Whether you have done it on the sporting field or while on the dance floor on a Saturday night, an ankle sprain can be extremely debilitating and can become a chronic issue if not initially managed correctly. As a podiatrist, a sprained ankle (‘rolled ankle’) is one of the most common causes of foot problems that I see in clinical practice. The most frustrating thing about ankle sprains is that the re-occurrence rate is high, however preventable. The goal of this article is to outline the best treatment mechanisms that can be implemented to ensure that your ankle does not cause long-term problems.  

What exactly is an ankle sprain?

An ankle sprain is one of the most common musculoskeletal injuries and usually happens when an excessive amount of force is applied to either the lateral (outside) or medial side (inside) of the ankle joint. This force causes the foot to abruptly move in an inward (inversion) or outward (eversion) position (1).

Often the terms sprains and strains are used interchangeably. However, note that these terms refer to two slightly different pathologies. A sprain is a stretch or tear of the ligaments that hold two bones together. The term strain refers to a tear (complete or partial) to a muscle and or tendon (7). Most commonly, ankle sprains result in a sprain and strain to both structures surrounding the ankle joint (2). From here we will use the term sprain, but be aware that both ligaments and muscles/tendons are usually damaged.  

Although it is possible to sprain the ankle in either a lateral or medial direction, inversion ankle sprains are the most common. The severity of ankle sprains will depend on the amount of force that is applied to the joint. More severe ankle sprains can result in a fracture with a full ligament tear. In comparison, minor ankle sprains can lead to localised swelling and ligament stress (3).

Who gets ankle sprains?

Though anyone can sustain an ankle sprain, there are factors which lead to an increased risk of sustaining this injury. If you have suffered an ankle sprain it’s likely that you have done it more than once. Overall, studies suggest that the biggest risk factor for sustaining an ankle sprain is a previous ankle sprain (3, 4, 5). Therefore, if you have sustained an ankle sprain in the past, it's important that correctly manage and fully rehabilitate the injury to prevent a long-term problem.

How are ankle sprains treated?

The most common issue that I see in clinical practice with patients that have sustained an ankle sprain is that they don’t get it moving soon enough. Through research, we know that pain can be maintained through thought processes (8). It is easy to see how when experiencing a painful experience such as an inversion ankle sprain, that has left the ankle swollen and often bruised, we can come to the conclusion that the ankle is severely damaged. And studies have found that our thought processes of pain (e.g. damaged ankle) lead to pain and suffering (8). This conclusion may result in loss of confidence in weight bearing and leads to a time delay in starting the rehabilitation process. I am not suggesting that ankle sprains don't cause damage to the musculature and ligaments surrounding ankle and foot- because they often do. But the take-home message should be that once any serious ankle damage is cleared then early movement is vital!  

Type of training

Rehabilitation should be made up of a combination of strength and proprioception exercises. Proprioception refers to the perception of your body and position of your limbs in space. Our brains are always receiving feedback from specialised neurons called mechanosensory neurons. These neurons capture information about the amount of stretch and tension in muscles and send this information back to the brain (6). Unfortunately, ankle sprains can cause damage to these neurons, resulting in a decrease in proprioception (balance loss). Fortunately, studies have shown that we can regain the ability to improve our balance again following an ankle sprain. However, this may take time. This is the reason that both strength and proprioception training is required to restore full function and decrease the risk of injury re-occurrence.

Proprioception programs involve exercises that get more and more challenging throughout a 12-16-week program. Typically, these activities include single leg balancing progressing to single leg balance with eyes closed, single leg balancing on an uneven surface (such as a wobble board or pillow) then finally using the un-even surface to test your balance with eyes closed (2). The key feature is progressive overload; once you have adapted to one challenge, then changes are made to make the exercise more challenging. E.g. Once the weight becomes easy to lift, the weight increases.    

As with all musculoskeletal injuries, ankle sprains are frustrating but with an early management intervention strategy with an emphasis on getting moving early sprains can be easily overcome.

Keys to fully recovering following an ankle sprain

1. Seek treatment ASAP to rule out a more serious injury- biggest issue! No amount of balance training will fix a broken bone.
2. Early movement with or without pain: Movement= regaining full function, faster.
3. Balance and strength training: Progressive, continually challenge yourself.
4. Rehabilitation program with progression for at least 16 weeks: stick with it!  

Bibliography

(1)    Doherty, C., Delahunt, E., Caufield, B., Hertel, J., Ryan, J., & Bleakley, C. (2014). The Incidence and Prevalence of Ankle Sprain Injury: A Systematic Review and Meta-Analysis of Prospective Epidemiological Studies (Vol. 44). Sports Medicine.

(2)    Schiftan, G., Ross, L., & Hahne, A. (2015). The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: A systematic review and meta-analysis (Vol. 18). Journal of Science and Medicine.

(3)    De Noronha, M., Franca, L., Haupenthal, A., & Nunes, G. (2012). Intrinsic predictive factors for ankle sprain in active university students: A prospective study (Vol. 23). Scandinavian journal of Medicine and Science in Sports.

(4)    Kofotolis, N., Kellis, E., & Vlachopoulos, S. (2007, March 1). Ankle Sprain Injuries and Risk Factors in Amateur Soccer Players during a 2-Year Period. The American Journal of Sports Medicine, 35(3).

(5)    Beynnon, B., Murphy, D., & Alosa, D. (2002, Oct ). Predictive Factors for Lateral Ankle Sprains: A Literature Review. Journal of Athletic Training.

(6)    Woo, S.-H., Lukacs, V., Nooji, J., Zaytseva, D., Criddle, C., Francisco, A., . . . Patapoutian, A. (2015, Dec 18). Piezo2 is the principal mechanotransduction channel for proprioception. Nat Neurosci, 12, 1756-1762.

(7)    Merrick, M., & Gillette, C. (2017). The Effect of ICE on Intramuscular Tissue Temperature. Human Kinetics, 1-15.

(8)    Price, D. (2000, June ). Psychological and Neural Mechanisms of the Affective Dimension of Pain. Science's Compass, 1769-1772.