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Oh Dang....I sprained my ankle!!!!



Ankle sprains.



A very common injury in both the sporting and non sporting population. It is 1/3 of all sports injuries (that shows how common it is!). It can result in considerable time lost to injury and long term disability up to 60% of patients.


Plenty of people sprain their ankles and unfortunately, usually does not do much other than taking a couple of pain killers and perhaps icing their ankles for a few times. Unfortunately, the poor initial care predisposes the person to further ankle sprains in the not to far future causing more pain and more injury to the ankle. Worst case scenarios ranges from severe cartilage injuries, early osteoarthritic changes to the ankle, pain on physical activities and worsening aches and pains along the kinetic chain of the lower limb.


In today’s article, let's discuss about what to do when you sprain your ankle, when to seek medical attention, what to expect at physical therapy and what should be your expectations in terms of outcomes.


Before we start, let’s scale back and look at what happens when you “sprain your ankle”. The most common type of ankle sprain is the lateral ankle sprain, which means your ankle is twisted outwards in. The pain and discomfort that you will experience subsequently will mostly be at the outer aspect of the ankle joint. For the ease of explaining in this article, when I discuss about ankle sprains, it will be the lateral type (as common things are common).

The ankle joint is held in place to maintain its stability by ligaments and tendons (to differentiate each other, ligaments attach from bone to bone, where as tendons attach muscle to bone).




Bony and ligamentous anatomy of ankle


Without getting into a too technical anatomy lesson, the outer aspect of the ankle (lateral side) has a few important structures that are commonly affected when you accidentally sprain your ankle. They are the Anterior Talofibular Ligament (ATFL), the Calcaneofibular Ligament (CFL), and the Peroneus Tendon (PT). Out of the three mentioned, ATFL is the most commonly affected ligamentous injury in an ankle sprain.


After the injury to the ankle has occurred, depending on the severity of the injury, you will experience swelling and pain over the outer aspect of the ankle. It may be painful to bear weight onto that affected side and there may also be bruising seen.


Most important at that point of injury is to control the pain and swelling. In this situation, ice compression is necessary and important. The better the control, the faster the ankle can be assessed properly and for early injury rehabilitation to begin. Assessment of the injury is to determine the grading of the ligament sprain.




Grading (and how it looks like) for ligamentous sprains/tears


WHY IS INJURY GRADING IMPORTANT?


When a ligament (or tendon/muscle) is in its normal and healthy state, the fibres are well aligned making it strong. Sometimes it is over stretched (like in a minor sprain) and the ligament starts having small tears within some of the fibres. However the general architecture is intact and it is still able to perform its normal function. On ultrasound scan, the integrity of the ligament will still appear intact. What I have just described is a Grade 1 sprain.


However if the sprain was a little bit more severe, some fibres will give way leading to a partial tear of the ligament which is visible under ultrasonic screening. This is a Grade 2 sprain.


A Grade 3 ligament sprain (or more accurately, a tear) is when there is a high force ankle sprain leading to a total tear of the ligament where there is no approximation of any fibres left.


In Grade 1 sprains, there may be pain and a bit of swelling in the ankle that goes away within a week or two. There is usually not much issue with bearing weight and normal physical activities can resume by the end of the week. There may hardly be any subsequent issues if this injury was to be taken lightly. Ice compression and a few days off should do the trick.


In Grade 2 sprains however, the pain and swelling takes a while longer to dissipate. There may be slight bruising and it will definitely be painful to bear weight on that affected ankle. Because there is a partial tear to the ligament, it will take time for the ligament to heal itself and usually the time to resolution is about 4 to 6 weeks. Because it takes quite a while before being able to resume normal physical activities without pain, physical therapy is important to maintain the muscles surrounding the ankle joint, regain the mobility of the ankle and also to re-learn balance (the actual term is proprioception which means the sense of body positioning). It is usually the combination of poor balance and weak surrounding muscles that cause recurrent ankle sprains. The more frequent the recurrent sprains occur, the more injuries that ankle will incur. So the aim of long term management is to prevent recurrence.


If unfortunate enough that the injury was very severe and the ligament injury sustained was a Grade 3 ligament tear, the initial pain and swelling will be equally severe and more frequently with bruising. It will be very painful to put pressure onto that ankle and it is recommended for crutches to off load the painful ankle (off loading walker boots help as well). The pain and swelling will take a while to subside and resuming normal physical activities pain free will take about 2 to 3 months. Sometimes if one is lucky, the completely torn ligament does eventually heal but usually it will be a weak and loose causing the loose sensation of the ankle. Physical therapy is important to regain range of mobility, to maintain and/or rebuild muscle strength not just for the ankle but also for the entire leg and to re-learn proprioception (balance). However sometimes the ankle instability persist then surgery should be considered.


This is why diagnosing early and determining the grade of injury to the ligament is important. In Grade 3 tears (or even a high grade partial tear), if the injury was detected within the first 2 weeks of the sprain, there is still a possibility of injecting hyaluronic acid under ultrasound-guidance, into the space between the torn ligament. This creates a “bridge” between the torn ends of the ligament aiding the formation of new fibres between the ends. Research has shown that this hasten the healing process by 2-4 weeks. With the addition of physical therapy, it is possible to return to normal physical activities to a degree without the need for surgery.


However, most cases of Grade 2 and 3 ankle sprains that I see were poorly managed. Patients usually dismiss their injuries until a few months have passed and are unable to return to daily activities without pain and/or instability, then will they seek help. By that time, they may have had a few more episodes of twisting their ankles (due to a combination of weakness and instability) and may also be suffering from other concurrent injuries such as cartilage injuries (leading to early onset of osteoarthritis of ankle joint) and straining the peroneus tendons. Thus it is important to not ignore your ankle sprains.





My advice for acute ankle sprains (for when it just occurred) is to (1) ice and compress the injured area for 15-20min and repeat every 2-3 hours, (2) take time off your feet and rest if necessary, and (3) start putting weight onto the ankle as you normally do ONLY when the pain and discomfort is minimal.


After that, to seek out your nearest Sports & Exercise physician to assess and grade your injury so that the appropriate mode of action can be taken. We aim to return you to your daily activities, whatever they may be, as soon as you can AND most importantly we want to prevent you from having recurrent ankle sprains that may cause further issues.

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