The Facts About Ankle Sprains
This article is neither meant to replace nor act as medical advice. It is merely presenting supplemental information to help you understand your injury and the safe return to play process. Please consult an athletic trainer, doctor, or other qualified medical professional for individualized information and treatment program.
this article's timeline is geared towards a young (less than 25) athlete. With an increase of age comes the increase of time required before entering the next phase.
The Quick View
- The ankle is a complex joint with many bones, ligaments, and tendons.
- A sprains and strains are graded either 1, 2, or 3.
- Sprains only happen in ligaments.
- Strains only happen in muscles.
- Rehab is simple but very important.
According to the American College of Sports Medicine, "an estimated 25,000 Americans suffer an ankle sprain each day." It's safe to assume that most people have suffered an ankle sprain, specifically athletes. These ankle sprains can range from minor annoyances to devastating setbacks in an athletic season. As a certified athletic trainer, ankle injuries are the most common injury I see on a daily basis. Unfortunately, ankle sprains are often inadequately treated leading to recurrent injury.
Anatomy of the Ankle
Overall, the ankle joint is more complex than most people assume. Remember, there are doctors who specialize their career with the lower leg and foot: podiatrists. Here is a brief, simplified ankle anatomy lesson.
Bones of the Ankle
The four bones that make up the ankle joint and are as follows:
- The tibia. This is your shin bone and make up the medial malleolus (the bump on the inside of your ankle).
- The fibula. This runs along the lateral aspect of the lower leg and mostly covered by muscle. It ends as the lateral malleolous (the bump on the outside of your ankle).
- The talus. This bone makes up part of the true ankle joint. If you plantar flex (point your toes to the ground) you can feel where the talar dome comes to the surface.
- The calcaneus. The is the bone that makes up your heel. the talus sits directly on top of this bone.
Anatomy of the Ankle
Ligaments of the Ankle
Several ligaments add stability to the ankle joint and are as follows:
- Anterior (front) & Posterior (back) inferior tibiofibular ligament. These ligaments help keep the tibia and fibula from separating when weightbearing. A high ankle sprain occurs when the anterior inferior tibiofemoral ligament is sprained.
- Anterior talofibular ligament. This ligament helps to prevent the foot anteriorly shifting (sliding forward) relative to the lower leg.
- Calcaneofibular ligament. This ligament assists with preventing excessive inversion (rolling your foot in).
- Posterior talofibular ligament. This ligament helps to prevent the foot from posteriorly shifting (sliding backwards) relative to the lower leg.
Muscles of the Ankle
Many different muscles act upon the ankle. The most important ones are as follows:
- Tibialis Anterior. The main motion that this muscle does is dorsiflexion (bringing your toes up towards you). This muscle contributes to other motions and other muscles contribute to dorsiflexion.
- Tibialis Posterior
- Peroneus (Fibularis) Longus & Brevis
Grade 1, 2, or 3 Ankle Sprain
Ankle sprains, and really any sprain is graded from 1 to 3.
- Grade 1 ankle sprain generally is a mild stretch of the ligament. There is no significant amount of swelling or discoloration with this type of sprain. An athlete can generally play through this type of sprain but it is recommended that you take at least one day off.
- Grade 2 ankle sprain involves a partial tear of the ligament(s). There is a noticeable amount of swelling and discoloration. Walking is painful and participation in sport is highly doubtful.
- Grade 3 ankle sprain is a complete tear and generally involves multiple ligaments. Swelling is prominent and discoloration is significant. Walking is not recommended. Crutch walking is highly encouraged at this point. X-rays may be needed to rule out a fracture.
Rehabing an Ankle Sprain
All stages can vary in length of time based on the severity of the injury, personal physiology, and the aggressiveness of the treatment. In general, I tell my athlete that it will be about a week before they can return to play and at least two weeks before they are close to feeling one hundred percent. It's important to give the healing process the time it needs. There is little one can do to change the length of this process. The following exercise can supplement this process and leave the athlete in a much better position to return to play at a competitive level.
All exercises should be completed pain free. There may be some discomfort but none of the exercises should increase pain. Increasing pain increases the time it takes to return to play.
Writing the Alphabet
A simple exercise I give to my athletes on the day of the injury involves them writing the alphabet with the ankle/foot. The key to this exercise is to have the motion come from the ankle and limit the "cheating" from the knee and hip.
The goal with this exercise is to help the lymphatic system remove the swelling. The lymphatic system is a passive system that uses the surrounding muscle move the lymph.
This is the second exercise I like to give to my athletes. Again, the goal here is the same as the alphabet. We are trying to limit the swelling. Too much swelling can cause secondary injury resulting in a delayed return to play.
4 Way Ankle
Four Way Ankle Exercise
Generally, on post injury day two I will give the athlete them the four way ankle exercise. The early goal of this exercise is two parts. The first part is to continue to reduce the swelling. The second part is to restore the range of motion with a little resistance.
The second goal of this exercise is to increase strength through the entire range of motion.
Body Weight Exercises
Body Weight Activity
The next step is to begin with bodyweight exercises. Simple two legged body weight squats are great from working the ankle more than it has been while still offering the safety of having the second foot on the ground in the event you might start to feel pain. The goal here is to increase strength and resume normal weight bearing.
Eccentric Calf Exercises
Eccentric Calf Exercises
Eccentric exercises are great during any injury. The allow the joint to go through the full range of motion with little to no pain. Eccentric exercises are not very common in a typical gym setting. An eccentric exercise is when the muscle slowly lengthens. A concentric exercise is very common. This is when the muscle shortens to move a weight. An example of a concentric motion would be a bicep curl. The eccentric motion would be the slow lowering of the weight.
With the eccentric calf exercise, you would stand on the edge of the step and lift yourself up with both legs. Next you would slowly lower yourself down with the injured leg. I tell my athletes to repeat until fatigue and not to push through any pain.
Regaining balance after an ankle sprain is incredibly important. When you injure any joint you also damage the proprioceptors. Proprioceptors are little nerve endings that send signal to your brain that constantly give you information about that joint's position.
The first phase of balance exercise involves standing on one foot on a solid surface. This can be standing barefoot on tile or hardwood floors. Once this becomes easy, you can close your eyes to increase the difficulty. The next step to increase difficulty would be standing on an unstable surface like a pillow or an Airex. Again, after that becomes easy, you can close your eyes to increase difficulty. To increase difficulty you can make the surface more unstable by standing on a dynadisc.
The final step in rehabbing the ankle is the plyometric step. This step builds on all the little blocks of the previous steps together. You utilize strength, balance, and coordination in a proper plyometric move. Plyometrics can include using a speed ladder, plyo boxes, most jumping exercises, and many other moves. Many examples can be found the lower body dynamic warm-up article.
In conclusion, rehabbing an ankle or any other injury takes time. If you try to rush it and cut corners you are just setting yourself for failure. Worse, you could be setting yourself up for a delay in returning or a more significant, severe injury.
Remember, it's better to miss a week or two now rather than a month or two when the season really counts.
Hertel, J. (2002). Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. Journal of Athletic Training, 37(4), 364-375.
Starkey, C., Brown, S. D., & Ryan, J. L. (2010). Examination of orthopedic and athletic injuries (Ed. 3. ed.). Philadelphia: F.A. Davis Co..