Ankle sprains are one of the most commonly occurring injuries in athletics. They can side-line any athlete from competing and are difficult to prevent from coming back.

Mechanism of Injury

• Lateral ankle sprain: usually from inversion with plantarflexion (turning the toes in while pointing them down) leading to injury of the ligaments on the outside of the ankle.
• Medial ankle sprain: usually from eversion with dorsiflexion (turning the toes out while pointing them up) leading to injury of the ligaments on the medial side of the ankle.  Because the ligament here (deltoid ligament) is very strong, this injury is rarer and can take up to twice as long to heal than lateral sprains.  It is also often associated with fractures of the fibula or other bones in the ankle (medial malleolus, talar dome, articular surfaces).
• Syndesmotic sprain: Injury to the front and/or back lower ligaments of the ankle. This often occurs from hyperdorsiflexion (pointing the toes up too far) and eversion (pointing the toes out).

Signs and Symptoms
Lateral Ankle Sprain

• Potential significant swelling within 2 hours because of the rich blood supply.
• Tender to the touch over the outside ankle ligaments, bruising that drains into the foot.
• Different levels of instability (depending on grade of the sprain).
• Positive tests for ligament laxity of your outside ankle ligaments.
• X-ray shows no signs of fracture.

Medial Ankle Sprain.

• Tender to the touch over the inside ankle ligament.
• Bruising and swelling along the medial side of the ankle
• Positive test for ligament laxity of the inside ankle ligament.
• X-ray needed to rule out avulsion fracture (bone fragment pulled away from the bone) or fracture of the inside ankle bone, or top of the ankle.

Syndesmotic Sprain

• Positive tests for front/back ligament laxity and severe swelling (possibly fracture) in the lower leg
• Pain and swelling over the front/back ligaments and the lower leg space.
• Specific X-ray may show abnormal joint space in the lower leg.
• Recovery time is longer compared to other sprains.
• Need to rule out fracture and avulsion.

There are 3 degrees of ankle sprains which indicate the severity of the sprain:

1st degree: involves minimal swelling, point tenderness, no ligament laxity, no limp or difficulty hopping. An athlete typically recovers in 2-10 days.

2nd degree: has more swelling specific to the ankle, increased ligament laxity, a limp and athlete is unable to heel raise, hop, or run. Typical recovery time is 10-30 days.

3rd degree : includes a lot of swelling, tenderness on both the inside and outside of the ankle, even more ligament laxity, and the athlete cannot put any weight on the ankle. Recovery can be anywhere from 30-90 days or more.

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On-Site Management
Immediate treatment of ankle injuries requires the P.R.I.C.E treatment principles.  This is in order to limit the swelling and subsequent delay of rehabilitation.  Any blood flow inducing activities such as hot showers, heat rubs or excessive weight bearing should be avoided.

P.R.I.C.E.

PROTECT the area from further injury by avoiding exercises that produce pain. A protective boot can be worn for 4 weeks with a syndesmotic ankle sprain.

REST: cutting back on the amount of training can be difficult, but key to recovery. Gradually return to any agility or jumping activities.

Place ICE on your ankle for 10-20 minutes every 1.5 to 2 hours for the first 2 to 3 days or until the pain goes away.

COMPRESS the area by having a trainer or physiotherapist use an ankle wrap with a tensor. This helps decrease swelling and internal bleeding.

ELEVATION is important to encourage blood flow to your heart for healing.

Medical Referral and Rehabilitation

When there is a 2nd or 3rd degree ankle sprain or a syndesmotic sprain it is important that you seek medical attention to rule out a fracture. A physician may prescribe anti-inflammatory medication to help decrease pain and swelling. Once a sprain has been confirmed it is important to see a therapist in order to properly treat and rehabilitate the injury before returning to play. Changes to footwear, posture and biomechanics, orthotics, bracing options and return to play protocol will be determined by the therapist, depending on the specific injury. 

A therapist may use ultrasound and laser treatment to reduce pain and swelling and promote healing. Friction massage is another treatment to promote healing and reduce scar tissue development. The therapist will also focus on restoring full range of motion in the ankle and regaining proprioception, and surrounding muscular strength.  The therapist will also prescribe a full ankle rehabilitation program to strengthen the joint and help prevent future ankle sprains.

Return to Activity 

This is a gradual process and time is dependent of a variety of factors including: degree of injury severity, duration of symptoms prior to treatment, history of injury to the area, compliance to treatment and rehabilitation protocol. The following is a list of guidelines to follow when returning to activity.

• Work towards full range of motion in the affected ankle compared to the unaffected ankle.
• Work towards full strength of the affected ankle compared to the unaffected ankle.
• Work towards jogging straight ahead without pain or limping and progress up to weaving and cutting laterally, in addition to hoping and jumping on the affected ankle.

Common tests your therapist may use to monitor your return to play:
Lateral hop test: You will stand on the “uninjured” leg and hop as far as possible in an outside direction with three continuous hops. You then stand on the “injured” leg and hop back to where you started, using three continuous hops.

Single leg stance (Modified Rhomberg Test): You stand and balance on the uninjured leg with your arms crossed over the chest. Then you stand and balance on the injured leg to compare.

Heel rocker test: You lean backward against a wall and pull the toes and front of both feet off the ground while rocking backward on your heels. You raise the toes repeatedly off the ground until full exhaustion. 

Ankle joint dorsiflexion: With a measuring device, your therapist will measure your range of motion with the knee straight and bent.

Test for joint laxity: A manual anterior drawer stress test (for ligaments of the ankle) will be applied to the injured and non-injured ankle.

Stair run: Your therapist will observe you running down stairs without holding on to the handrail.

For competitive athletes, the list may be extended to include the following:

• You can sprint straight ahead without pain or limping.
• You can do 45-degree cuts, first at half-speed, then at full-speed. You can do 20-yard figures-of-eight, first at half-speed, then at full-speed. 
• You can do 90-degree cuts, first at half-speed, then at full-speed.
• You can do 10-yard figures-of-eight, first at half-speed, then at full-speed.
• You can jump on both legs without pain and you can jump on the affected leg without pain. (Pierre Rouzier, M.D).

Prevention

In order to prevent an ankle sprain from becoming a chronic injury several preventative measures should be taken.  After an ankle sprain the risk of reinjuring the ankle post-injury is increased for at least 6 to 12 months. Both prophylactic and neuromuscular techniques can be utilized to decrease the incidence of inversion sprain re-injury.  Prophylactic methods can include a variety of taping and bracing options.  Prophylactic methods give support to the ankle joint and prevent full range of motion; therefore they are good temporary options. Neuromuscular training looks to re-establish the protective reflexes and strengthen the joints ligaments.  There is support that after eight to ten weeks of intensive training neuromuscular training can help prevent re-injury but immediate effects are not generally seen.

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Brukner, P. and Khan, K. Brukner and Khan's Clinical Sports Medicine Brukner, P. and Khan, K. (2007) Brukner and Khan's Clinical Sports Medicine. 4th ed. North Ryde: McGraw-Hill.