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Ankle Sprain and Instability

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Introduction

Ankle sprains are among the most common musculoskeletal injuries that present to primary care providers and emergency departments. In fact, they make up about 50% of all sports-related injuries. The term ‘sprain’ indicates an injury to the ligaments of the ankle, and is usually graded mild, moderate or severe based on the degree of ligament injury and ankle instability.

Ankle sprains may be associated with bone fractures (commonly to the ankle or the metatarsal of the 5th toe), injury to the ankle ligaments, or tendon tears. These injuries can lead to long-term ankle instability (feeling of looseness) and chronic pain. When severe and/or recurrent, ankle sprains can result in significant time lost to injury, missed athletic participation, and even long-term disability.

Certain sports may predispose an individual to ankle sprains and recurrent instability, which includes soccer, volleyball, and basketball, and high-demand activities such as ballet and dancesport. These activities are risk factors for ankle sprains as they are rigorous, involve physical contact, and result in high torsional forces at the ankles. Ankle sprains have been found to be the most common cause of missed athletic participation, and are the most common injury amongst dancers.

Additionally, some people have underlying risk factors for recurrent ankle sprains, such as generalised ligamentous laxity, abnormal foot shapes such as flat foot (pes planus) and high-arched foot (pes cavus), connective tissue conditions, and nerve conditions leading to abnormal sensation or weakness in the ankle.

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ankle sprain treatment Singapore - Oxford Orthopaedics
ankle sprains diagram

How do Ankle Sprains Happen?

Typically, ankle sprains are a result of inversion injuries, which happen when the ankle is twisted or rolled inwards with excessive force. This forces all the weight from the body onto the outer edge of the foot, which stresses the ligaments on the outer side of the ankle, and this in turn can stretch out the ankle ligaments and lead to tears. Eversion injuries, which happen when the ankle rolls outwards under excessive force, are less common but can likewise cause injury and chronic instability.

If not treated early, the ankle may not heal well, which can lead to recurrent ankle sprains and functional instability of the ankle, with progressive weakening of the ankle ligaments. Functional instability occurs when the ankle is easily turned in or sprained even with low impact daily activities such as walking and climbing stairs. This culminates in a sensation that the ankle is about to “give way”, especially when walking on uneven ground or rough terrain, and patients often feel that they have lost confidence and are unable to rely on their ankles. Patients can also develop recurrent pain and swelling around the ankle, which is worsened after every sprain.

Up to 30% of patients with acute ankle sprains may end up with chronic ankle instability, especially if they have had recurrent sprains, a high-grade ankle injury, or other medical conditions such as ligamentous laxity. Hence, it is important to seek early diagnosis and treatment.

The anatomy of the ankle

The ankle has 2 main motions: dorsiflexion (angling your foot upwards) and plantarflexion (angling your foot downwards, e.g. tiptoeing).  To aid in these movements, there are several ligaments that stabilise the ankle in both dorsiflexion and plantarflexion.

The 3 ligaments on the lateral (outside) part of the ankle are:

  • Anterior talofibular ligament (ATFL), which keeps the ankle joint from turning inwards (inversion) in plantarflexion
  • Calcaneofibular ligament (CFL), from turning inwards (inversion) in dorsiflexion
  • Posterior talofibular ligament (PTFL), which supplements the ATFL and CFL, and is rarely injured

As mentioned earlier, the most common mechanism of injury is when the ankle is turned inwards (inversion injury).  In over 90% of ankle sprains, the ATFL is the ligament injured, with the CFL being occasionally involved as well.

anatomy of an ankle

What are the symptoms of a sprained ankle?

The first few symptoms of an acute ankle sprain include pain, swelling, and bruising. For more severe sprains, the pain may even lead to difficulty standing up. Bruising and swelling are often the result of rupture of blood vessels around the ankle following soft tissue injury.

In addition to the early symptoms above, there may also be a feeling of chronic instability around the ankle following an acute sprain. Patients often report recurrent sprains and a feeling of ankle looseness. They also express a loss in confidence when walking on uneven ground or engaging in high impact exercises, and often have difficulties participating in sports and dance activities.

How are ankle sprains and instability diagnosed?

The diagnosis of ankle sprains is made by your doctor after a thorough history and physical examination of the foot and ankle. Radiological imaging of the ankle and foot are also routinely ordered to look for signs of other injuries.

The physical examination involves the doctor inspecting the ankle and feeling for areas of tenderness. The doctor will then move the ankle and apply stress in different positions to check on the integrity of the ligaments and tendons around the ankle. X-rays of the ankle and foot are usually obtained to rule out fractures and look for signs of cartilage injury (also called osteochondral lesions). Sometimes, an MRI scan may be needed for further evaluation of the ligaments and tendons, and to look for cartilage damage.

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Treatment

Typically, treatment of ankle sprains usually involves a short period of bracing and physiotherapy to promote early recovery. Early physiotherapy is important in restoring ankle range of movement, strength and stability, and can help to reduce recurrent sprains. Surgery is typically recommended if nonoperative treatment methods fail to relieve the ankle instability, pain or swelling.

The best results after ankle sprains come when treatment is started as soon as possible. The main principles of nonoperative treatment include: easing swelling and pain, enabling recovery of the ligaments and soft tissues around the ankle, and engaging in rehabilitative physiotherapy to allow for early mobilisation and quick return to physical activity.

The mnemonic ‘RICE’ is a simple way to remember the initial treatment strategy to help in recovery:

  • Rest - The initial immobilisation period typically involves a short period of weight-bearing immobilisation in a walking boot or cast.
  • Ice - Applying ice to the ankle can help reduce pain and swelling.
  • Compression - An elastic wrap can be used to provide gentle compression to the ankle, which can help reduce swelling.
  • Elevation - Supporting the ankle above the level of the heart is important in reducing swelling.

Certain medications may be prescribed by your doctor to help reduce pain and inflammation of the ankle during the early treatment period. Common drugs include paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs).

Once the initial pain and swelling have subsided, physiotherapy is prescribed for early functional rehabilitation.  Physiotherapy can help restore joint range of motion, strength, and overall ankle stability. Extensive research has shown that early physiotherapy and mobilisation facilitates faster and better recovery in patients with ankle sprains, with quicker return to physical activity.

Typically, ankle joint motion exercises are first prescribed during the first few physiotherapy sessions, before progressing to strengthening and activity-specific exercises for the ankle once the swelling and pain have subsided.

ankle sprain treatment in Singapore

A functional brace (orthosis) may also be prescribed during this period to control and prevent excessive inward and outward turning of the ankle during these physiotherapy sessions.  Patients should also refrain from wearing high-heel shoes and loose slippers during this period, as it may lead to further ankle instability and can hinder recovery.

In some patients with moderate to severe sprains, autologous plasma therapy may be recommended by your doctor to accelerate ligament healing.  Autologous plasma therapy utilises platelets from your own body to enhance ligament recovery and facilitate early return to sports.  As your own blood is used in autologous plasma injections, there is no significant risk of allergic or adverse reactions, and it is a safe and effective treatment for acute ligament injuries.

Surgery is typically recommended for patients who have ankle fractures, or who develop ankle instability and recurrent sprains that persist despite undergoing a period of rehabilitative physiotherapy.  Chronic injuries to the ligaments on the outer side of the ankle (lateral ligaments) is by far the most common cause of recurrent ankle sprains.

Conventionally, chronic ankle instability is treated with open reconstruction of the ankle ligaments (Brostrom-Gould technique).  During the operation, a 6 to 8cm incision is typically made over the injured ankle ligaments (most commonly over the outer aspect of the ankle), and the ligaments are repaired using stitches.  Although results are typically good, the main drawbacks of open surgery are skin complications and infection, significant pain and delayed recovery post-operatively, and unsightly scars along the ankle.

In view of this, arthroscopic ankle ligament repair (arthoscopic Brostrom surgery) has gained popularity in recent years.  This “keyhole” operation is typically performed using 2 or 3 small skin incisions (approximately 1cm each), and the repair is performed with suture anchors to fasten the torn ligament ends back to the fibula bone.  This arthroscopic technique has shown success rates comparable to open surgery, reduces skin complications and long scars, and facilitates early recovery.

A further refinement of the arthroscopic Brostrom technique has been the development of percutaneous minimally invasive surgery (MIS) Brostrom-Gould reconstruction of the ankle ligaments.  This minimally invasive surgical (MIS) technique employs the use of only a single 1cm incision on the outer side of the ankle, and the ankle ligaments are repaired by using a single suture anchor; the repair is reinforced by recruiting an adjacent band of tissue (called the extensor retinaculum) for additional strength.  This MIS method for reconstructing the ankle ligaments has been published as the “Lasso” technique, and has the distinction of achieving successful outcomes using only a single 1cm incision.

The MIS “Lasso” technique for percutaneous ankle ligament reconstruction results in minimal pain and swelling after surgery, facilitating rapid recovery and early return to high-level sports and dance activities.  In addition, the single 1cm incision minimises the risk of skin complications and infections, and leaves a scar that is often hardly visible.

In some cases, additional treatment may be recommended based on the presence of co-existing injuries to the cartilage in the ankle joint (osteochondral lesions) or to the peroneal tendons. Osteochondral lesions of the ankle joint, if significant in size and causing pain, may be addressed by ankle arthroscopic microfracture or retrograde drilling techniques to stimulate cartilage regrowth.  The risk of developing osteochondral injuries increases with every subsequent sprain, hence it is important to treat recurrent sprains early.  Peroneal tendon injuries may require a period of immobilisation in a walker boot and/or autologous plasma therapy injections to promote healing; in the most severe cases, the peroneal tendons may have to be surgically repaired.

ankle sprain healing timeline

How long does it take for a sprained ankle to heal?

Ultimately, the time it takes for a sprained ankle to heal depends on the severity of the sprain and how soon the patient seeks treatment. With proper rest (RICE) and rehabilitation, a mild ankle sprain will usually heal in several weeks. For more severe sprains, it may take approximately 3 months (or longer) of rehabilitative physiotherapy for healing and restoration of ankle stability.

Consult your doctor early if you suffer a sprained ankle that results in significant pain and swelling, so that your doctor can craft a treatment plan that best suits you. Early diagnosis, treatment and rehabilitation is crucial for rapid recovery, minimising the risk of chronic ankle instability, and avoiding long-term injuries to the ankle joint.

For patients who suffer from recurrent ankle sprains, modern minimally-invasive surgical (MIS) reconstruction techniques can allow you to return to activity and sports, with the benefits minimal pain, rapid recovery, low complication rates and a barely-visible single centimetre scar.

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