Ankle sprains. It’s a biggie. For sporting types and those how don’t too. Over half of ankle sprains happen in sport. Which is a lot. But that also means just less the 50% happen to the less sporting part of the population.
In fact some of the more serious ankle sprains we see occur in general life. Many involve imbibing alcohol based beverages. Some simply occur missing the pavement crossing the road. In sports they account for 14% of all injury and the ankle is the second most injured body part after the knee.
But what do you need know about it? Here we combine our clinical experience from the last 16 years together with the latest research to give you a comprehensive practical guide for everything you need to know about ankle sprains. What they are. How to get over them and how to avoid or deal with any complications
Our Experience Of Ankle Sprains
In 16 years I’ve seen quite a few ankle sprains as you can imagine. There are certain structures that get involved that we see time and time again. Some are the obvious you’ll be able to read on loads of different websites. I’m going to include here too the ‘physio’ stuff. The bits you need to know to understand what’s going on with ankle and the implication it has, or may have, throughout your body.
What Is An Ankle Sprain?
An ankle sprain is commonly regarded as varying degrees of damage to the ligaments around the ankle. Alongside muscles these provide support and co-ordination to the ankle and beyond.
Ligament strains are most common on the outside of the ankle. The picture here shows the classic mechanism of injury. The more up on your toes you were when you injured yourself the more likely you involved other ligaments too.
Much less common is an eversion sprain which simply where the ankle goes the other way. Generally speaking these are trickier to get over. But with the right rehab and the right approach healing time can be similar to inversion sprains. It really depends how much of a mess you’ve made of yourself in the first place.
Is It Really The Ligaments That Cause Ankle Sprains To Swell?
It’s traditionally been thought that the swelling comes from the ligament damage that occurs. A more modern theory is that the swelling comes from the joint where it has gone too far. Rather than the ligaments.
What difference does that make to you? It means you should be less fearful of stretching the ligaments too far again – the immobility associated with the swelling won’t allow it anyway. You should be more wary of asking the joint to do too much in the early stages of rehab to optimise the amount of swelling. The word optimise and swelling may sound a peculiar mix – more on this later.
It’s Not Just The Ligaments That Cause The Pain
One of the key considerations in rehabilitating ankles is what additional to the ligament are causing pain. We’ve already mentioned the joint ‘going too far’ and causing swelling. What about structures on the other side of the ankle that got compressed?
Very commonly we see issues with the tendons on other side. (I’ll deal with inversion sprain here only). There are three tendons on the inside of the ankle – tibialis posterior, flexor hallucis longus and flexor digitorum longus if you’re interested – that frequently get squished (technical term!) and can be an important factor in rehab.
Another factor can be the muscles that went too far. If we continue to think about inversion sprain mechanism above and consider the picture here of the peroneal muscle you can see the tendons wrap themselves around the out ankle bone (malleolus). These in themselves can be strained during inversion injuries.
Lesser known perhaps is that the pull on these muscles can affect the other end of your fibula. The low end of your fibula is your outside ankle bone and the upper end if the little knobbly (another technical term!) bit that sticks out on the outside of your shin. This joint, and the nerve closely associated with it, can be another factor in pain and we always check this at the clinic.
What about the retinaculae I hear you cry? Just another showy piece of Latin but in real terms these are the ‘wrappers’ that keep the tendons in place. As labelled in the picture here. If you rupture one of these you will know as your tendons will very obviously flick all the way across your ankle bone. More commonly, in later stages of rehab, the retinaculae can get a bit stiff and sticky and limit restoring full ankle range of motion. Something our hands on techniques are very good at releasing.
That’s most of the localised factors we consider when rehabbing ankle sprains. There are a few more but they’re quite rare and a bit fiddly. I don’t’ want to drown you guys in more jargon than I have to.
What Impact Does An Ankle Sprain Have On The Rest Of The Body?
Most people will understandably limp after an ankle sprain. The pain isn’t pleasant. It’s a natural thing to do. As the ankle gets better the limp gets better. Usually. We have seen cases that don’t. But in the majority of people that history of limping stays with them. Even when they don’t know.
It becomes an altered movement pattern. This is where our holistic approach comes into it’s own. It’s super important to rehab the whole body after an ankle sprain to consider it’s full impact. Classically, and easiest to explain, we find that the muscles on the same side that run from your pelvis to your rib cage get short and tight. Leaving your pelvis in a permanently ‘hiked up’ position.
Perversely when we release this hip hike down using our jiggery pokery more often than not we see the ankle feel better. Immediately on the spot. It’s as if the altered movement pattern is maintaining the pain. It’s helping the body to remember how painful the injury was. But now doesn’t need to be.
Of course if we release off your hip hike and it doesn’t work we look silly. But that’s ok. We’ve still had a positive impact on the overall mechanics. In these cases it suggests the local tissues are more important to look at. I have a theory on why this might be…
Are You Too Tough Or Too Scared?
One of my favourite ankle sprain stories was back at the Swindon clinic some years ago when our treatment room was up a flight of stairs. A very tentative 18 year old lady struggled up the stairs on crutches only an hour later to walk comfortably down the stairs with crutches in hand after a little bit of re-alignment and allaying of fears.
Compare that to a burly rugby player who has sprained their ankle on numerous occasions. Sprained it a couple of weeks ago. Played on until the end of the game and then went out for a beers afterwards. Re-alignment generally won’t touch their pain.
What’s the difference here? The first case is someone who is very scared. Scared of making things worse. Scared of what it might be having not experienced it before. Their protective movement patterns will be more extreme. In these cases the whole nervous system will be on edge. When we use a combination of calming the nervous system and re-aligning the body we can get dramatic changes.
Less so with our rugby player. As a rule of thumb we are normally better to treat the local issues first with rugby players to patch them up and feel less pain. Then we need to look at the bigger picture to stop them doing it over and over again.
I have seen rugby players who have a response like the scared 18 year old example. If they’ve had a previous very serious injury on that same side or area. Their body can go back to that trauma and ramp up the sensitivity of the condition. Equally if there is a lot riding on being able to play this will also have an effect on sensitivity of the injury. The classic example would be a big game coming up. But also for someone who’s enjoyment of rugby and the social aspect of training and playing was important for their mental health.
Some nice practical examples of the power of the mind specifically related to ankle sprains. Regular readers will know all about my thoughts on how important it is to consider the mind in all kinds of injuries. If you’d like to read more about this idea have a read of our article about Just What Pain Is.
Sprained Ankle Symptoms and Recovery Time
Now most ankle injuries heal well with time but a quick piece of housekeeping. If you are in any doubt whether you have broken you ankle please consult with a doctor. If for no other reason than peace of mind. This in itself will make you less defensive of the issue and maintain a better movement pattern.
The Ottawa ankle rules are used by medics as a guide to help determine whether or not you need an x-ray to be absolutely sure nothing is broken. As a general rule if you are in excruciating pain on weight bearing then seek medical assistance.
How long your ankle sprain will take to recover depends on how much you have damaged the ligaments, muscles and other connective tissue around the ankle. Generally speaking we say physiological healing of these soft tissues should take about 6 weeks.
Any longer than that and we start suspecting that there are compensations afoot that we need to address. Maybe compensations in your body maybe in your brain. Probably both.
Below is a table I have referenced from some American research (Maughan KL, “Ankle Sprain,” UpToDate, version 14.3, and Ivins D, “Acute Ankle Sprain: An Update,” American Family Physician (Nov. 15, 2006), Vol. 74, No. 10, pp. 1714–20.) on symptoms and recovery time.
|Severity||Ligament Damage||Symptoms||Recovery time|
|Grade 1||Minimal stretching, no tearing||Mild pain, swelling, and tenderness. Usually no bruising. No joint instability. No difficulty bearing weight.||1–3 weeks|
|Grade 2||Partial tear||Moderate pain, swelling, and tenderness. Possible bruising. Mild to moderate joint instability. Some loss of range of motion and function. Pain with weight bearing and walking.||3–6 weeks|
|Grade 3||Full tear or rupture||Severe pain, swelling, tenderness, and bruising. Considerable instability and loss of function and range of motion. Unable to bear weight or walk.||Several months|
As with all physiotherapy research the grading is fairly irrelevant. What’s more important is how it feels and how it works. Even people with complete ruptures (grade 3) frequently go un-operated on. Depending on what you need to use the ankle for.
What Shouldn’t I Do With My Sprained Ankle?
Certainly don’t do what 21 year old me did and limp to the pub after a sprain playing football and then run home as I couldn’t feel it anymore! As stupid as this was I am still very grateful for this moment as it was one of the defining moments in my life which encouraged my to change career. Without which I wouldn’t be writing and you wouldn’t be reading.
This very personal anecdote is a classic example of exactly what not to do. Ankles that I have been the most stubborn to heal over the years have involved playing through. Carrying on because you felt you had to. Or you were too stubborn to admit defeat.
In a World Cup final or in Olympic events maybe it’s worth it. Maybe you have your own personal Olympics or Everest to climb. But always consider the implications of carrying on… or running back from the pub!
If My Ankle Doesn’t Hurt After Should I Still Get It Looked At?
Yes! Please get it look at. Hopefully the explanations and ideas above give the reasons for this. We or any other therapist will soon tell you if we think your ankle is fully functional again. The better therapists will also analyse and address any repercussions from altered movement throughout the body before giving you a clean bill of health too. Whether that’s an ankle sprain that’s a few weeks old or one that you had 20 years ago.
Ankle Sprain Treatment
So what should you be doing with your ankle. Traditionally we would say RICE regimen or even PRICE – Protection, Rest, Ice, Compression, Elevation. Protection I would certainly recommend. Protection may mean getting you away from the pitch or away from having to walk on your freshly sprain ankle. Crutches are recommended for 4 days post injury to minimise swelling and bleeding in and around the joint.
Rest is pretty obvious. If you can’t use crutches in the first 4 days use the ankle as little as possible. Give it time to do it’s thing as nature intended. Heal. We need to be patient and give this process time. The more patient we are up front the quicker we will heal and get back to our best.
Ice is accepted practice as you probably know in the physiotherapy world. However, as with a lot of practices in the physiotherapy world there isn’t really any concrete evidence for it! My argument against using ice is that we are trying to interrupt our bodies natural response to injury. Why would we do that? Thousands of years of evolution and we’re coming along and saying it’s all wrong.
Ice is great for distracting your nerves from pain and perhaps allowing you to get on with your day less inhibited by your injury. But is it the right thing to do to enable your body to do what it needs to do to heal? Same argument goes for anti-inflammatory medication. Ultimately it’s your choice. Here is a link to a good article which has links to the conflicting research to help you decide which side of the fence you want to sit on.
If you are going to ice every 2-3 hours for 20 minutes is widely recommend for again hypothesised reasons. Crushed ice to mould to the shape of your ankle through a damp tea towel so you don’t get frost bite!
Compression doesn’t really cut it for me. Again the reasons for it’s use are old school and theoretical. If you feel it working for you great. My personal opinion is the more naturally we can let healing happen the better.
Elevation for me feels quite natural. From bitter experience if your foot is elevated it feels like blood flow is easier. Good blood flow is surely essential for optimal healing. Venous return which sends de-oxygenated blood away from the ankle back to heart, has to work harder against gravity in standing. With your foot up this is much easier. You’ll notice if you sit with dangled legs when your ankle is heavily swollen it starts to throb.
Oxygenated blood carries the white blood cells needed for healing. This is what swelling is. Adding my thoughts that swelling is a good thing, to a point. Blood is also important to transport the by-products of healing away from the ankle many of which actually cause pain. We want as few of these around as possible please to minimise pain and keep as much function as possible through the ankle.
Ankle Sprain Rehabilitation and Exercises
From a rehab perspective we look to start gentle mobility work 4 days after injury. We want to encourage the right kind of healing to happen by gently stressing the area in the way in which it will be used. This simple idea works down to a cellular level. Here’s a link to this concept called mechanotransduction if you want to bore friends at dinner parties!
The best way to do this is by starting with pain free range of movement exercise in the four directions available at the ankle:
- Plantarflexion – pointing the toes away from you
- Dorsiflexion – pulling your toes up towards you
- Inversion – probably the direction you injured yourself in the first place – moving the line of your little toe inwards – see picture towards the top of the article if in doubt
- Eversion – the opposite direction – moving the line of your little toe upwards and outwards
It’s ok to feel stiff as you do these but you don’t want to feel sharp pain. You can combine all of these movement into ankle circles. Start off small and build up to bigger circles as your ankle continues to heal. Later on in your rehab you can spell out your name with your toes to test all ranges of motion in the ankle.
Don’t get despondent if you have a bad day. It happens. Most likely if you’re a bit stressed or simply in a bad mood. We are more sensitive emotionally and physically on these days and so we feel more pain.
Another good one to do in this early phase to get the joint moving and muscles working is seated calf raises. Simply sit in a chair and do a calf raise – firstly on your good side so you know what it should feel and look like. Secondly on the injured side. Try to copy the way the uninjured side works. Keep it pain free folks. This will also help blood flow which we discussed in the section above.
Breathing is important right? It provides oxygen to our muscles to help them work. It makes everything work in our bodies. Including our ability to heal. So if we optimise the oxygen going into our bodies we surely optimise healing. In the most natural way possible.
Not only that but breathing exercise is great for calming our nervous system as a whole. Making us less sensitive to everything that is going on. Check out our previous article on using breathing as part of pain management here. Give it a try. Worst case scenario you feel more relaxed about your ankle hurting!
When you are able to weight bare pain free we can start working on your balance. Start by simply standing on the uninjured leg. Notice how it feels and how wobbly you are. Compare with the injured side. Chances are you’ll be more wobbly on the injured side.
This is because the ligaments feedback to the rest of the body information about the position of the joint. This is impeded after injury. We need the muscles to learn to adapt. See how long you can hold – always keeping things pain free. You can progress this exercise by placing your hands on your head, closing your eyes and standing on a pillow to add extra instability.
A nice piece of research here confirms this kind of training reduces the likelihood of recurrence. Interestingly it also suggests that it can increase pre-existing knee symptoms. That simply to me says that the whole body needs realigning to take the pressure off the knees and ankles. It may well have been a causative factor in the original injury.
That’s the basics covered. You can find even more exercises here from Harvard. Then the really fun stuff starts! That’s the bit tailored to you. This is where you can’t beat specific treatment from a therapist. Exercise wise we need to understand what we need to get you fully fit for. We need to understand how your body has dealt with this injury from top to toe and make sure that doesn’t lead to recurrence of further compensatory issues in the future.
At our clinic we always check the whole body. I would recommend you to do the same. A little bit of research here confirms how movement at the hip is affected. But it won’t stop there. This altered hip movement will continue up the body and can affect as high up as the neck or shoulder.
When Should I Start Walking After My Ankle Sprain?
If in doubt use common sense. Ideally you would start partial weight bearing walking with crutches – you can see how to do this in this NHS video here. We want to start loading your foot slightly. As you progress you can start to walk as normally as possible full weight baring.
Monitor the duration and slowly increase your full weight baring walking and reduce the amount of walking with crutches. If you feel like your ankle gets aggravated then you have gone too far. Reduce the duration of your full weigh baring walk the following day. If it doesn’t make it worse increase the duration.
How quickly you progress through to full weight baring depends on many factors such as severity of original injury, age, fitness levels, weight and mental approach to name some off the top of my head. This phase could be a couple of days for someone with someone young and athletic with a mild injury. It could be more like weeks for others. It will be different for each person. Try to be sensible to challenge yourself but at the same time not push yourself too much – trust your body to let you know if you have done too much.
We also need to teach you how to walk again. We need to teach you to walk without a limp. Rock walking is a really nice way of doing this. Simply stand with your legs split as if you were walking. One leg in front of the other. Rock your weight forwards and then backwards allowing toes and heel to lift at appropriate times, but not actually taking the whole foot off the ground. Compare how it feels between the injured side and uninjured side. It takes a little while to get a rhythm going but you’ll get it.
Can I Just Ignore An Ankle Sprain?
Well yes you can. I just would strongly urge you not to. On a professional level and on a personal one as someone age 21 who was too stupid to do this properly! The younger you are the quicker you will recover. But even if you don’t feel any obvious after effects from the injury you may have a compromised movement pattern that could come back to haunt you in later years.
The number of times at the clinic we might be treating a knee, hip, back or even shoulder issue and we trace the problem back to an old ankle sprain. Don’t say I didn’t warn you!
When Should You Get Physiotherapy For Your Ankle?
There’s some interesting research which suggests that having physio and doing RICE is not much better than doing just RICE. In the early phases of injury I would tend to agree. If you are fearful of the injury and worried about it though then physio sessions can guid you through the process benefiting from the experience of the therapists who will have seen hundreds of similar conditions. We would recommend you start with hands on physio work about 2 weeks after injury.
Should You Use an Ankle Brace?
We prefer to rehab people to a point where they are 100% confident in their ankles. We can’t guarantee you’ll never sprain one again. Life doesn’t work that way. But we’ll have done all things possible to minimise the risk.
For most people that means that using ankle braces isn’t necessary. However, for those people who like to indulge in sports that have a high risk of recurrence of injuries than we would recommend to wear one as a protective measure and this has been shown to reduce re-injury rates.
Firstly well done for making it the bottom of my longest ever article. It shows you how complicated an area this truly is. Just for a simple ankle sprain. I could have put a lot more in here too. But I had to stop somewhere otherwise this would have turned into a text book!
I’ve given you lots and lots of information and advice here. More than I’ve seen on any other article on the internet. Please make the most of it. I’ve included all this generic information here to reach a wide audience and encourage them to take action where so many people don’t.
There is however no substitute for having a your body specifically checked out and rehabbed so that ankle no longer hurts, works as well as it ever has done and doesn’t impact the rest of your body in any way. I would say that of course. It’s up to you whether you do something about it.
If you do have an ankle problem that you would like to see the back of then please click the Contact Us button below now.
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This post first appeared on our Brighton site.