Understanding Lateral Ankle Sprains

What is a Lateral Ankle Sprain?

An injury that occurs from rolling the ankle inwards (inversion injury), injuring the ligaments on the outside of the ankle. The role of these ligaments is to prevent excessive ankle movements in an inwards and downwards direction. If the ankle is forced beyond what these ligaments can withstand these ligaments will sustain an injury.

Mechanism of injury:

Two most common mechanisms:

1. Landing on uneven surface (someone’s foot, pot hole, off the edge or gutter, high heels etc.) 

2. Pushing off laterally during cutting or changing direction maneuver in sport 

What structures are likely to be involved?

There are 3 main ligaments on the outside of the ankle (ATFL, CFL, PTFL) these ligaments may be sprained during an inversion injury. There may also be involvement of the deltoid ligament on the medial (inside) of the ankle in some cases.

An Avulsion fracture may also occur. This occurs when the ligament pulls off a fragment of the fibula bone (Which it attaches to) during the injury.

Ruling out fractures:

Ligament injuries do not show up on X-Ray however if a fracture is suspected an X-Ray should be considered. To determine whether an X-Ray is needed we follow the Ottawa ankle rules.  

Ottawa Ankle Rules:

1. Tenderness from lateral or medial from tip of the posterior part, 6 cm up from the lateral malleolus

2. Tenderness over base of 5th Metatarsal 

3. Tenderness over the Navicular 

4. Cannot immediately weight-bear or cannot currently weight-bear

Recovery Time

Returning to every day activities will vary depending on severity. It is important to return to daily activities as soon as possible. Below are the estimated timeframes for returning to sporting/higher stress activities.

– Grade 1: 2-4 weeks

– Grade 2: 4-6 weeks

– Grade 3: 6-8 weeks (Avulsion fractures will take longer)

Initial Management

Treatment days 0-3

48-72 hours

PRICER:

Protect, Relative rest, Ice, Compression, Elevate, Referral 

– Protect the ankle from excessive inward ankle movement – Taping or bracing 

– Relative rest: Daily activities should be as normal as possible, when the ankle becomes uncomfortable then have a rest

– Ice: 15-20 mins regularly throughout the day if the ankle is swollen and bruised

– Compression: tubigrip, elastic bandage, tape for compression

– Elevation: Above the heart level 

– Referral to physio or X-Ray 

Rehabilitation

20% of acute ankle sprains lead to chronic instability, therefore rehabilitation is very important. Reoccurrence of ankle sprains are most likely within the first 12 months following the initial injury. Rehabilitation reduces the risk of re-injuring the ankle.

Rehabilitation should include range of motion, strength, balance, proprioception and return to activities/function.

Range of motion

1. Address Range of motion, this may be limited by swelling, stiffness or soft tissue)

2. Movement will help with swelling and regaining motion of the ankle

3. Muscle tone increases as a response to limit excessive movement, but we want to limit some of that muscle tone.

4. In the early stages is using dry needling may be useful as it decreases muscle tone without increasing inflammation

5. Physiotherapists can also do some mobilization and manual therapy around the ankle joint to help improve range of motion and help get you walking as normally as possible

Strength

1. The most common strength deficit is usually from the peroneal muscles (Outside of the lower leg)

2. Peroneals often also get strained during an inversion injury

3. The peroneals become overtoned with protective muscle spasm, we need to activate a normal peroneal contraction and decrease some of the excess tone

Balance

1. Balance training should start as soon as possible (in first week if able to) as soon as it is comfortable to do so (Can be in the first week – This may start with balancing for 2-5 mins/day and have a rest when it becomes uncomfortable)

2. Start with single leg stance, slight knee flexion (Soft knee – so that glutes and quads can be incorporated for better balance)

3. Progress to more advanced balance exercises

Function

1. You want to walk as normally as possible so the brain knows the normal walking pattern so you don’t get stuck with an altered walking pattern

2. Taping or bracing can help in the early stages

3. Try to avoid limping

4. Heel raises in the shoes for a short time can help limit the amount you have to pull your foot back while walking which may make walking slightly more comfortable.

After the initial/acute phase:

Once you get past the acute phase of the injury it is important to continue with rehab and strengthening the ankle to prevent chronic ankle instability in the future. This may include extensive balance exercises and strengthening exercises.

Written by Ashley Holliday

Physiotherapist