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The Ankle Odyssey: A Guide to Sprains
Navigating the anatomy, biomechanics, and treatment of ankle sprains
It happens all of the time. It’s a beautiful morning so you decide to go for a walk in your neighborhood to enjoy the weather. As you’re walking down the sidewalk, the sun is shining through the trees, there is a light breeze, and you hear birds chirping. Up ahead, one of your neighbors is watering her garden. You look over to say hello and that’s when it happens.
You step awkwardly off of the curb, stumble, and nearly fall. Searing pain shoots along the outside of your ankle and your foot starts to throb. You can barely stand when you regain your balance. The swelling starts almost immediately and you realize - you’ve sprained your ankle.
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Ankle sprains are one of the most common orthopedic injuries, yet they’re often poorly managed. With teens and young children, people may assume that they’ll heal and be able to return to their previous activity level with rest alone.
While this might be true with some, most would also benefit from some basic exercises, balance training, cold packs, and elevation. Ankle sprains can become chronic or recurrent, leading to instability of the joint if not properly managed.
Note: The information contained in this article is for educational purposes and should not be considered as medical advice. Consult your physician and physical therapist for specific treatment and advice for your condition.
Anatomy & Biomechanics
A basic understanding of the anatomy and function of your ankle will help in your recovery. The ankle, or talocrural joint, is created by the articulation of three bones called the tibia, fibula, and talus. The tibia is the large bone of the lower leg that forms your shin and the fibula is the smaller bone along that outside of your lower leg. These two bones are connected at the top and bottom by ligaments. Where the lower ends of the bones meet, they form a concave surface that rests on the dome-shaped portion of the talus.
As you bend your ankle up and down, the dome of the talus slides forward and backward. The ankle is supported by ligaments that stabilize the joint and muscles that create movement. Ligaments run along the medial (inside) and lateral (outside) aspects of the joint. The medial ligaments are very strong and are collectively called the deltoid ligament. There are three primary ligaments that support that lateral ankle. These are the anterior talofibular, the posterior talofibular, and the calcaneofibular ligaments.
Normally, if you roll your ankle one way or the other, the motion will take up the slack in the ligaments and they will prevent injury by limiting the motion. It is a precise system that relies on structural integrity and mechanical efficiency. Even small changes in the system can affect performance, including speed, power, and balance. Injuries, weakness and poor motor control lead to impaired functional mobility.
Mechanism of Injury
In the case of an ankle sprain, the ligaments and muscles are unable to stop the movement, the joint moves beyond the normal range, and the ligaments become injured. The most commonly sprained ligament in the human body is the anterior talofibular ligament — just in case it ever comes up in a trivia game.
Ankle sprains can result from many different activities including walking on uneven surfaces, running, falling down, or participating in sports that require cutting actions such as basketball and soccer. An ankle sprain happens when one or more of the ligaments stretch beyond their normal limits causing a tear. They are graded based on how much damage has occurred and range from mild to severe.
A Grade 1 (mild) ankle sprain results from slight stretching and microscopic tearing of the ligament fibers. The symptoms include mild, localized tenderness and swelling around the ankle. Grade 2 (moderate) sprains involve partial tearing of the ligament, moderate tenderness, and swelling around the ankle. There is also abnormal looseness of the ankle joint.
A Grade 3 (severe) ankle sprain results from a complete tear of one or more ligaments. The anterior talofibular ligament is the most frequently sprained ligament, but the calcaneofibular ligament can also be involved. Upon examination, a Grade 3 sprain exhibits substantial instability of the ankle joint.
3 Phases of Treatment
Most ankle sprains can be managed conservatively without surgery. Even Grade 3 injuries can heal with proper management including appropriate immobilization. The rehabilitation program is divided into three phases — Phase1: Acute Phase, Phase 2: Recovery Phase, and Phase 3: Maintenance and Prevention. The length of this three-phase program will vary depending on the severity of the injury. It can take two weeks for mild injuries or up to 12 weeks for severe sprains.
Phase 1: Acute Phase
The primary goals in the Acute Phase of ankle sprain rehabilitation are to decrease pain, reduce swelling, and protect the joint to allow proper healing. Treatment follows the RICE protocol as soon as possible after the injury. The components of RICE are rest, ice, compression, and elevation.
Resting your ankle is important in this phase to allow healing and to prevent further injury. Crutches are commonly used to allow you to walk without weight bearing on the injured leg. In severe injuries, your physician might encourage you to wear a specialized boot or brace that restricts ankle motion and supports the joint. Braces should be worn for the prescribed amount of time, but wearing them too long can delay recovery of strength and proprioception.
Ice and compression are vital to managing pain and swelling in the acute phase of an ankle injury. This can be accomplished with separate cold packs and compression wraps, but using a dual-purpose device is the better. These products combine the benefits of cold therapy with compression to allow deeper cooling of the injured tissues. This particular device also has a removable pump that allows you to control to amount of compression.
The final component of RICE, elevation, should be performed as often as possible in the first 48 hours to help manage ankle swelling. A key factor is raising your leg above the level of your heart. Using elevation with ice and compression will be even more effective in reducing pain and swelling in this stage.
It is important to protect your ankle in the acute phase to promote healing and to prevent further injury. You should avoid walking on the leg by using crutches or a walker for the first few days. A soft brace secured with laces or velcro can give sufficient support for mild Grade 1 sprains. However, Grade 2 sprains are supported better by removable plastic supports such as air stirrups. Grade 3 ankle sprains may require a short leg cast or a specialized boot for a few weeks.
Phase 2: Recovery Phase
The Recovery Phase of an ankle sprain is focused on regaining range of motion, increasing strength, and improving proprioception to restore functional mobility. Early motion will prevent stiffness, reduce muscle guarding, and prevent contractures. Swelling and pain can be managed using a flexible cold pack that wraps around the ankle after exercises. Strength and proprioception exercises improve support, prevent future injuries, and restore functional mobility. The exercises can be categorized as open-chain (foot off of the floor) and closed chain (foot on the floor).
Regaining Range of Motion
Regaining your ankle range of motion allows you to walk without a limp, use stairs with a normal step over step pattern, and perform your daily activities with minimal difficulty. Open chain exercises are the most basic type and involve active muscle contraction, but no contact with the ground. Examples of open chain exercises are actively raising (dorsiflexion), lowering (plantarflexion), and moving your ankle side to side (inversion and eversion) within a pain-free range. Other examples of open chain range of motion exercises include ankle circles and drawing the alphabet in the air with your foot. Open chain exercises are great for achieving early motion without putting excessive stress on the joint.
Closed chain range of motion exercises improve active muscle contraction and give additional sensory feedback by maintaining contact with the ground. This type of exercise includes towel slides and seated heel to toe rocking. Towel slides are performed by placing a small towel on an uncarpeted floor, then moving the ball of your foot from side to side while gently pivoting on your heel. The foot moves like a windshield wiper within a pain-free range to improve ankle inversion and eversion.
For seated heel-toe rocking, you sit with your knee bent at 90 degrees. Gently lift your heel and raise up onto the ball of your foot as far as you can without pain, then lower the heel to the floor. Next, raise the ball of your foot while keeping the heel on the floor, then return to the start position. This exercise improves active ankle dorsiflexion and plantarflexion.
Strengthening exercises can be performed once you can bear weight on the ankle without increasing pain or swelling. These exercises should be progressed from open-chain to closed-chain like the range of motion exercises. Strengthening happens when muscles are frequently stressed with appropriate resistance. As they overcome the resistance, physiological changes occur in the tissue and they are able to generate more force over time.
One of the most effective and most common open-chain ankle strengthening exercises is the 4-way band-resisted exercise. In this exercise, an elastic band is looped around the ball of your foot while the other end is secured or held by an assistant. The “4-way” movements of the ankle are dorsiflexion (up), plantarflexion (down), and side-to-side (inversion and eversion). As you perform this exercise, you slowly move as far as you can against the resistance without increasing pain, then slowly return to the start position.
You should perform 2–3 sets of 8–10 repetitions in each direction daily. Two key factors for this exercise are slow, controlled movements and appropriate resistance. The resistance should be challenging, but it should allow you to perform 8–10 repetitions with correct form and no increased pain. Most brands of elastic resistance bands are color-coded by resistance for easy identification.
Closed chain strength exercises not only improve strength, but they also simulate functional activities and give additional sensory input to improve muscle control. These exercises include standing calf raises, mini squats, and lateral step-ups. In standing calf raises, also called heel raises, you lift the heels raising onto the ball of your feet, then slowly lowering the heels to the floor while holding using the countertop for support. This improves the strength in your calf muscles while improving muscle control as you maintain your balance.
Mini squats and lateral step-ups help strengthen your calf muscles, but they also recruit the thigh muscles including the quadriceps, hamstrings, and hip abductors. To perform mini squats, stand by a kitchen counter, table, or rail with your feet shoulder-width apart. While holding onto the support surface, slowly bend at the hips and knees to lower your body until your knees are flexed 45 degrees.
Be sure to keep your shoulders, hips, and heels in a straight line to protect your joints. Avoid letting your knees move forward past your toes as this places unnecessary stress on the knee joints. Hold in the half squat, or mini squat, position for 5–10 seconds then slowly return to the standing position. You should perform 2 sets of 10 repetitions at least once each day.
Lateral step-ups are great for improving strength around the hips, knees, and ankles. They improve your ability to step up or down on curbs, as well as, ascending and descending stairs. This exercise has a greater impact on the hip abductors and adductors than standard step-ups.
To perform lateral step-ups, stand with your involved ankle next to a 6–8" step or block. Step up and to the side onto the block lifting your body as you straighten the knee. Hold yourself up for a couple of seconds, then slowly lower your uninvolved foot to the floor. As with the mini squat, you should perform 2 sets of 10 repetitions at least once per day.
Proprioception is the sensory component that detects joint motion and joint position. It also controls the firing of muscles to maintain your balance and to prevent joint injuries. An example of this function happens when you’re walking on a grassy surface and step on an uneven clump of grass. Your ankle starts to roll over too far, but proprioception detects the rapid change in joint position and relays the information to your brain.
Your brain sends a signal to activate the appropriate muscles to prevent movement beyond the normal range. Many studies show deficits in proprioception occur during ankle sprains. If this isn’t properly addressed during rehabilitation, poor proprioception can lead to repeat sprains and ankle instability. There are specialized exercises that can improve your proprioception and balance to help prevent future injuries.
A basic proprioception exercise is a single leg standing on a stable surface with your eyes open. During this exercise, you stand on one leg with your knee slightly bent and try to maintain your balance for at least 10 seconds. You should perform 1–2 sets of 10 repetitions at least once per day. When you can perform this exercise easily without loss of balance, progress to the single-leg stance with your eyes closed. The technique is the same, but you will close your eyes and attempt to maintain your balance without holding on to anything for support. By closing your eyes, you take out the effect of vision on your balance and force the proprioception system to be more active in maintaining your balance.
Once you have mastered the single-leg stance on a stable surface, you are ready to progress to standing on an unstable surface. This can be accomplished by standing on a pillow or foam pad. Standing on an unstable surface offers a greater challenge to the proprioception system. The exercise technique is the same as standing on a stable surface and you can progress to performing it with your eyes closed for the greatest challenge. Proprioception exercises can also be progressed by extending the balance time, increasing the number of repetitions, or increasing the number of sets performed. Restoring proprioception will improve function and help prevent future injuries.
Phase 3: Maintenance and Prevention Phase
When you’ve completed the Recovery Phase, you can gradually begin to return to activities that don’t require turning or twisting of the ankles. It is also important to keep exercising 2–3 times per week to avoid future injuries. You can incorporate a few ankle strength and flexibility exercises into your usual fitness routine. Including proprioception and balance, activities will improve ankle stability and your overall function.
The best way to prevent ankle sprains is to maintain good flexibility, strength, and balance. You should warm-up before physical activity and wear shoes that are made for the activity. When running and walking, pay attention to the type of surface, especially on uneven surfaces. You should rest or stop an activity if you feel pain or notice excessive fatigue.
Open and closed chain strength exercises will help you reach your goals. However, closed chain exercises incorporate functional movements that directly translate to daily activities such as ascending and descending stairs. Another benefit of closed chain activities is maintaining and improving proprioception.
Ankle sprains should be managed appropriately to avoid long term deficits and functional limitations. You should never assume that your ankle will heal without treatment. In the Acute Phase, use rest and RICE to decrease symptoms and to promote healing. There are many options for delivering cold therapy and compression.
During the Recovery Phase, focus on restoring range of motion, strength, and proprioception. Once you have recovered from the ankle sprain, following the guidelines in the Maintenance/Prevent Phase should reduce the risk for future injuries.
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