation in the muscles and tendons. Most ankle sprains fall into this category.
b. Grade II ankle sprains happen when the ligaments or tendons partially tear. This is a severe ankle sprain. Ultrasound is commonly used to diagnose ankle sprains. Grade II sprains present with moderate swelling, tenderness on palpation and areas of increased trauma along with pain when mobile. Balance (proprioception) is affected with limited range of motion and instability present. NSAIDS are commonly advisable for pain relief. Rehabilitation is longer then a Grade I, usually around 20 days and therapy is suggested with bracing or taping being commonly required and passive movement to prevent joint stiffness. Strengthening exercises should be prescribed by your therapist.
c. Grade III ankle sprains happen when the ligament tears completely, tendon rupture (complete tear of tendon) or an avulsion fracture occur. This is a severe ankle sprain. Grade III sprains present with significant pain and moderate swelling. Balance is affected, limited range of motion and instability within the joint is present. A visit to a health professional is required to obtain an accurate diagnosis along with an Xray and ultrasound referral, due to a risk of bone fracture and surgical opinion is advisable. NSAIDS are commonly prescribed for pain relief. Rehabilitation is long, involving crutches or air cast walkers to immobilise the ankle while weight bearing and passive exercises are advisable.
Where Grade II and Grade III ankle sprains are present it is strongly recommended to seek advice from a health professional otherwise chronic ankle instability can occur along with further injury. A doctor, physical therapist or our podiatrists can assist with proper treatment and exercise prescription including passive exercises eg. ankle alphabet, stretching and strengthening exercises all improve ankle stability.
High ankle sprain will increase range of motion in the ankle. This type of ankle sprain occurs along with twisting in the leg bones and a spiral fracture could be evident. This will affect the ankle syndesmosis (the tibiofibular joint); and difficulty bearing weight and severe pain will be evident.
Ankle bracing is another way of protecting you from a sprained ankle. Bracing is best for people with chronic ankle instability, if you are going through rehabilitation or have hypermobile joints. Ankle braces come in four main types, these being:
Lace-ups (fabric based that may/may not have wrap around straps)
Neoprene compression braces
Hinged (semi-rigid plastic shell with wrap around strap)
Hinged-Cuff (semi-rigid or flexible shell with straps)
Bracing will control inversion and eversion through the ankle joint but should not be relied upon completely as this can weaken the muscles, ligaments and tendons and have a concern with neurological feed back / proprioception.
Exercises to Assist with Ankle Sprains
Exercises to strengthen the ankle post ankle sprain are very important as they assist with the recovery process, and development of fine nerves as well as restoring function to the joint. These exercises fall into 4 groups,
1. Strengthening exercises
2. Stretching Exercises
3. Balance Exercises
4. Functional Exercises.
Rest and trauma associated with an ankle sprain will weaken the muscle groups around the ankle. These strengthening exercises focus on the 4 muscle groups around the ankle:
- Dorsiflexors. The dorsiflexors are the muscles on top of the ankle and are located in the shin and travel down to the top of the foot and toes. A great exercise to strengthen this muscle group is to loop a theraband around a table leg and your foot and pull your foot back towards you – repeat this 20-30 times twice daily.
- Plantar flexors. The plantar flexors are the muscles in your calf and consist of the gastrocnemius and soleus muscles. This muscle group is very powerful and assists in stabilising the ankle and propulsion. A great exercise to strengthen this group of muscle is to stand on both feet, shoulder width apart and take your heels off the ground and come up onto your toes. Hold this position and slowly return the heel to the floor, repeat 15 times.
- Everters. The everters are called the peroneal muscles. This muscle group is in the outside area of your lower leg. A great exercise to strengthen the peroneals is to place a theraband around both feet firmly. During this exercise you rotate your ankles out so your forefoot move away from each other. Slowly return to the start position and repeat 15 times.
- Inverters. The inverters sit in the deep lower leg calf and assist in supporting the arch of the foot and ankle. An excellent strengthening exercise for your inverters is to loop a theraband around a table leg and your foot and pull your foot inwards and upwards.
Stretching, Balancing & Functional Exercises
Stretching exercises are important to improve the length of muscle. When muscle is in trauma from a strain it is important to do routine stretches to restore proper function. A calf stretch along with ankle alphabet exercises are good exercises to perform.
Balance exercises help to improve proprioception, our sixth sense. The ankle holds many nerves which can be damaged in an ankle sprain, the more severe the injury more nerve damage can result.
Athletic training requires the introduction of functional exercises that mimic the activity that is normally performed in sport. Such functional exercises could involve hopping, lunges, lateral steps, high jumps etc. and should only be performed when the injury has completely healed.
Orthotics can help stabilise your injured ankle and prevent further injury. Orthotics at Erica Dash Podiatry are made from a weight bearing cast and will not over correct your ankle. All of our orthotics are fabricated by your prescribing podiatrist.
Dry needling and acupuncture techniques are an excellent way to heal your muscles and reduce inflammation. Only some of the podiatrists at Erica Dash Podiatry are trained in providing dry needling and acupuncture techniques so be sure to mention your interest with this therapy when booking your appointment.
Shockwave therapy is an effective treatment for Grade I and Grade II ankle sprains as it increases blood flow to your tissues and promotes healing of your ligament tears without the need for surgery.
High Powered Laser Therapy
High powered laser therapy is excellent for treating acute and chronic injuries, including ankle sprains. Our high powered laser has unique analgesic abilities to help decrease pain immediately. it decreases inflammation around the nerve which promotes long term relief.
The therapy is not painful, all you as a patient should experience is gentle warmth, if choosing laser therapy as a treatment option you will require a number of treatments as one treatment is generally not enough.
Laser therapy will help you get out of pain quickly and reduce the need for medication. It will help reduce swelling and promote better tissue healing, and it will enable treatment sessions to be progressed faster; therefore enabling you to return to doing what you love. Laser therapy is often used in conjunction with other therapies.
Shockwave is a great alternative to treatments such as dry needling if you’re needle phobic and not keen on dry needling. We also have effective treatment offers for kids.