Ankle Sprain

The ankle joint, which connects the foot with the lower leg, is injured often. An unnatural twisting motion can happen when the foot is planted awkwardly, when the ground is uneven, or when an unusual amount of force is applied to the joint. Such injuries happen during athletic events, while running or walking, or even doing something as simple as getting out of bed.

Ankle injuries can be painful and can make it hard to carry out your daily activities.

A review of the important parts of the ankle, and injuries that can happen to them, is appropriate:

• The ankle joint is made up of 3 bones.
  
  
  • The tibia is the major bone of the lower leg. It bears most of the body's weight. Its bottom portion forms the medial malleolus, the inside bump of the ankle.
    
    
  • The fibula is the smaller of the 2 bones in the lower leg. Its lower end forms the outer bump of the ankle.
    
    
  • The talus is the top bone of the foot.
    
    
  • Fractures are breaks in these bones.
  
  
• Tendons connect muscles to bones.
  
  
  • Several muscles control motion at the ankle. Each has a tendon connecting it to one or more of the bones of the foot.
    
    
  • Tendons can be stretched or torn when the joint is subjected to more than normal stress.
    
    
  • Tendons also can be pulled off the bone to which they attach. An example of an injury of this type would be an Achilles tendon rupture.
  
  
• Ligaments provide connection between bones. Injuries to the ligaments are called sprains.
  
  
  • The ankle has many ligaments holding it together. Stress on these ligaments can cause them to stretch or tear.
    
    
  • The most commonly injured ligament is the anterior talofibular ligament that connects the front part of the fibula to the talus bone.

Ligaments are injured when more than normal stretching force is applied to them. This happens most commonly when the foot is turned inward or inverted. This kind of injury can happen in the following ways:

• Awkwardly planting the foot when running, stepping up or down, or during simple tasks such as getting out of bed

• Stepping on a surface that is irregular, such as stepping in a hole

• Athletic events when one player steps on another player (A common example is a basketball player who goes up for a rebound and comes down on top of another player’s foot. This can cause the rebounder’s foot to roll inward.)

When an ankle is injured with a sprain, tendon injury, or fracture, inflammation occurs. Blood vessels become "leaky" and allow fluid to ooze into the soft tissue surrounding the joint. White blood cells responsible for inflammation migrate to the area, and blood flow increases as well. Typical changes that happen with inflammation, include the following:

• Swelling because of increased fluid in the tissue: Sometimes the swelling is so severe that you can leave an indentation in the swollen area by pressing on it with your finger.

• Pain because the nerves are more sensitive: The joint hurts and may throb. You can make the pain worse by pressing on the sore area, by moving the foot in certain directions (depending upon which ligament is involved), and by walking or standing.

• Redness and warmth caused by increased blood flow to the area

Usually, an ankle sprain itself does not call for a trip to the doctor. The problem is how to tell a sprain from a more serious injury such as a fracture. If the following happen, you should contact your doctor:

• Your pain is uncontrolled, in spite of over-the-counter medications, elevation, and ice.

• You cannot walk or cannot walk without severe pain.

• Your ankle fails to improve within 5-7 days. The pain need not be gone, but it should be improving.

• A follow-up visit 1-2 weeks after the injury is advisable to help with flexibility and strengthening exercises.

The indications to go to a hospital's emergency department are similar to those for which to call the doctor. The following conditions suggest you might have a fracture, or you may need a splint for pain control.

• Severe or uncontrolled pain

• Foot or ankle is misshapen beyond normal swelling

• Cannot walk 4 steps, even with a limp

• Severe pain when pressing over the medial or lateral malleolus, the bumps on each side of the ankle

The doctor will check to see if a fracture or other serious injury has happened to require immediate care.

• The examination should make sure that you haven’t injured the nerves or arteries to the foot.
  
  
  • The doctor will handle and move the foot and ankle to determine what bony areas are involved.
    
    
  • Finally, the Achilles tendon will be checked for signs of rupture.
  
  
• X-rays are often, but not always, needed to make sure that a fracture is not present.

|Self-Care at Home|

Care at home is directed toward lessening the pain and helping healing. Because most of the pain is caused by inflammation, you should try to reduce inflammation and keep it from happening.

• Ice is probably the best treatment.
  
  
  • Applying ice to the injury will do more for most people than medications.
    
    
  • Ice will counteract the increased blood flow to the injured area.
    
    
  • It will reduce the swelling, redness, and warmth.
    
    
  • Applied soon after the injury, ice will prevent much of the inflammation from happening.
    
    
  • Do not apply ice directly to the skin. Use a towel between the ice and the injury, or use an ice bag. Apply ice for 20 minutes at a time, with at least 20 minutes between applications. This is to prevent frostbite, which can occur if you use ice too much or use it directly on your skin.
  
  
• Rest prevents further injury and avoids stress on already inflamed tissue.
  
  
  • Put the ankle joint at rest by wearing a brace or splint.
    
    
  • Compression wraps, such as Ace bandages, do not provide much support to prevent movement of the ankle, and you should not apply them tightly.
  
  
• Elevation (keeping the injured area up as high as possible) will help the body absorb fluid that has leaked into the tissue.
  
  
  • Ideally, prop the ankle up so that it is above the level of your heart.
    
    
  • You can do this in a reclining chair.
  
  
• Anti-inflammatory pain medications will reduce the pain and combat the swelling. Several are available over-the-counter, such as ibuprofen (Motrin IB and Advil are common brands) and naproxen (Aleve or Naprosyn are examples).

|Medical Treatment|

Treatment by a doctor will be very similar to that described for home care, especially using ice to lessen the inflammation.

• The doctor may elect to apply a brace or cast to reduce motion of the ankle. Crutches are frequently provided so you do not have to bear weight on the injured ankle.

• The most common medications used for ankle sprains are anti-inflammatory pain medications that both reduce pain and help control inflammation. If you cannot tolerate these drugs, acetaminophen (such as Tylenol) or narcotics are common alternatives.

|Follow-up|

Follow-up for ankle sprains is needed only if the ankle is not healing well. This could indicate there is a previously undetected fracture or torn ligaments. Go to a doctor for follow-up care if either of the following is true.

• You cannot walk on the injured ankle within a week of the injury.

• Your ankle continues to hurt after 2 weeks.

|Prevention|

Ankle sprain prevention can be as simple as wearing the right shoes or as complicated as balance training for athletes.

• Keep your ankles strong and flexible. Check with your doctor or physical therapist for strengthening exercises.

• Wear the proper shoes for the activity. You should always wear stable shoes that give your ankle the proper support. High-top basketball shoes are a good choice. (High heels or platform shoes are not the best choice if you're trying to prevent an ankle sprain.)

• If you are participating in a sport, you might want to consider having a weak ankle taped to offer extra support. If you have repeated sprains, wearing an ankle brace while playing may help as well.

• Making sure that the playing field (or bedroom) is clear of any holes or obstacles also can help you avoid injury.

|Outlook|

Most ankle sprains (70-90%) heal without complications or difficulty.

• Surgery is seldom needed for torn ligaments. Ligament tears are often noticed when sprains fail to get better. If the diagnosis of a tendon tear that needs surgery is not made right away, the outcome of the surgery is the same as if the doctor did the operation immediately.

• You should start exercises to maintain flexibility and strength when the swelling has resolved and you can walk without pain.

Media file 1: Ankle sprain. Medial and lateral malleoli, the "bumps" on either side of the ankle. The medial malleolus is formed by the tibia, while the fibula forms the lateral malleolus.

Media type:  Photo

Media file 2: Ankle sprain. Inversion injury of ankle. Note it is turned inward.

Media type:  Photo

ankle sprain, twisted ankle, turned ankle, rolled ankle, tibia, medial malleolus, fibula, talus, anterior talofibular ligament

Author: Howard A Blumstein, MD, FAAEM, Assistant Professor, Surgery; Medical Director, Department of Emergency Medicine, Wake Forest University School of Medicine.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Anthony Anker, MD, FAAEM, Attending Physician, Emergency Department, Mary Washington Hospital, Fredericksburg, VA.