Sprained Ankle

• To evaluate other structures, such as cartilage and tendons, around the ankle
• If you exhibit signs of a high ankle sprain — an injury to the ligaments and structures connecting the bones of the lower leg (tibia and fibula)
• If your symptoms persist beyond 6 to 8 weeks after the injury despite conservative treatment

Grade 1

• Slight stretching and microscopic tearing of the ligament fibers
• Mild tenderness, bruising, and swelling around the ankle
• Typically no pain with weightbearing
• No instability on examination

Grade 2

• Partial tearing of the ligament
• Moderate tenderness, bruising, and swelling around the ankle
• Mild pain with weightbearing
• Slight instability on examination

Grade 3

• Complete tear of the ligament
• Significant tenderness, bruising, and swelling around the ankle
• Severe pain with weightbearing
• Substantial instability on examination

Treatment

Nonsurgical Treatment

Phase 1

• Includes a short period of immobilization, rest, and ice to reduce the swelling.
• Early weightbearing as tolerated is typically recommended during this phase.
• For a Grade 2 sprain, a removable plastic device, such as a walking boot or aircast brace, can provide support.
• Grade 3 sprains may require a short leg cast or cast-brace for 10 to 14 days.
• In most cases, swelling and pain will last 2 to 3 days. Walking may be difficult during this time, and your doctor may recommend that you use crutches as needed.

Phase 2

• Is typically initiated early and includes functional rehabilitation that focuses on:
  • Range of motion exercises
  • Isometric strengthening
  • Proprioception (balance) retraining exercises
• It is important to discontinue ankle immobilization during this phase to avoid stiffness.

Phase 3

• Includes advancement of strengthening and proprioception exercises and the gradual return to pre-injury activities. This begins with activities that do not require turning or twisting the ankle, followed later by activities that require sharp, sudden turns (cutting activities), such as tennis, basketball, or football.
• Early return to sporting and work activities may require ankle taping or bracing.

An air stirrup-type ankle brace.Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Physical therapy. Rehabilitation exercises during phase 2 and 3 of recovery are used to improve flexibility, strength, and proprioception (balance).

• Early motion. To prevent stiffness, your doctor or physical therapist will provide you with exercises that involve range-of-motion or controlled movements of your ankle without resistance.
• Strengthening exercises. Once the swelling and pain have improved, exercises to strengthen the dynamic stabilizers (muscles and tendons) in the front and back of your leg and ankle will be added to your treatment plan. Water exercises may be used if weightbearing strengthening exercises, such as toe-raising, are too painful. Exercises with resistance are added as tolerated.
• Proprioception (balance) training. Poor balance often leads to repeat sprains and ankle instability. A good example of a balance exercise is standing on the affected foot with the opposite foot raised and eyes closed. Balance boards are often used in this stage of rehabilitation.
• Endurance and agility exercises. Once you are pain-free, other exercises, such as agility drills, may be added gradually. Running in progressively smaller figures-of-8 is excellent for agility and calf and ankle strength. The goal is to increase strength and range of motion as balance improves over time.

Surgical Treatment

• Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for patients who experience persistent ankle instability and pain after months of rehabilitation and nonsurgical treatment.
• Surgery may also be indicated for some high ankle sprains with instability of the ankle syndesmosis.
• Sometimes surgery is recommended if a severe ankle sprain is associated with additional injuries, such as an ankle cartilage injury or tendon rupture.

This X-ray shows extreme instability of the ankle.Espinosa N, Bluman EM: Lateral Ankle Ligament Reconstruction Using Allograft, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 349-355.

Recovery