Sprained Ankle

Sprained Ankle

Article by I.Kelly, N.Stewart

What is a Sprained Ankle?

sprained ankle occurs when you overstretch your ankle ligaments. Ankle sprains vary in their severity. Mild “twisted ankle” or “rolled ankle” sprains, through to severe complete ligament ruptures. In extreme cases, avulsion fractures (small attachment fractures) or fracture (significantly broken bones).

What Causes a Sprained Ankle?

Ankle sprains are over-stretched ligaments. Injuries can occur by simply rolling your ankle on some unstable ground. Common examples of this happen. Landing unbalanced from a jump, awkwardly planting your foot when running, or stepping onto an unstable surface can cause an ankle sprain.

What is Sprained Ankle Symptoms?

sprained ankle

The mechanism of injury is a history of your ankle rolling. This description is the key ingredient to suspecting a sprained ankle. When rolled, you may hear a popping or cracking sound. Severe ankle pain, swelling, and bruising follow. Lateral or medial ligament sprains are locally tender over the injured ligament.

You may have trouble standing on your foot or walking, depending on the severity of your ankle sprain,  In these cases, walking boot, crutches, or strapping may provide comfortable support to help you mobilise.

In more severe cases, sharp pain deep in the ankle joint can be associated with a talar dome fracture. Pain between your lower shin bones may be a syndesmosis or high ankle sprain. These injuries are far may disabling than a more moderate, low ankle sprain and misdiagnosis can lead to premature ankle joint osteoarthritis and potentially, ankle surgery.

How is a Sprained Ankle Diagnosed?

Your physiotherapist is highly skilled in the assessment and diagnosis of an ankle sprain. Your physiotherapist will listen to your injury history and perform a thorough clinical examination to determine the severity of your sprained ankle.

If required, your physio may refer your physio for additional diagnostic tests such as an X-ray, or MRI. These tests will confirm or exclude specific ligament or bone injuries.

ankle sprain

MRI – Sprained Ankle.

Which Ankle Ligaments Sprain?

Your ankle joint, which is known as the talocrural joint, is made up of three bones. Your tibia (shin bone; inside ankle bone), fibula (outer lower leg bone; outside ankle bone), and your talus (deep ankle bone). Beneath your talocrural joint lies the subtalar joint, which is the articulation between the talus and the calcaneus (heel bone). This forgotten joint is overlooked frequently during assessment, diagnosis and rehabilitation.

Your ankle ligaments attach bone-to-bone. They passively limit the motion available at each joint.

sprained ankle ligaments

Outside of the ankle are the lateral ligaments, which are the most frequently injured in an ankle sprain. These include the:

  • anterior talofibular ligament (ATFL)
  • calcaneofibular ligament (CFL)
  • posterior talofibular ligament (PTFL)

The main medial (inside of the ankle) ligament is the much stronger deltoid ligament.

High ankle sprains involve the inferior tibiofibular ligament and syndesmosis. These are more disabling ankle injuries. Unfortunately, misdiagnosis is common.

Sprained Ankle Treatment

Unfortunately, a sprained ankle can increase your risk of re-injury as much as 40-70%, but the correct post-injury rehabilitation exercises significantly decrease the risk.

There are essential treatment aims that need to be covered to rehabilitate your sprained ankle and prevent a recurrence effectively.

Physiotherapy Treatment Aims

  • Injury Protection, Pain Relief & Control Inflammation
  • Regain Full Range of Motion
  • Strengthen your Ankle and Calf Muscles
  • Restore Joint Proprioception & Balance
  • Restore Normal Function
  • Speed & Agility
  • Sport-Specific Skills
  • Graduated Return to Training
  • Return to Competition

Sprained Ankle Treatment Progressions

There is no specific time frame for when to progress from each stage to the next. Many factors will determine your injury rehabilitation during your physiotherapist’s clinical assessment. You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves.

It is also important to note that your physiotherapist monitors each progression. Attempting to progress too soon to the next level can lead to re-injury and the frustration of a delay in your recovery.

Phase 1 – Injury Protection: Pain Relief & Control Inflammation

As with most soft tissue injuries, the initial treatment is RICE – Rest, Ice, Compression and Elevation.

(Active) Rest: In the early phase, you’ll most likely be unable to walk on your sprained ankle. Your first aim is active rest from pain-provoking postures and movements. Active rest means that you should stop doing the action or activity that provokes the ankle pain. In most cases, you will need to be non-weight-bearing. You may need to be placed in an ankle walking boot, a supportive ankle brace or utilise crutches.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.

Compression: A compression bandage, Tubigrip compression stocking or kinesiology supportive taping will help to both support the injured soft tissue and reduce excessive swelling.

sprained ankle treatment

Elevation: Elevating your injured ankle above your heart will assist gravity in reducing excessive swelling around your ankle.

Your physiotherapist will utilise a range of helpful tricks including pain-relieving techniques, joint mobilisations, massage, strapping and acupuncture to assist you during this painful phase.

Anti-inflammatory medication and natural creams such as arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the first 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as a pain reliever.

Phase 2: Regain Full Range of Motion

If you protect your injured ankle ligaments appropriately, the torn ligaments will successfully reattach and heal a standard functional length. Mature scar formation takes at least six weeks. During this period, you should be aiming to optimally remould your scar tissue to allow for full functional ankle movement and prevent a poorly formed scar that will re-tear in the future.

It is important to lengthen and orientate your healing scar tissue via massage and exercises designed to address your joint range of motion, muscle length and normal neural tissue motion.

IMPORTANT: Researchers have identifies that the history of a sprained ankle predisposes you to a stiff ankle joint that further predisposes you to an array of injuries including ankle sprains, foot pain, calf and leg injuries plus back pain.  Therefore, anyone who has suffered a sprained ankle should seek professional guidance to assess the amount of ankle joint motion you have. Please contact your physiotherapist for specific testing and advice.

Just as importantly, you should not overstretch ligaments and soft tissue, or you may develop a passively unstable ankle. Your physiotherapist will prescribe the exercises that are best suited to your needs.

Phase 3: Restore Muscle Strength

Your calf, ankle and foot muscles will require strengthening after an ankle sprain. It is essential to regain normal muscle strength to provide standard dynamic ankle control and function. Your strength and power should progress gradually. Weight-bearing progressions are from non-weight bear to partial, and then full weight bear and resistance loaded exercises. You may also require strengthening for your other leg, gluteal and lower core muscles depending on your assessment findings.

Your physiotherapist will guide you.

Phase 4: Normalise Foot Biomechanics

Sprained ankles can occur from poor foot biomechanics, e.g. flat foot or high arch. Your physiotherapist should assess your foot arch and its control. In some instances, you may require a foot orthotic (shoe insert), or you may be a candidate for the Active Foot Posture Stabilisation Program.

Your physiotherapist will happily discuss the pros and cons of both options to you.

Phase 5: Restore High Speed, Power, Proprioception, and Agility

Most sprained ankle injuries occur during high-speed activities, which place enormous forces on your ankle and adjacent structures.

Balance and proprioception are both known to be adversely affected by injuries such as a sprained ankle. Your physiotherapist can assess and treat both aspects.

Your physiotherapist will guide you through exercises as you return to sport. They’ll address these essential rehabilitation components to improve your sporting performance and prevent a recurrence.

Depending on what your sport or lifestyle entails, a customised speed, agility, proprioception and power program will prepare you for light sport-specific training.

Phase 6: Return to Sport

If you play sport and depending on the demands of your chosen sport, you may require sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport.

Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete and safe return to sport. The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury.

Sprained Ankle Recovery Time

How long does it take for an ankle sprain to heal?

There is no specific time frame that sprained ankle recover. While we do know that the ligaments themselves will take at least six weeks to heal, your muscle strength, the range of motion, proprioception, and return to function can vary considerably. Here are some general guidelines.

Grade 1 – Mild

In mild cases, you can expect full ligament healing within 2 to 3 weeks, but it will take at least six weeks for full scar tissue maturation.

Despite most people being told to simply “rest” and it will recover, we find that these mild sprains often result in joint stiffness, ligament laxity, muscle weakness or tightness plus reduced proprioception (balance and joint awareness).

If not adequately treated these often cause your ankle and foot joints to compensate movement at adjacent joints, which can lead to several other injuries months or years down the track.

Grade 2 – Moderate

Grade 2 injuries occur when you have a significant ligament injury that allows the ligament to excessively stretch. In most cases, these injuries result in a recovery period of 4 to 6 weeks. With increasing injury severity, the rehabilitation process becomes more complex and extensive.

All Grade 2 injuries should be thoroughly rehabilitated to enable:

  • full range of motion and strength
  • full proprioception, power, and agility
  • full return to sport-specific drills

Grade 3 – Severe

Grade 3 ligament injuries are when the ligament is completely ruptured. More severe ankle sprain injuries can also include fractures of the bones or high ankle sprains, which will require additional rehabilitation time to a simple lower ankle sprain.

The rehabilitation of a Grade 3 ankle sprain normally takes 6 to 12 weeks but is quite variable depending on your specific injury. Your physiotherapist or surgeon will be able to provide you with more specific guidelines and advice.

For more specific advice about your sprained ankle, please ask your physiotherapist.

Common Ankle Injuries

ankle pain
Sprained Ankles

The most common ankle injury is a sprained ankle, but ankle pain can have numerous sources.

Ankle pain that results from a traumatic injury is often a sports-related injury. But you don't necessarily have to be an athlete or even a social sportsperson to twist your ankle.

Something as simple as walking on an uneven footpath can cause a rolled ankle, resulting in an ankle sprain. Ankle injuries can potentially occur at any age. Thousands of people sprain their ankle every day around the world. Just while you've been reading this article, a few hundred people have sprained their ankle. While ankle pain can result from a large number of ankle and foot injuries, the most common ankle injuries are sprains (low and high ankle), which involve ligaments and bones in the ankle. But you can also fracture a bone, tear muscles or over-stress a tendon when you sprain your ankle.

High ankle sprains are generally a more significant injury. These injuries require thorough assessment and treatment to avoid long-term ankle arthritis. If you can't perform a single-leg calf raise within a few weeks of the injury, please seek an early professional ankle assessment.

Related links:

Ankle Fractures

An ankle fracture occurs when there is a break in one or more of the bones. The most common ankle fractures are avulsion fractures of your distal fibula, which can be a side effect of an ankle sprain. These are generally less troublesome than if you experience a talar dome fracture with your actual ankle joint. Potts fracture is a significant fracture of your tibia and fibula simultaneously. All suspected fractures require medical investigation and professionally managed by your health professional to avoid long-term foot and ankle issues. If your healthcare professional suspects an ankle fracture, you will be referred for at least an Xray and potentially to an orthopaedic surgeon. Related links:

Ankle Tendinopathies

While muscle strains are more common in your legs, there are important muscles which converge into tendons that wrap around your ankle to stabilise your ankle and foot to protect them from sprains and allow you to walk and run. These muscles and their tendon vitally provide you with a normal foot arch and avoid flat feet.

Your muscles or tendons can become injured or inflamed as a result of overuse or trauma. The inflammation is called tendonitis. They can also tear, completely rupture, or sublux out of place. Medically tendon injuries are known as tendinopathies, and at the ankle may include:

Ankle Arthritis

Your ankle pain and dysfunction can lead to degenerative conditions such as ankle osteoarthritis. While arthritis usually is a chronic deterioration of your ankle joint, it is crucial to slow the progression of ankle arthritis. Please seek the professional advice of your ankle and foot health practitioner, e.g. physiotherapist or podiatrist.

Biomechanical Conditions

Biomechanical disorders may result in foot deformation, painful weight-bearing and potentially nerve compression. In simple terms, this is where your foot and ankle do not have normal bone alignment and motion contr. Here are a few possible conditions related to poor ankle biomechanics.

Muscle Injuries

Nerve-Related Ankle Pain

Children & Youth Conditions

Systemic Conditions That Can Cause Ankle PAin

Soft Tissue Inflammation

Other Useful Information

What Happens If You Leave a Sprained Ankle Untreated?

While the sprained ligaments most commonly heal within 6 to 12 weeks, it is actually the functional disability that is important in the long-term for a sprained ankle.

Stiff ankles that do not regain their full motion have been shown to not only hamper your ability to descend stairs or point your toes, which may hinder your ability to swim or dance. Ideally, stiff ankles should be loosened to regain full range of motion.

Loose ankles will feel unstable and can render you susceptible to re-sprain and further ankle joint damage, which can increase your likelihood of degenerative arthritis. Wobbly ankles can normally be strengthened to dynamically control your ankle. Weak ankles fall into a similar bracket.

At the end of the day, there is rarely a simple ankle sprain that doesn’t have an ongoing functional impact. Professional rehabilitation guidance cannot only accurately assess your ankle, but also promptly correct any deficits while the ankle injury is in the youthful tissue healing phase. Chronic ankle sprains are always harder to treat due to scar tissue stiffness, established muscle weakness, or reduced proprioception.

High ankle sprains involve ligament damage to the stabilising structures supporting your two weight-bearing shin bones (tibia and fibula). High ankle sprain are a far more disabling ankle injury and are often misdiagnosed as a simpler lower sprained ankle. Failure to treat an unstable high ankle sprain can quickly destroy your weight-bearing ankle joint surfaces and result in ankle joint destruction. Joint destruction will be both painful and functionally disabling. This often results in ankle/foot surgery to either fuse your ankle joint or total ankle joint replacement.  Neither are perfect outcomes if prevention is an option.

For more specific advice about your sprained ankle, please consult your physiotherapist or foot healthcare specialist.