Ankle sprains account for 1/4 of all sports injuries (6). Of those ankle sprains, 75 percent of them occur on the outside of the ankle, also called an inversion sprain. This common injury occurs when someone "rolls their ankle", where they roll onto the outside of their foot . In an ankle sprain, the ligaments that stabilize the joint are stretched or torn. Lateral ankle sprains are more common because the ligament structure on the outside of the ankle are not as strong or numerous as the ligaments on the inside of the ankle.
Ankle stability comes from three sources: joint surfaces, muscle/tendon support, and ligament support. The inside (medial) part of the ankle has a thick and strong ligament called the deltoid ligament. The lateral (outside) ankle has 3 smaller, thinner ligaments including the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL) (1).
Which ligament that is injured is mostly determined by the position of the ankle at the time of injury. If your toes are pointing down, as if you were pushing off of the ground (called plantar flexion), the ATFL ligament is most likely to be affected. If the ankle is in a more neutral position, the CFL is more often affected. If your toes are pointed up towards you (called dorsiflexion) at the time of the injury the PTFL is most commonly affected (3,4). The ATFL is also the least elastic, making it the most easily injured of the 3 lateral ankle ligaments. About 75 percent of ankle injuries are to the ATFL (5).
Ankle sprains are generally classified based on severity, with Grade I being a stretch with no fiber disruption, Grade II having partial fiber disruption, and grade III a rupture (8). Males and females are affected equally. Ankle sprains are most common in the 15-19 year old group. The highest incidence of ankle injuries occurs in basketball (41 percent), football (9 percent), and soccer (8 percent) (12).
Several risk factors increase the likelihood of suffering an ankle sprain. Limited ankle dorsiflexion is a significant risk factor, because the ankle tends to roll (invert) when ground forces can no longer be accommodated by dorsiflexion. Normal dorsiflexion is 45 degrees- patients who have lost an average of 11 degrees are five times more likely to suffer lateral ankle sprain. (14) Having a previous ankle sprain doubles one’s risk of injury. (15) Improper conditioning or warm up may contribute to ankle sprain. (16) Taping or the use of an external ankle support may decrease one’s risk of injury. (16-23) The biomechanical factors of Q- angle, tibiofemoral angle, and excessive foot pronation/ supination do not appear to be associated with ankle sprain. (24-26)
Are there risk factors for ankle sprains?
There are several risk factors that increase the likelihood of having an ankle sprain. Limited ankle dorsiflexion is a significant risk factor, because the ankle tends to roll (invert) when the joint runs out of adequate motion. Normal dorsiflexion of the ankle is 45 degrees- patients who have lost an average of 11 degrees are five times more likely to suffer lateral ankle sprain (14). Having a previous ankle sprain doubles the risk of injury. (15). Improper conditioning or inadequate warm up may contribute to an ankle sprain (16). Taping or the use of an external ankle support brace may decrease one’s risk of injury (16-23). The biomechanical factors of Q- angle, tibiofemoral angle, and excessive foot pronation (also known as flat feet) or supination (high arches) do not appear to be associated with ankle sprain (24-26).
Ankle sprains commonly occur when landing from a jump, especially on a competitor’s foot, or when stepping into a hole. Patients may recall a “pop” at the time of injury. Pain may range from mild aching to sharp pain and may be worse by putting weight on the injured ankle. Swelling and bruising are possible. Pain and swelling are often worse late in the day. Rapid onset swelling and bruising suggests a ruptured ligament (1). Bruising and discoloration often move toward the foot over time. The presence of a cold foot could indicate compartment syndrome, which would require an emergency room visit (1).
I sprained my ankle what should I do?
Our office will first evaluate the ankle to determine the severity of the sprain. We will perform range of motion, muscle strength testing, and other orthopedic testing to determine ligament integrity and to determine the exact location of the ankle sprain. Treatments will be based on severity of the injury based on the current research guidelines.
Do I need X-rays for my ankle sprain?
The Ottawa ankle rules are a well-established standard for determining the need for radiographs following trauma (36-38). The simplest guideline is the inability to bear weight for at least four steps. (Radiographs are also appropriate if the patient has pain over the medial malleolus, base of the fifth metatarsal, or navicular bone and is unable to bear weight for four steps.) If unable to bear weight for four steps, X-rays are suggested to rule out fracture of the 5th metatarsal (pinky toe) or other bones of the foot. Employing the Ottawa rules allows clinicians to exclude fracture with nearly 99% accuracy (36-38). These rules were intended for adults but have since been shown to be accurate for children as young as 2 (37,38). These rules are contingent upon the patient presenting within 10 days of injury.
Advanced imaging may be appropriate for patients with “red flags”, instability, crepitus, catching, or those who have not responded to 4-6 weeks of conservative care. (40) MRI may be used to assess the ligamentous complex and to rule out any other pathology or injury. (40) Diagnostic ultrasound is useful but not as accurate as MRI for detecting ligamentous injury (41).
How long does it take for an ankle sprain to heal?
While the majority of ankle sprains heal relatively quickly, up to 1/3 of patients continue to note symptoms at one year, and up to 25% report pain, instability, clicking, weakness, stiffness, or swelling at three years (42). Re-injury is common, with rates reaching almost 75% in sports, like basketball (11).
What should I do for my ankle sprain?
Traditional conservative management utilizes of anti-inflammatory measures, protection/support, and functional rehabilitation (41). Initial management may be described with the acronym PRICES (Protection, relative rest, ice, compression, elevation, and support). Home ice or ice massage for 15 minutes each hour may help decrease inflammation.
Do I need a boot (or immobilizing) for an ankle sprain?
Grade III sprains may require immobilization, but Grade I and II ankle sprains should forego complete immobilization and rather focus on regaining full range of motion (44). Protection from additional injury or recurrent sprain may be achieved by taping or by using devices like an air splint or Velcro brace.
What about athletic taping for an ankle sprain?
The usefulness of ankle taping is partially dependent upon the expertise of the person applying the tape. Also to be noted, the effectiveness of athletic tape diminishes during activity, and taping becomes virtually useless after 40 minutes of activity (45,46). Ankle braces may be a more effective long-term means of protection (17-23). Combining an air stirrup brace (air cast) with an elastic wrap results in a faster return of function than using either method of support alone (47).
Can manual therapy help my ankle sprain? Do I need surgery for my ankle sprain?
The goals of manual therapy include regaining full range of motion, strength, and proprioception (sense of where a joint is in space). The presence of three out of four of the following variables predict greater than a 95% success rate for manual therapy and exercise: 1) Symptoms worse when standing 2) Symptoms worse in the evening 3) Navicular drop greater than 5 mm 4) Distal tibiofibular joint hypomobility. This suggests that most cases will not require further treatment or surgery. Patients with Grade III injuries (rupture) may benefit from a surgical consult- although surgical outcomes for Grade III injuries are comparable to conservative care (61). Surgery is associated with a decreased risk of re-injury, but an increased risk of post-traumatic osteoarthritis (61). Younger patients whose occupation or activities place them at higher risk of re-injury are the most likely surgical candidates.
Can my ankle be adjusted after an ankle sprain?
Joint restrictions commonly accompany ankle sprains, and literature advocates the judicious use of mobilization and/or manipulation for restoring function (49-54,64). Joint mobilization is been shown to reduce pain, increase dorsiflexion, and enhance ankle function (54). IASTM, Graston, or transverse friction massage to the affected ligament may help mobilize scar tissue and increase pliability. Myofascial release may help release tightness or adhesions in the calf muscles including gastroc and soleus.
What rehab exercises should I do for an ankle sprain?
Rehab programs should aim to restore range of motion before function (55). Active range of motion (ankle alphabet) exercises can begin immediately. Achilles tendon and calf stretching should begin within 48-72 hours (55). As range of motion improves patients may begin strengthening, which is essential for recovery and prevention of re-injury (56).
Strengthening exercises begin with isometric exercises against an immobile object, and progress to dynamic resistance with weights or resistance bands (55). Strengthening should incorporate the four cardinal planes of motion for the ankle: dorsiflexion, plantar flexion, inversion, and eversion. Peroneal muscle weakness is associated with recurrent injury, so rehab of this group (resisted eversion) is critical (57). Patients with ankle instability may benefit from hip abductor strengthening such as the gluteus medius and TFL (62).
Re-gaining proprioception is another important component of rehab. Proprioceptive training may begin early with single leg stance exercises- transitioning to progressively more complex, multi-planar exercises (i.e. BOSU/wobble board) (58).
Our doctors will help you determine where you should start and when to progress to the next step of rehab exercises.
When can I play again after spraining my ankle?
Return to activity should start with straight line activities (i.e. jogging) then progress to forward/backward, side to side, and finally, pivoting and cutting motions. Return-to-play criteria include: full, pain-free range of motion, and ankle strength greater than 80-90% of the uninvolved side.
At Creekside Chiropractic & Performance Center, we are highly trained to treat each of these conditions. We are the only inter-disciplinary clinic providing services to Sheboygan, Sheboygan Falls, Plymouth, and Oostburg including chiropractic, manual therapy, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
1. Ivins D. Acute ankle sprain: an update. Am Fam Physician. Nov 15 2006;74(10):1714-20.
2. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002;37:364-375.
3. van den Bekerom MP, Oostra RJ, Alvarez PG, van Dijk CN. The anato¬my in relation to injury of the lateral collateral ligaments of the ankle: a current concepts review. Clin Anat. 2008;21:619-626.
4. Coughlin MJ, Saltzman CL, Anderson RB. Mann’s Surgery of the Foot and Ankle. 9th ed. 2014. Elsevier ISBN-13 9780323072427
5. Renström P, Wertz M, Incavo S, et al. Strain in the lateral ligaments of the ankle. Foot Ankle. 1988;9:59-63.
6. Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007;37:73-94.
7. Weindel S, Schmidt R, Rammelt S, Claes L, Campe A, Rein S. Subtalar instability: a biomechanical cadaver study. Arch Orthop Trauma Surg. 2010;130:313-319.
8. Malliaropoulos N, Papacostas E, Papalada A, Maffulli N. Acute lateral ankle sprains in track and field athletes: an expanded classifica- tion. Foot Ankle Clin. 2006;11:497-507.
10. Willems TM, Witvrouw E, Delbaere K, Mahieu N, De Bourdeaudhuij I, De Clercq D. Intrinsic risk factors for inversion ankle sprains in male subjects: a prospective study. Am J Sports Med. 2005;33:415-423.
11. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basket¬ball: injury rate and risk factors. Br J Sports Med. 2001;35:103-108.
12. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ, Jr. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92:2279-2284
13. Cameron KL, Owens BD, DeBerardino TM. Incidence of ankle sprains among active-duty members of the United States Armed Services from 1998 through 2006. J Athl Train. 2010;45:29-38.
14. de Noronha M, Refshauge KM, Herbert RD, Kilbreath SL, Hertel J. Do voluntary strength, proprioception, range of motion, or pos- tural sway predict occurrence of lateral ankle sprain? Br J Sports Med. 2006;40:824-828; discussion 828.
15. McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006;34:1103-1111.
16. Martin RL. Ankle Stability and Movement Coordination Impairments: Ankle Ligament Sprains J Orthop Sports Phys Ther. 2013;43(9):A1-A40.
17. Pedowitz DI, Reddy S, Parekh SG, Huffman GR, Sennett BJ. Prophylactic bracing decreases ankle injuries in collegiate female volleyball players. Am J Sports Med. Feb 2008;36(2):324-7. 1
18. Meana M, Alegre LM, Elvira JL, Aguado X. Kinematics of ankle taping after a training session. Int J Sports Med. Jan 2008;29(1):70-6.
19. Anderson DL, Sanderson DJ, Hennig EM. The role of external nonrigid ankle bracing in limiting ankle inversion. Clin J Sport Med. 1995;5(1):18- 24
21. Sitler M, Ryan J, Wheeler B, McBride J, Arciero R, Anderson J, et al. The efficacy of a semirigid ankle stabilizer to reduce acute ankle injuries in basketball. A randomized clinical study at West Point. Am J Sports Med. Jul-Aug 1994;22(4):454-61.
21. Surve I, Schwellnus MP, Noakes T, Lombard C. A fivefold reduction in the incidence of recurrent ankle sprains in soccer players using the Sport-Stirrup orthosis. Am J Sports Med. Sep-Oct 1994;22(5):601-6.
22. Rovere GD, Clarke TJ, Yates CS, Burley K. Retrospective comparison of taping and ankle stabilizers in preventing ankle injuries. Am J Sports Med. May-Jun 1988;16(3):228-33.
23 Garrick JG, Requa RK. Role of external support in the prevention of ankle sprains. Med Sci Sports. Fall 1973;5(3):200-3
24. Dahle LK, Mueller MJ, Delitto A, Diamond JE. Visual assessment of foot type and relationship of foot type to lower extremity injury. J Orthop Sports Phys Ther. 1991;14:70-74
25. Pefanis N, Karagounis P, Tsiganos G, Armenis E, Baltopoulos P. Tibio- femoral angle and its relation to ankle sprain occurrence. Foot Ankle Spec. 2009;2:271-276.
26. Pefanis N, Papaharalampous X, Tsiganos G, Papadakou E, Baltopoulos P. The effect of Q angle on ankle sprain occurrence. Foot Ankle Spec. 2009;2:22-26.
31. Mawdsley RH, Hoy DK, Erwin PM. Criterion-related validity of the figure-of-eight method of measuring ankle edema. J Orthop Sports Phys Ther. 2000;30:149-153
33. Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013;48(4):528-45.
34. de César PC, Avila EM, de Abreu MR. Comparison of magnetic resonance imaging to physical examination for syndesmotic injury after lateral ankle sprain. Foot Ankle Int. Dec 2011;32(12):1110-4.
35. Young CC. Ankle Sprain Differential Diagnoses. www.emedicine.medscape.com 2013 accessed 5/18/14
36. Stiell IG, Greenberg GH, McKnight RD, Wells GA. Ottawa ankle rules for radiography of acute injuries. N Z Med J. 1995;108:111
37. Dowling S, Spooner CH, Liang Y, Dryden DM, Friesen C, Klassen TP, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. Apr 2009;16(4):277-87.
38. Plint AC, Bulloch B, Osmond MH, Stiell I, Dunlap H, Reed M. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. Oct 1999;6(10):1005-9.
40. Campbell SE, Warner M. MR imaging of ankle inversion injuries. Magn Reson Imaging Clin N Am. 2008;16:1-18
41. Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013;48(4):528-45.
42. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med.
44. Goodier R. Don't immobilize grade I or II ankle sprains: guidelines. Medscape Medical News. July 1, 2013.
45. Lohrer H, Alt W, Gollhofer A. Neuromuscular properties and functional aspects of taped ankles. Am J Sports Med. Jan-Feb 1999;27(1):69-75.
46. Manfroy PP, Ashton-Miller JA, Wojtys EM. The effect of exercise, prewrap, and athletic tape on the maximal active and passive ankle resistance of ankle inversion. Am J Sports Med. Mar-Apr 1997;25(2):156-63
47. DeFranco MJ, et al, J of Musculoskeletal Med, Sept 2008, p 438-443
48. Whitman, Julie M., et al. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther 2009,39(3): 188-200.
49. Bleakley CM, McDonough SM, MacAuley DC. Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Aust J Physiother. 2008;54(1):7-20.
50. Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001;81(4):984-994.
51. Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. J Orthop Sports Phys Ther. 2002;32(4):166-173.
52. van der Wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J, de Bie RA. Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: a systematic review. Aust J Physiother. 2006;52(1):27-37.
53. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003;103(9):417-421.
54. Janice K Loudon, Michael P Reiman, and Jonathan Sylvain The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review Br J Sports Med doi:10.1136/bjsports-2013-092763
55. Mattacola CG and Dwyer MK. Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. J Athl Train. 2002 Oct-Dec; 37(4): 413–429.
56. Thacker S B, Stroup D F, Branche C M, Gilchrist J, Goodman R A, Weitman E A. The prevention of ankle sprains in sports: a systematic review of the literature. Am J Sports Med. 1999;27:753–760.
57. Hartsell H D, Spaulding S J. Eccentric/concentric ratios at selected velocities for the invertor and evertor muscles of the chronically unstable ankle. Br J Sports Med. 1999;33:255–258.
58. Osborne MD, Rizzo TD Jr. Prevention and treatment of ankle sprain in athletes. Sports Med. 2003;33(15):1145-50.
59. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19:653-660.
60. Karlsson J, Eriksson BI, Renström PA. Subtalar ankle instability. A review. Sports Med. Nov 1997;24(5):337-46
61. Pihlajamäki H, Hietaniemi K, Paavola M, Visuri T, Mattila VM. Surgical versus functional treatment for acute ruptures of the lateral ligament complex of the ankle in young men: a randomized controlled trial. J Bone Joint Surg Am. 2010;92:2367-2374.
62. Smith BI, Docherty CL, Curtis D, et al. Hip strengthening protocol effects on neuromuscular control, hip strength, and self-reported deficits in individuals with functional ankle instability. J Athl Train 2014;49(3 Suppl):S-29
63. Flatt DW. Common Diagnoses and Treatments Affecting the Lower Limbs. Presentation at the 2015 American College of Chiropractic Orthopedists Convention. Las Vega,s NV April 24, 2015.
64. Southerst D, Yu H, Randhawa K, Côté P, D'Angelo K, Shearer HM, Wong JJ, Sutton D, Varatharajan S, Goldgrub R, Dion S, Cox J, Menta R, Brown CK, Stern PJ, Stupar M, Carroll LJ, Taylor-Vaisey A. Chiropr Man Therap. 2015 Oct 27;23:30. The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Chiropractic & Manual Therapies (2015) 23:30