Sprained Ankles

Ankle sprains are a common soft tissue injury not limited to those of us with sporting prowess! Having sprained my ankle myself several years ago I know exactly how painful it can be. The term sprained refers to damage to the collagen* fibres that form the ligament structures, on either side of the ankle. The most common injury is to the lateral ligament (on the outside of the ankle) following an inversion injury (the foot turns inwards) and we cause damage to the structure by placing a physiological load that is too stressful for that structure, causing pain, reduced range of motion & reduced functionality.

The most commonly injured structures are muscles, tendons & ligaments which are classified into strains (muscles/tendons) and sprains (ligaments). These injuries can then be further classified depending on the severity and the % of fibres torn; this can range from Grade I where we see up to 15% of fibres torn to Grade III where we see over 80% of fibres torn to total rupture. The severity of the injury combined with the make-up and the function of the damaged structure will determine how long roughly the treatment will take and what treatment options there are available.

Grade % of fibres torn Swelling/Bruising? Pain? Loss of functionality Able to carry on with activity
I
0-15%
Minimal to none
Minimal to none
Minimal loss of function
Most likely able to continue
II
15-80%
Moderate
Moderate
Moderate loss of function
Unlikely able to continue
III
80% to total rupture
Severe
Usually severe, may be no pain at all if nerves have been ruptured
Total loss of function
Completely unable to continue/weight bear

 

The Healing Process – Applicable to every Soft Tissue Injury

The healing process occurs in 4 stages;

  1. The bleeding phase (up to 10 mins): Here oxygen supply is cut off resulting in cell death and a release of chemicals into the blood causing a clot.
  2. The inflammation phase (up to 72 hours): Here bloody supply is increased allowing the damaged tissue (cell debris) to be cleared away.
  3. The repair phase (from 48 hours to 6 weeks): Here we create new blood supplies & collagen (our tissue building blocks) is laid down at a high rate as we look to create new tissue. At this stage, gentle stress to the injury site will allow the collagen to be laid down in the correct orientation / alignment. This increases the strength of the new collagen tissue to reduce the risk of a repeat injury.
  4. The remodelling phase (from 3 weeks to 12 months): There is now a reduction in collagen production but the newly developed tissue increases in strength, function and structure according to the SAID principle (more on this later…)

It is important to note that these phases overlap so early-stage management (see below) will vary from person to person depending upon the grade of tear, degree of pain and swelling and loss of function.

The pain is usually immediate! Swelling can appear quite quickly (depending upon how much bleeding / tissue injury there is) often within an hour of the injury occurring but bruising can take a few days to appear. The pain that is experienced is purely to prevent further ‘harm’ to the already damaged tissue, if you cannot weight-bear on the ankle and foot fully then you are far less likely to ‘re-injure’ it and cause more damage!

What should I do initially to help?

Early-stage management is primarily to help you ease pain and sleep as well as you can. We also want you to start to put weight through your ankle as soon as possible as this helps with the long-term recovery. Early management is known as RICE.

 Rest Ice Compression & Elevation.

With RICE we reduce the swelling at the joint with ice and elevation, pain is eased with ice and relative rest (this basically means using your ankle as much as pain allows) and finally we provide support and prevent further damage with compression (bandage).

Early stage management (for a Grade I, II or III injury (excluding a complete rupture)):

  • Relative Rest – only using the ankle as much as pain allows.
  • Ice – for 10 to 15 mins max (as long as you have no loss of sensation over the skin area) several times per day to start with.
  • Elevation – of the foot/ankle so it is higher than your hip, when you are sat down
  • Compression – Compression bandages can be used to help swelling and reduce pain. A sprained ankle can feel particularly vulnerable for a while so the contact the compression bandage has on the skin can help reduce the risk of spraining it again while the ligament heals (more on this later)

A Grade III complete rupture of the ligament would need a surgical opinion.

So how long does it take to get better?

Pain will always vary from person to person depending on a number of different factors such as whether you have sprained that ankle before (or even the other one), how much damage is done (whether it’s a grade 1, 2 or 3) or if other structures are involved, such as muscles or nerves.

In my experience generally speaking:

  • A grade I ankle sprain – It is normal for the first 6 or 7 days to have constant pain, even when resting, the degree of pain will be relative to the grade of injury. Between 7 to 21 days pain may start to become more intermittent and you may find you can put more weight through the foot/ankle. Beyond 3 weeks pain will often be easier at rest but you may find you still have pain when being more active. Around six weeks the pain and the swelling (although this can still come and go beyond the 6 weeks) are usually significantly better and many of you will be able to begin resume your normal activities.
  • A grade II / III (excluding a complete rupture) ligament sprain is often more painful due to the larger number of damaged and torn collagen fibres which can mean it takes longer for you to be able to put weight onto it, there will be more swelling and less available movement initially. The healing process takes the same amount of time, so all tissues heal at the same rate no matter how many have been injured BUT your pain experience can be very different, hence why full recovery can really vary from person to person.

So what happens if you are still struggling with pain and weight-bearing at 6 weeks post-injury?

Firstly, this is NOT unusual for few reasons:

  1. The peroneal nerve which lies over the outside of the ankle (this supplies the skin sensation to the outside and front of the lower leg, ankle and top of the foot) can also be injured – usually from the sudden and unexpected ‘stretch’ as you went ‘over’ on your ankle. Nerves are pretty robust structures but if you do ‘over stretch’ them the pain can be quite significant and persist beyond the healing of the ankle ligament. Other nerve symptoms following an ankle sprain can include pins and needles or numbness over the outside and top of the foot. If you are experiencing these symptoms a qualified physiotherapist will be able to assess and treat you and this is usually the quickest route to recovery! They will also be able to rule out any other reasons for the persistent pain.
  1. Pain can still be experienced even after the tissue has healed (hence why so many people have pain without having injured themselves) sometimes it can be due to other structures being involved (like the peroneal nerve) or it could be that you have sprained the ankle (or even the other one) before. The brain is an amazing piece of kit but it can lead us to believe there is still a risk of harm and therefore create the sensation of more pain thinking that it is ‘protecting’ you. Thoughts about what it was like before, it may have taken months to settle down you may have been unable to work or take part in your regular sport or exercise for quite sometime afterwards, mean that the brain feels that there is a large ‘risk’ to you of the same thing happening again.
  1. How much advice, education and understanding you received immediately after the injury can make a big difference to how you feel and what you are physically able to do at 6 weeks. A graded return to physical activity, pain management and reassurance are key to recovery especially if this is not the first time you have sprained your ankle. In this situation it is natural to worry about doing more harm or how question how much pain is ok? This comes back to the SAID principle.

The SAID Principle

Our bodies are amazing so that when we injure ourselves have an injury the body will heal itself however, this can be a slow process (for you!) and not always done as perfectly as we would like. In any ligament sprain we ideally want the fibres to be perfectly arranged (aligned) to meet the demands of the structure, this is the SAID principle, Specific Adaptions to meet Imposed Demand (I said it’d be back). As the body produces new collagen fibres rather than them lying down in perfect straight lines they resemble more of a spilt bowl of spaghetti, haphazard criss-crossing pattern. This means the structure of ligament may not be a strong as it was previously, increasing the risk of re-injury. It is therefore our job to carefully pick & choose the right combination of exercises/stretches/clinical treatments to ensure that the structure’s new fibres are arranged perfectly to meet the imposed demands, in other words what you need your ankle to be able to withstand in your everyday life.  These functional activities include being able to balance no matter what type of surface you are walking on, bending your ankle forward and backwards when standing on it, be able to jump, land, stop and change directions on it.  Obviously some of us require more rehab than others but the principle is the same, exercises need to be specific and graded depending upon the grade of tear and your normal activity and sporting levels. In our experience just ‘go and walk on it’ is not enough!
 

I sprained my ankle badly years ago and now it is ‘weak’ – I just avoid things that cause me to ‘re-injure’ it – surely there is nothing I can do to strengthen it now as it has been years?

Yes there is!! But the following are some common misconceptions…

“When you damage the ligament, the fibres heal and so the ligament is as strong as at was previously” – Yes it does heal but the collagen fibres are at their strongest if they line up uniformly. This doesn’t always happen by chance – specific weight-bearing exercises can gradually load the ankle ligament and encourage uniform alignment of the fibres.

“Your balance returns to being as good as it was pre-injury” – Yes it can, in fact it can be better! But only with specific balance training. The ankle ligaments have very sensitive stretch receptors which detect any slight change in length of the ligament and the muscles respond instantly to ensure you stay upright! When you injure your ankle your stretch receptors are also commonly damaged and so your sense of where you are in space (joint positional sense or ‘proprioception’) is significantly reduced. This is one of the most common reasons for ‘chronic’ ankle sprains, the stretch receptors only sense bigger changes in length so the muscles are  slower to respond, before you know it you have sprained your ankle again! Which leads me on to…

…Balance exercises, which are possibly the most important exercises to do following an ankle sprain!

Stand on one leg (no shoes or socks), relax those toes and see you can just stand & breathe!

Imagine your body lengthening towards the ceiling.

When you feel confident with this try turning your head right or left, look up & down. Move one arm upwards or sideways, take one leg back and forward – keep your body & your foot relaxed – Breathe!

Balance exercises

 

Is there anything I can do to improve my mobility & strength?

Yes absolutely! Here are a couple of simple exercises

Problem: Loss of weight-bearing ankle movement – pain or stiffness at the front of the ankle going down the stairs is a common problem.

Solution: ‘Knee to Wall’ Exercise

Stand with your toes (of the sprained ankle) close to the wall (foot straight)

Keeping the foot, knee & hip in line with each other – drop the knee down towards the wall – Keeping the heel on the floor

Repeat 15 times, rest & repeat a 15 x 2 more

As it gets easier slide your toes slightly further away from the wall.

Knee to wall

Problem: Loss of calf power – rising up onto your tip-toes

Solution: Calf Raise Exercise

Stand with both heels hanging over the edge of a step (if you need some help with your balance have your finger tips touching a wall)

Slowly rise up onto your tip-toes as high as you can and then slowly lower your heels over the edge of the step (make sure your feet & ankles don’t roll in or out!)

Repeat these 15 times, rest and repeat 15 x 2 more

Calf raise

 

 

Other movement related problems that can also follow on from an ankle sprain

 A loss of ‘bounce’ – the ability to bounce up and down especially off the toes. This can be frustrating for those of us who enjoy activities that involve running and sprinting.

Compensatory hip or knee pain when walking or running – either because of a stiff ankle or weaker calf muscles or because to avoid further injury some people change their walking pattern so their foot ‘collapses’ inwards.

Once again these can be resolved with a good rehab programme – so don’t just ‘put up’ with pain or stiffness if you have sprained your ankle! Seek help from an experienced physiotherapist.

 

jenny-SEP15-closeup     James Cameron Sports Rehabilitator

Jenny Manners MCSP MSc. & James Cameron BasRAT

 

WANT TO READ MORE LIKE THIS?
To receive our weekly newsletter filled with interesting and thought provoking articles just like this one, then just fill in your details and click sign up!
We hate spam. Your email address will not be sold or shared with anyone else.

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>