A sprained ankle, also known as a twisted ankle or rolled ankle, is an injury where
sprain
A sprain, also known as a torn ligament, is an acute soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers ...
occurs on one or more
ligament
A ligament is the fibrous connective tissue that connects bones to other bones. It is also known as ''articular ligament'', ''articular larua'', ''fibrous ligament'', or ''true ligament''. Other ligaments in the body include the:
* Peritoneal li ...
s of the ankle. It is the most common injury to occur in
ball sports
This is a list of ball games and ball sports that include a ball as a key element in the activity, usually for scoring points.
Ball games
Ball sports fall within many sport categories, some sports within multiple categories, including:
*Bat-and- ...
, such as
basketball
Basketball is a team sport in which two teams, most commonly of five players each, opposing one another on a rectangular Basketball court, court, compete with the primary objective of #Shooting, shooting a basketball (ball), basketball (appr ...
,
volleyball
Volleyball is a team sport in which two teams of six players are separated by a net. Each team tries to score points by grounding a ball on the other team's court under organized rules. It has been a part of the official program of the Summ ...
,
football
Football is a family of team sports that involve, to varying degrees, kicking a ball to score a goal. Unqualified, the word ''football'' normally means the form of football that is the most popular where the word is used. Sports commonly c ...
, and
racquet sports
Racket sports are games in which players use a racket or paddle to hit a ball or other object. Rackets consist of a handled frame with an open hoop that supports a network of tightly stretched strings. Paddles have a solid face rather than a ne ...
.
Signs and symptoms
Knowing the symptoms that can be experienced with a sprain is important in determining that the injury is not really a break in the bone. When a sprain occurs,
hematoma
A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillary, capillaries. A he ...
occurs within the tissue that surrounds the joint, causing a
bruise
A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close ...
.
White blood cells
White blood cells, also called leukocytes or leucocytes, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. All white blood cells are produced and derived from mult ...
responsible for inflammation migrate to the area, and blood flow increases as well. Along with this inflammation, swelling and pain is experienced. The nerves in the area become more sensitive when the injury is suffered, so pain is felt as throbbing and will worsen if there is pressure placed on the area. Warmth and redness are also seen as blood flow is increased. Also there is a decreased ability to move the joint.
Image:Freshspraininbrace.JPG, Right foot, housed in an air brace, has become swollen as a result of a more severe 2nd degree sprain to the ankle.
File:Schwellung am Fußknloechel und Blutergussl.jpg, Right foot, 3rd degree sprain. One day after injury.
Cause
Movements – especially turning, and rolling of the foot – are the primary cause of an ankle sprain.
[Sprained Ankle – American Academy of Orthopedic Surgeons](_blank)
Retrieved on 22 January 2010.
The risk of a sprain is greatest during activities that involve explosive side-to-side motion, such as tennis, skateboarding or basketball. Sprained ankles can also occur during normal daily activities such as stepping off a curb or slipping on ice.
Returning to activity before the ligaments have fully healed may cause them to heal in a stretched position, resulting in less stability at the ankle joint. This can lead to a condition known as
Chronic Ankle Instability (CAI), and an increased risk of ankle sprains.
The following factors can contribute to an increased risk of ankle sprains:
* Weak muscles/tendons that cross the ankle joint, especially the muscles of the lower leg that cross the outside, or lateral aspect of the ankle joint (i.e. peroneal or fibular muscles);
* Weak or lax ligaments that join the bones of the ankle joint – this can be hereditary or due to overstretching of ligaments as a result of repetitive ankle sprains;
* Inadequate joint
proprioception
Proprioception ( ), also referred to as kinaesthesia (or kinesthesia), is the sense of self-movement, force, and body position. It is sometimes described as the "sixth sense".
Proprioception is mediated by proprioceptors, mechanosensory neurons ...
(i.e., sense of joint position);
* Slow neuron muscular response to an off-balance position;
* Running on uneven surfaces;
* Shoes with inadequate heel support; and
* Wearing high-heeled shoes – due to the weak position of the ankle joint with an elevated heel, and a small base of support.
Ankle sprains occur usually through excessive stress on the ligaments of the ankle. This can be caused by excessive external rotation, inversion or eversion of the foot caused by an external force. When the foot is moved past its range of motion, the excess stress puts a strain on the ligaments. If the strain is great enough to the ligaments past the yield point, then the ligament becomes damaged, or sprained.
Diagnosis
The diagnosis of a sprain relies on the
medical history
The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other peo ...
, including symptoms, as well as making a
differential diagnosis
In healthcare, a differential diagnosis (abbreviated DDx) is a method of analysis of a patient's history and physical examination to arrive at the correct diagnosis. It involves distinguishing a particular disease or condition from others that p ...
, mainly in distinguishing it from strains or bone fractures. The
Ottawa ankle rule is a simple, widely used rule to help differentiate fractures of the ankle or mid-foot from other ankle injuries that do not require x-ray
radiography
Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...
. It has a sensitivity of nearly 100%, meaning that a patient who tests negative, according to the rule almost certainly does not have an ankle fracture. If ankle pain is persistent 6–8 weeks after initial sprain, MRI imaging of the joint can be considered to rule out peroneal tendon, osteochondral, or syndesmotic injury.
Classification of severity
Ankle sprains are classified grade 1, 2, and 3.
Depending on the amount of damage or the number of ligaments that are damaged, each sprain is classified from mild to severe. A grade 1 sprain is defined as mild damage to a ligament or ligaments without instability of the affected joint. A grade 2 sprain is considered a partial tear to the ligament, in which it is stretched to the point that it becomes loose. A grade 3 sprain is a complete tear of a ligament, causing instability in the affected joint. Bruising may occur around the ankle.
Types
Inversion (lateral) ankle sprain
The most common type of ankle sprain occurs when the foot has a force, typically body weight, causing it to internally rotate to a higher degree than it is supposed to, affecting the lateral side of the foot. When this type of ankle sprain happens, the outer, or lateral, ligaments are stretched too much. The
anterior talofibular ligament
The anterior talofibular ligament is a ligament in the ankle.
It passes from the anterior margin of the fibular malleolus, anteriorly and laterally, to the talus bone, in front of its lateral articular facet. It is one of the lateral ligaments ...
is one of the most commonly involved ligaments in this type of sprain, followed by the calcaneofibular ligament
and posterior talofibular ligament
respectively, the later found in more severe ankle sprains. Approximately 70–85% of ankle sprains are inversion injuries.
![Ankle Inversion](https://upload.wikimedia.org/wikipedia/commons/a/a8/Ankle_Inversion.jpg)
When the ankle becomes inverted, the anterior talofibular and calcaneofibular ligaments are damaged. This is the most common ankle sprain.
Eversion (medial) ankle sprain
A less common type of ankle sprain is called an eversion injury, affecting the medial side of the foot. This happens when, instead of the ankle rotating medially resulting in an inversion injury (the foot rolling too much to the inside), the ankle rotates laterally resulting in an eversion injury (when the foot rolls too much to the outside). When this occurs, the
medial, or deltoid, ligament is strained.
High (syndesmotic) ankle sprain
A
high ankle sprain
A high ankle sprain, also known as a syndesmotic ankle sprain (SAS), is a sprain of the syndesmotic ligaments that connect the tibia and fibula in the lower leg, thereby creating a mortise and tenon joint for the ankle. High ankle sprains are desc ...
is an injury to the large ligaments above the ankle that join the two long bones of the lower leg, called the tibia and fibula. High ankle sprains commonly occur from a sudden and forceful outward twisting of the foot. This commonly occurs in contact and cutting sports such as football, rugby, ice hockey, roller derby, basketball, volleyball, lacrosse, softball, baseball, track, ultimate frisbee, soccer, tennis and badminton and horse riding.
Treatment
Initial treatment commonly consists of
rest, icing, compression and elevation (which is often referred to by the mnemonic RICE or sometimes PRICE with P being "protection"). These elements have been recommended by physicians for decades for the treatment of soft tissue damage, and sprained ankles, one of the most common soft tissue injuries. RICE helps limit the amount of swelling to the area, and "facilitates venous and lymphatic drainage".
[ While nearly universally accepted as a treatment, there is insufficient evidence to determine its relative effectiveness as therapy for acute ankle sprains in adults,] and the National Athletic Trainers Association notes that most of the rationale for using RICE or individual components is based largely on low-quality clinical trials and laboratory studies with uninjured participants or animal models
Conservative measures
Ice is often used to reduce swelling in cycles of 15–20 minutes on and 20–30 minutes off. Icing an ankle too long can cause cold injuries, which is indicated by the area turning white.[Lifestyle and home remedies](_blank)
MayoClinic.com. Retrieved 3 May 2010. Also, it is often recommended that ice not be applied directly to the skin, but should have a thin buffer between the ice and the affected area, and some professionals think ice need not be applied at all. Recently, Gabe Mirkin
Gabe Baron Mirkin (born 18 June 1935) is a physician, author, professor, columnist, former guest lecturer, and a former marathon runner who hosted a radio show on health and fitness for more than 20 years, and wrote several books on sports medic ...
, MD, who coined and popularized the acronym RICE in his ''The Sportsmedicine Book'' in 1978, no longer recommends "complete" rest or ice for healing a sprain. After reviewing modern studies, he notes that because ice closes off the blood vessels, "ice doesn't increase healing—it delays it," and "complete Rest may delay healing." He now advises skipping ice altogether unless needed to reduce pain from swelling. A small but growing number of doctors no longer recommend RICE for sprains.
In uncomplicated lateral ankle sprains, swelling of the soft tissue can be prevented with compression around both malleoli, elevation of the injured ankle higher than the heart, and pain-free exercises.
An orthopedic walking boot
A controlled ankle motion walking boot, or CAM boot, also sometimes called a below knee walking boot or moon boot, is an orthopedic device prescribed for the treatment and stabilization of severe sprains, fractures, and tendon or ligament tears ...
is often used for the treatment of a sprained ankle injury. Braces and crutches are also used to help alleviate the pain so the injured ankle can heal as quickly and painlessly as possible.
Although found to be less effective than casts, compression bandages are used to provide support and compression for sprained ankles. Wrapping is started at the ball of the foot and slowly continued up to the base of the calf muscle; this allows the swelling to travel up toward the center of the body so that it does not gather in the foot. In addition, other external supports such as Kinesio taping does not "improve ankle functioning or performance in people with or without ankle injuries." The "current evidence does not support or encourage the use of Kinesio taping applied to the ankle for improvements in functional performance, regardless the population."
Rehabilitation and recovery
Many different types of rehabilitation exercises can be done to aid an ankle sprain regardless of the severity of the injury. The purpose of rehabilitation gives the ability for the ankle to regain strength and flexibility. A sprained ankle becomes swollen due to the increased amount of edema
Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's Tissue (biology), tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels t ...
within the tissue. Physiologically, edema contributes to the sensation of pain in the ankle and so priority is given to allowing the fluid to leave the ankle. This can be done instantly by implementing the RICE
Rice is the seed of the grass species ''Oryza sativa'' (Asian rice) or less commonly ''Oryza glaberrima
''Oryza glaberrima'', commonly known as African rice, is one of the two domesticated rice species. It was first domesticated and grown i ...
mechanism which is resting the ankle, applying ice, compressing, and elevating it. The emphasis of the first week of rehabilitation should be on protecting the ankle to avoid further damage. As the healing progresses, stress can be applied by different mechanisms until the ankle is fully recovered. The key to a fast recovery is to implement all the different types of ankle sprain exercises so that the range of motion
Range of motion (or ROM), is the linear or angular distance that a moving object may normally travel while properly attached to another. It is also called range of travel (or ROT), particularly when talking about mechanical devices and in mechanic ...
will increase while the pain is decreasing.
In cases where the ankle does not heal in an appropriate amount of time, other exercises need to be implemented so that strength and flexibility can be regained. Physical therapists
Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patien ...
assign different types of ankle sprain exercises that deal with ankle flexibility, strengthening, balance, and agility
Agility or nimbleness is an ability to change the body's list of human positions, position quickly and requires the integration of isolated movement skills using a combination of balance (ability), balance, coordination (physiology), coordination ...
. If an ankle sprain does not heal properly, the joint may become unstable and may lead to chronic pain.[Sprained Ankle Overview – Webmd.com](_blank)
Retrieved on 22 January 2010. Receiving proper treatment and performing exercises that promote ankle function is important to strengthen the ankle and prevent further injury.
Ankle immobilization
A short period of immobilization in a below-knee cast or in an Aircast leads to a faster recovery at 3 months compared to a tubular compression bandage. In contrast, a randomized controlled trial has concluded that appropriate exercise immediately after a sprain improves function and recovery. These exercises were focused on increasing ankle range of movement, activation and strengthening of ankle musculature, and restoring normal sensorimotor control, and were carried out for 20 minutes, three times a day.
After the injury, it is advisable not to walk for a couple of days. Bed rest will help to accelerate the healing process and eliminate the chance of mishandling the affected limb. Driving vehicles or operating machinery should not be attempted. Acute lateral ankle sprain (LAS) is a common injury in athletes and is often associated with decreased athletic performance and, if treated poorly, can result in chronic ankle issues, such as instability. Physical performance demands, such as cutting, hopping, and landing, involved with certain sport participation suggests that the rehabilitation needs of an athlete after LAS may differ from those of the general population. Depending on the patient's goals, early dynamic training after an acute lateral ankle sprain in athletes can result in a shorter recovery time and reduced likelihood of reinjury
The amount of therapy that a person can handle will depend on their level of pain and the grade of sprain they experienced. It is not recommended to return to sports or extreme physical activities until hopping on the ankle is possible without pain. Wearing high-top
The high-top is a shoe that extends slightly over the wearer's ankle. It is commonly an athletic shoe, particularly for basketball. It is sometimes confused with the slightly shorter mid-top, which typically extends no higher than the wearer's a ...
tennis shoes may also help prevent ankle sprains if the shoes used are laced snugly and if the ankle is taped with a wide, nonelastic adhesive tape.[Ankle Sprains: Healing and Preventing Injury – Family doctor.org](_blank)
Retrieved on 22 January 2010.
Ankle mobilization/manipulation
For acute ankle sprains, manual joint mobilization
Joint mobilization is a manual therapy intervention, a type of straight-lined, passive movement of a skeletal joint that addresses arthrokinematic joint motion (joint gliding) rather than osteokinematic joint motion. It is usually aimed at a 'tar ...
/ manipulation of the ankle has been found to diminish pain and increase range of motion. For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of-motion, decreased pain and improved function.
Ankle exercises
To prevent sprains or re-injury from occurring, strengthening and stretching exercises should be done through a full range of ankle motion. To improve ankle mobility, ankle circles can be performed by extending the legs in front of the body and then moving the foot up and down, side to side, or rotating the foot in a circle. Another common exercise to improve mobility, as well as proprioception, is to use the toes to draw the letters of the alphabet in the air. Most importantly, the lateral aspect of the ankle joint should be strengthened with eversion exercises (i.e., underside of the foot is turned outward against resistance) to improve lateral ankle stability. Stretching is also an important component of a strengthening program, to help maintain joint flexibility.
Balance and stability training are especially important to retrain the ankle muscles to work together to support the joint.[Sprained Ankle: Treatment and Drugs – Mayo clinic.com](_blank)
Retrieved on 22 January 2010. This includes exercises that are performed by standing on one foot and using the injured ankle to lift the body onto its toes. To further enhance balance and stability, exercise devices such as the wobble board
The wobble board is a musical instrument invented and popularized by the Australian musician and artist Rolf Harris, and is featured in his best-known song " Tie Me Kangaroo Down, Sport". A wobble board, like some other musical instruments, can be ...
can be used, progressing from double-leg to single-leg stance, first with eyes open and then with eyes closed, for enhanced effectiveness.
Flexibility exercises
Flexibility exercises include a towel stretch and writing the alphabet with the toes, which will increase the range of motion.
Strengthening exercises
Ankle strengthening exercises are step ups and walking on toes which will strengthen the muscles around the swollen area.
Balance exercises
Balance exercises include the use of a balance board
A balance board is a device used as a circus skill, for recreation, balance training, athletic training, brain development, therapy, musical training and other kinds of personal development.
It is a lever similar to a see-saw that the use ...
, which helps the whole body function to maintain balance. The use of balance boards has been shown to produce significantly positive results in gaining proper balance.[
While performing balance exercises, the activity can be altered by using a single legged stance instead of a double legged stance, by opening or closing one's eyes, or changing the surface of balance to stable or unstable. This exercise can also be used for primary prevention of ankle sprains, as a meta-analysis exploring it's efficacy in prevention showed that there is a significant decrease in ankle sprain incidence among those who perform these exercises compared to people who don't.
]
Agility exercises
Plyometrics
Plyometrics, also known as jump training or plyos, are exercises in which muscles exert maximum force in short intervals of time, with the goal of increasing power (speed-strength). This training focuses on learning to move from a muscle extensi ...
exercises such as squat jumps and power skipping should not be implemented until the ankle has regained full agility.
Other strategies that can be used to prevent ankle injury include:
* Ensure proper warm-up prior to stretching and activity;
* When running, choose level surfaces and avoid rocks or holes;
* Ensure that shoes have adequate heel support;
* If high-heeled shoes are worn, ensure that heels are no more than two inches in height, and avoid heels with a narrow base.
Prognosis
Most people improve significantly in the first two weeks. However, some still have problems with pain and instability after one year (5–30%). Re-injury is also very common. There are currently no published evidence-based criteria to inform RTS (return to sport) decisions for patients with a lateral ankle sprain injury. Return to sport decisions following acute lateral ankle sprain injury are generally time-based.
Mild sprains (Grades 1-2) relating to over stretching or partial tears typically begin to feel better in a few days to a week and heal by six weeks. More severe ankle sprains (Grades 2-3) involving a full tear or rupture could take more than a few weeks or months to fully recover. The mean time patients return to sports is 12.9 weeks. Average time to return to work after injury range from less than one week to two months.
Epidemiology
Ankle sprains can occur through either sports or activities of daily living, and individuals can be at higher or lower risk depending on a variety of circumstances including their homeland, race, age, sex, or profession. In addition, there are different types of ankle sprains such as eversion ankle sprains and inversion ankle sprains. Overall, the most common type of ankle sprain to occur is an inversion ankle sprain, where excessive plantar flexion
Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relativ ...
and supination
Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...
cause the anterior talofibular ligament
The anterior talofibular ligament is a ligament in the ankle.
It passes from the anterior margin of the fibular malleolus, anteriorly and laterally, to the talus bone, in front of its lateral articular facet. It is one of the lateral ligaments ...
to be affected. A study showed that for a population of Scandinavia
Scandinavia; Sámi languages: /. ( ) is a subregion#Europe, subregion in Northern Europe, with strong historical, cultural, and linguistic ties between its constituent peoples. In English usage, ''Scandinavia'' most commonly refers to Denmark, ...
ns, inversion
Inversion or inversions may refer to:
Arts
* , a French gay magazine (1924/1925)
* ''Inversion'' (artwork), a 2005 temporary sculpture in Houston, Texas
* Inversion (music), a term with various meanings in music theory and musical set theory
* ...
ankle sprains accounted for 85% of all ankle sprains. Most ankle sprains occur in more active people, such as athletes and regular exercisers.
Previous ankle sprains
When an ankle sprain occurs, subsequent ankle sprains are much more likely to follow. The rate of recurrence is particularly high for athletes in high-risk sports. The most widely recommended preventative measures for recurring sprains are wearing ankle-protective gear (tape, or ankle brace
An ankle brace is a garment that is worn around the ankle to protect it or for immobilization while allowing it to heal from sprains and other minor injuries. Ankle braces are used to immobilize the joint while providing heat and compression to t ...
) and implementing exercises designed to strengthen the ankle and improve one's balance (e.g., balance ball exercises). In a review article of ankle sprain prevention research, the authors reference a season-long study on a group of soccer players. 60 players wore ankle-protective (tape or ankle-braces) throughout the soccer
Association football, more commonly known as football or soccer, is a team sport played between two teams of 11 players who primarily use their feet to propel the ball around a rectangular field called a pitch. The objective of the game is ...
season, and another 171 players were enrolled in the control group, as they wore no ankle protective gear. At the end of the season, 17% of the players who did not wear ankle braces/tape sprained their ankles, while only 3% of the players who wore protection incurred the same injury. Amongst the players who sprained their ankles and did not wear ankle-protective gear, 25% had a history of previous ankle sprains. Another peer-reviewed article references a study which concluded that ankle exercising could decrease the risk of recurring sprains by 11%.
Age
In a study comparing the prevalence
In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
of ankle sprains between age, race, and sex, individuals who were aged 10–19 years old had highest instances of ankle sprains. It can be suggested that adolescents
Adolescence () is a transitional stage of Developmental biology, physical and psychological Human development (biology), development that generally occurs during the period from puberty to adulthood (typically corresponding to the age of majo ...
are more physically active, which leads to higher chances of ankle sprains. Since sports deal with high utilization of the ankle, over 50% of ankle sprains are due to sport-related injuries.
U.S. military
Moreover, average ankle sprains for the general U.S. population are estimated at 5–7 ankle sprains for every 1000 person-years; however, a study showed that for military cadets, instances for ankle sprains were about 10 times those of the general population
Male vs. female
Another study comparing sex influences on ankle sprains found that male and female counterparts had similar incidence rates of ankle sprains. However, at a specific age range of 19–25 years old, males were found to have a substantially greater rate of ankle sprains than females. Furthermore, at ages 30 and over, females showed a higher incidence of ankle sprains than males. From this, it can be said that age and activity levels are better indicators of ankle sprain risks than gender.
References
Further reading
*
*
*
*
External links
{{DEFAULTSORT:Sprained Ankle
Dislocations, sprains and strains
Ankle