Updated: May 4
An ankle sprain refers to the tearing of the ligaments of the ankle and accounts for approximately 40% of all athletic injuries. In addition 40% of those who experience an ankle sprain have recurrent symptoms. (3)
85% of ankle sprains occur on the outside (lateral side) of the ankle and are known as an inversion sprain. This is the type of injury that most runners experience when they sprain their ankles. Medial ankle sprains (along the inside of the ankle) occur less frequently and are usually caused by fractures or other traumatic events. (1)
Without appropriate treatment and rehabilitation, a severely injured ankle may not fully heal and could lose its stability. This loss of stability could, in turn, result in chronic ankle pain, recurrent sprains, gait imbalances, osteoarthritis, and a path of on going dysfunction.
So, why is an inversion sprain so common? You can put it down to our lopsided anatomy! The bone on the lower outside of the ankle (the lateral malleolus - distal fibula) extends further down than the bone on the inside of the ankle (medial malleolus – fibula). This difference gives the inside of the ankle (medial side) more stability than the outside of the ankle (lateral side).
At a symptomatic level, most ankle sprains appear to resolve completely without rehabilitation. In reality, ankle sprains that have not been rehabilitated correctly are usually susceptible to further injury.
Recent Research: Research now shows that individuals with a history of recurrent ankle sprains demonstrate decrease muscle firing activity of the ankle, knee, and hip when performing tasks. This is called AMI (Athrogenic Muscle Inhibition). This shows that an ankle sprain not only affects the local area but can cascade up the entire leg. (2)
ANATOMY OF AN ANKLE SPRAIN
The outside (lateral side) of the ankle achieves its stability from a three-ligament complex. These three ligaments are the:
Calcaneofibular ligament (CFL)
In an inversion sprain, the Anterior Talofibular ligament (ATFL) is the most commonly injured ligament.(4) Ligaments in the ankle are named according to the bones to which they connect. In this case, the Anterior Talofibular ligament connects to the talus bone of the ankle as well as to a long bone of the lower leg - the fibula. The function of the ATFL is to prevent forward (anterior) displacement of the ankle (the talus).
In a severe ankle sprain another ligament called the calcaneofibular ligament (CFL) may also be damaged. This ligament connects your heel bone (calcaneous) with the fibula. This is a stronger ligament than the ATFL, and is not damaged as easily.
Both the ATFL and the CFL are usually damaged in motions where the foot is both pointed down (plantar flexed) and rolled out (inverted). Considerable instability in the ankle can occur when both these ligaments are injured.
The posterior talofibular ligament (PTFL) is not injured very often, except when there is a complete dislocation of the ankle (talus). The PTFL is the strongest ligament in the lateral complex.
Another sprain injury that is becoming more prevalent is called a “High Ankle Sprain” (syndesmotic ligament complex). In this injury, the ligament and connective tissue between your shin bones (tibia and fibula) are torn. This is a serious injury that may require surgery to resolve.
Not Just Ligaments
An ankle sprain may also result in damage to other structures. You may also experience damage to connective tissue, tendons, muscles further up the ankle, and even to the bones (possible fractures). This is why, with a severe ankle sprain, it is important to see a medical professional who can determine exactly which structures have been injured, and then provide treatment recommendations.
Anatomy of the Lateral Ankle & Foot: Want to learn more about the anatomy that is involved in an ankle click the video to the right.
TREATMENT OF AN ANKLE SPRAIN
THE ACUTE STAGE
Immediately after spraining your ankle, it is important to do everything you can to reduce the swelling in the ankle. The faster you can implement treatment, the faster you will recover. An ankle sprain injury that is addressed quickly will often resolve in a short period of time. If the injury is ignored, the ankle sprain could be prolonged for extensive periods of time.
So, immediately after the injury, while still in the acute stage - use RICE - rest, ice, compress, and elevate!
Rest: During this stage, it may be necessary to take all weight off of the injured ankle. In such cases, crutches are commonly used. In my opinion, it is important to quickly return to weight-bearing as soon as possible to improve healing. I have found that reintroduction of weight-bearing stresses tends to decrease recovery time. When should you do this? As soon as possible, but not too soon! Rest is also essential.
ICE: Ice for at least 20 to 30, minutes 4 to 5 times per day to reduce swelling. In most cases we do not recommend icing long than 72 hours after the initial injury.
Compression: Compression (with an ACE wrap) reduces both swelling and bleeding. With a Grade 3 sprain, wear a brace at all times until you are able to bear weight on your ankle.
Elevation: Elevating the injured area acts to reduce swelling and bleeding.
Once you have used “RICE”, it is very important to introduce motion into the ankle as soon as possible. Depending on the degree of injury, the patient could be asked to perform gentle ankle circles, or if able to do so, write the alphabet with their feet. Light calf stretching and using a stationary bicycle may also be beneficial.
Ankle Exercises - Acute Injury: Here are examples of ankle mobilization exercises after an ankle injury. These exercises are often combined with RICE: Rest, Ice, Compression and Elevation. These exercises are only for the acute stage of injury to increase fluid exchange and get rid of waste by products.
MANUAL THERAPY FOR AN ANKLE SPRAIN
Manual therapy can make a huge difference in the recovery and prevention of an ankle sprain. Manual therapy speeds healing by increasing blood supply, oxygen, essential nutrients, and displace waste products that accumulate after an injury. This is especially important in treating ligaments because they generally have a very poor blood supply to begin with.
The following videos are a few examples of how we would address both soft tissue and joint dysfunction using Motion Specific Release (MSR) procedures.
4 Point Dorsi Flexion Protocol: Dorsiflexion is the movement at the ankle joint where the toes are brought closer to the shin. The muscles of the shins help your foot to clear the ground during the Swing Phase (concentric contraction) of your stride, and absorb much of the impact shock during running.
MSR - 7 Point Ankle & Foot Mobilization: Improving joint mobility is critical if you are going to effectively address the body's full kinetic chain. In fact, we greatly reduce the effectiveness of any myofascial treatment if we don’t also address restrictions in joint mobility.
THE KINETIC CHAIN
Earlier, I mentioned that there might be damage to several types of structures after an ankle sprain, especially the connective tissue, tendons, muscles, and nerves. The following is list of structures that are often injured in a lateral ankle sprain (besides ligaments).
With an inversion sprain, it is common for the tendons of the peroneal muscles to be injured. It also common for the peroneal tendon to move out of its normal position (subluxate) during the recovery stage of an ankle sprain.
Peroneus brevis muscle – Longitudinal tears of the peroneus brevis are commonly associated with lateral ankle sprains.
Peroneus longus muscle – These muscles often show a different activation pattern when there is ankle instability. This is often due to restrictions that have formed in the muscle. These restrictions, if not removed, could make a person more susceptible to future injuries.
The retinaculum is a band of connective tissue that keeps the peroneal tendons in place. When a tear in the retinaculum occurs, patients will notice a snapping sensation in the lateral ankle. A severe tear of the retinaculum is not a candidate for standard manual therapy and may require corrective surgery.
Superficial peroneal nerve - This nerve is at risk for traction injury during a lateral ankle sprain (inversion sprain). Some of the MSR procedures we use are specifically designed to release the peroneal nerve if it is involved.
The Peroneal Nerve Release: Peroneal nerve injuries are the most common peripheral nerve injury of the lower extremity. Most peroneal nerve injuries occur at the region of the fibular head (common peroneal nerve). Click the image to view the video.
REHABBING AN ANKLE SPRAIN
After you are out of the acute stage of a lateral ankle sprain you need to start rehabbing the ankle using stretching, strengthening and finally balance exercises. The actual exercises we would recommend will be specific to each individual. The following are examples of exercises that we could possibly prescribe depending on the case and the severity of injury.
Stretching Your Calf Muscles: Calf stretches for both your calf muscles the gastrocnemius and soleus. Minor changes in technique can make a huge difference in increasing your calf flexibility.
The Peroneal Muscles - Stretching & Myofascial Release: The peroneal muscles are a key link in foot stability. This video shows you some great ways to stretch and release myofascial restrictions.
Foot & Ankle Strengthening Routine: This foot and ankle strengthening routine works the flexor, extensors, internal and external foot rotators using a Theraband.
Calf Strengthening - Eccentric Calf Raises & Pulsations: The Eccentric Calf Raise is a great way to increase calf strength, without causing further injuries. These dynamic calf-pulsations are ideal exercises for improving sports performance and power. This is an advanced exercise, so before attempting this exercise, make sure you can easily perform the standard Eccentric Calf Raises & Pulsations.
Balance Exercises with the Bosu Ball: Here are some suggestions on how to improve your balance using a Bosu Ball (or wobble board). Balance is essential for both rehabilitation and sports performance.
Ankle sprains are a common injury. Using a combination of both treatment and exercise increases your chances of a faster recovery, in addition to reducing the chances of developing a chronic or recurring injury.
If you have had a recent ankle sprain get the help you need! Make your appointment today!
DR. BRIAN ABELSON DC.
Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.
Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publications which will be available later this year.
Make an appointment with our incredible team at Kinetic Health in NW Calgary. Just scan the QR code with your phones camera and click the link, or call Kinetic Health at 403-241-3772 to make an appointment today!
Wolfe MW. Management of ankle sprains. Am Fam Physician 2001; 63(1): 93-104.
Effects of Tibiofibular and Ankle Joint Manipulation on Hip Strength and Muscle Activation, Lawrence MA, Raymond JT, Look AE et al. Journal of Manipulative and Physiological Therapeutics 2020; 43(5): 406-417.
Fukuhara T, Sakamoto M, Nakazawa R, et al. Anterior positional fault of the fibula after sub-acute anterior talofibular ligament injury. J Phys Ther Sci 2012; 24(1): 115-117.
Fong DT, Chan YY, Mok KM, Yung PS, Chan KM. Understanding acute ankle ligamentous sprain injury in sports. BMC Sports Science, Medicine and Rehabilitation. 2009 Dec 1;1(1):14