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Sprained Ankle

A sprained ankle, also known as a twisted ankle, rolled ankle, or turned ankle, is an injury involving one or more ligaments of the ankle. It is prevalent in sports, especially those involving ball activities like basketball, volleyball, football, and tennis.

Lateral view of the human ankle
Lateral view of the human ankle

Signs and Symptoms

A sprained ankle typically presents with swelling, bruising, and pain. Hematoma occurs within the tissue around the joint, leading to a bruise, while white blood cells migrate to the area, increasing blood flow and resulting in inflammation. This inflammation causes the area to swell and become painful, with the pain worsening under pressure. Other signs include warmth and redness due to increased blood flow and decreased joint mobility.

Right foot, housed in an air brace, has become swollen as a result of a more severe 2nd degree sprain to the ankle.
Right foot, housed in an air brace, has become swollen as a result of a more severe 2nd degree sprain to the ankle.
Right foot, 3rd degree sprain. One day after injury.
Right foot, 3rd degree sprain. One day after injury.

Cause

Ankle sprains are caused primarily by movements such as turning and rolling the foot. High-risk activities include those with explosive side-to-side motions, like tennis and basketball, but sprains can also occur during daily activities like stepping off a curb or slipping on ice. Factors increasing the risk include weak muscles or tendons, weak or lax ligaments, inadequate joint proprioception, slow neuromuscular response, running on uneven surfaces, inadequate heel support in shoes, and wearing high-heeled shoes.

Diagnosis

Diagnosing a sprained ankle involves a medical history review and physical examination to differentiate from ankle strains or fractures. The Ottawa ankle rule is commonly used for this purpose, boasting nearly 100% sensitivity. Persistent pain after 6-8 weeks may necessitate MRI imaging.

Classification of Severity

Sprains are classified into three grades:

  1. Grade 1: Mild damage to ligaments without joint instability.
  2. Grade 2: Partial ligament tear, causing looseness.
  3. Grade 3: Complete ligament tear, leading to joint instability.

Types

Inversion (Lateral) Ankle Sprain

This is the most common type, occurring when the foot internally rotates excessively, damaging the lateral ligaments.

Ankle inversion
Ankle inversion

Eversion (Medial) Ankle Sprain

Less common, this type involves the ankle rotating laterally, straining the medial (deltoid) ligament.

High (Syndesmotic) Ankle Sprain

This type affects the ligaments above the ankle, joining the tibia and fibula, often from a forceful outward twisting of the foot.

Treatment

Initial Treatment

Initial treatment typically follows the RICE mnemonic (Rest, Ice, Compression, Elevation). This approach helps limit swelling and facilitate drainage. However, recent insights suggest that ice may delay healing, and complete rest might not be beneficial.

Conservative Measures

Compression bandages, braces, and crutches are commonly used. Icing should be done in cycles to prevent cold injuries. Immobilisation in a below-knee cast or Aircast can lead to faster recovery, though some studies suggest that early exercise improves function and recovery.

A brace offering moderate support and compression for a Grade I ankle sprain.
A brace offering moderate support and compression for a Grade I ankle sprain.

Rehabilitation and Recovery

Rehabilitation involves exercises to regain strength and flexibility, with the initial focus on protecting the ankle. Exercises include range of motion, strengthening, balance, and agility exercises. Ankle mobilisation techniques can reduce pain and increase range of motion.

Ankle Exercises

Exercises such as ankle circles, alphabet drawing, and eversion exercises improve mobility and stability. Balance training, like using a wobble board, is very important. Stretching exercises maintain joint flexibility.

Flexibility and Strengthening Exercises

Flexibility exercises include towel stretches, while strengthening exercises involve step-ups and walking on toes. Balance exercises, using devices like balance boards, help retrain muscles. Agility exercises, such as squat jumps and power skipping, should be done after regaining full agility.

Rehabilitation exercises for an ankle sprain
Rehabilitation exercises for an ankle sprain

Prognosis

Most people improve significantly within two weeks, although some experience pain and instability for up to a year. Re-injury is common, with a recurrence risk of up to one-third. Mild sprains (Grades 1-2) typically heal within six weeks, while severe sprains (Grades 2-3) may take months.

Epidemiology

Ankle sprains are common in sports and daily activities. The most frequent type is an inversion sprain. Adolescents and military personnel have higher incidences due to their activity levels. Males aged 19-25 and females over 30 are particularly susceptible.

Adolescents vs general population ankle sprain instances
Adolescents vs general population ankle sprain instances
Ankle Sprain Epidemiology- U.S. Military vs General Population
Ankle Sprain Epidemiology- U.S. Military vs General Population
Ankle sprain incident rates of average males to females
Ankle sprain incident rates of average males to females

Self-assessment MCQs (single best answer)

What is another term for a sprained ankle?



Which activity is most likely to cause a sprained ankle?



What is a common symptom of a sprained ankle?



Which grade of ankle sprain involves a complete ligament tear?



Which type of ankle sprain is the most common?



Which initial treatment method uses the mnemonic RICE?



What does the Ottawa ankle rule help to diagnose?



Which component is NOT typically included in ankle rehabilitation exercises?



Which of the following is a risk factor for spraining an ankle?



Which demographic is particularly susceptible to ankle sprains?



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