Ankle sprains are one of the most common injuries seen in athletic competition. What is the best initial management in terms of protection and return to play, and when is medical consultation necessary?
“Sprain” is a term that refers to an injury to a ligament, which is the soft tissue structure connecting bones together. Examples of ligaments include the ACL and MCL in the knee, the UCL in the elbow, and the glenohumeral ligaments of the shoulder. These structures prevent excessive translation of joints (dislocation), and can be torn (sprained) when a joint is injured. Ankle sprains most commonly occur when an inversion injury occurs where the foot and ankle are turned inward and under the leg. This results in injury to the lateral ankle ligaments, usually the anterior talofibular and calcaneofibular ligaments (ATFL and CFL), which are on the outside part of your ankle, on the same side as your small toe. 90% of ankle sprains are of this type, causing swelling, pain, and ecchymosis (bruising) on the lateral side of the foot and ankle. Other less common types of ankle sprains involve the deltoid ligament on the medial (inside) part of the ankle, and the syndesmosis ligaments, which connect the tibia and fibula together above your ankle joint – a “high ankle sprain.” These sprains usually result from an eversion or external rotation injury, where the foot is turned outward.
Initial treatment for all of these injuries involves RICE – rest, ice, compression, and elevation – to control the initial pain and swelling from the ligament tear, Compression with an ace wrap along with intermittent icing for at least the first 48 hours, elevation to decrease swelling, and protection from re-injury is standard care. Crutches may be used for ambulation if pain is excessive, and anti-inflammatory medicine such as ibuprofen or naproxen are usually adequate for pain. Lateral ankle sprains are treated functionally – meaning return to normal activities including sports as soon as symptoms allow. This may be as soon as a day or as long as 4-6 weeks, depending on the injury and the patient. Immobilization in a cast or boot is generally not necessary, and may slow recovery. Protection with a functional brace, usually a lace-up type that provides structural support to the ankle during activities, and exercises to strengthen the peroneal muscles, which support the lateral structures, decrease the risk for re-injury. High ankle sprains are the exception here, and may require immobilization for up to 6 weeks to avoid long-term dysfunction.
90% of lateral ankle sprains have no long term functional issues and can be treated as above. When pain and swelling persist or worsen for more than 2-4 weeks, recurrent instability occurs, or mechanical symptoms such as locking and catching are present, medical evaluation is appropriate. Also, anytime primary symptoms are present in other areas of the foot and ankle, or in patients who are skeletally immature (kids), X-ray evaluation is necessary. Children may have growth plate fractures that require cast or boot protection to avoid future growth issues, and fractures of the foot or ankle may require immobilization or surgical treatment. X-rays and evaluation by an orthopaedic surgeon are usually adequate to definitively determine appropriate initial treatment in these situations. MRI evaluation is necessary when mechanical symptoms persist to rule out a cartilage injury that may require surgical treatment.
For patients with mechanical symptoms or recurrent instability as above, surgical treatment including ankle arthroscopy to remove or repair loose cartilage fragments and ligament reconstruction to eliminate instability are appropriate. 90% of patients with recurrent lateral instability are effectively treated with ATFL/CFL repair and can return to sports with a stable ankle. Down time from sports is generally 4 months when this is necessary, and recent refinements to the traditional surgical technique may enhance stability. More extensive reconstructions involving tendon transfers from other parts of the ankle are rarely needed, and usually only for patients who have recurrent instability after previous
I hope this information has been helpful. If you or your family member needs to be evaluated for a significant ankle injury, feel free to call us at 802-6700 or 271-6503 and we would be happy to help you.