It was the end of a full day and I was carrying many things when I stepped on the edge of the sidewalk, my foot twisted sideways over the edge and boom, down I went. So with a scraped bloody knee and throbbing pain in my ankle, I sat for a moment and was inspired to blog. Once the nausea eased up, I cleaned up and bandaged my knee and iced my ankle. After icing, I diagnosed myself with a lateral grade 1 ankle sprain. Phew, nothing major.
An ankle sprain happens when you quickly over stretch the ligaments and tendons around your ankle. The most common ankle sprain is a lateral or inversion ankle sprain when one lands on the outside of the foot as I did. The classic ankle sprain involves the anterior talofibular ligament (ATFL) and sometimes the Calcaneaofibular ligament.
Ankle sprains are divided into three levels of injury:
Grade 1- Over stretched ligaments but not torn. People may be able to walk with out pain but it hurts to stretch or touch the area associated with minor swelling.
Grade 2 – Ligaments partially torn, swelling and pain to touch or stretch. People return to normal activity in 10-18 days depending on the activity.
And
Grade 3 –A fully torn ligament which could be combined with a fracture as well. Often people experience extreme pain and cannot walk. Often requires crutches and sometimes a boot. Medical intervention is recommended to rule out a dislocation, syndesmosis (injury to a ligament that connects the tibia and fibula) or a fracture.
If you have pain in the midfoot or bone tenderness at the fifth metatarsal (outside midfoot) or at the navicular bone (inside midfoot), or inability to bear weight for four steps, an x-ray is indicated.
Most people heal without medical intervention. The standard of care is to get rid of swelling with P.R.I.C.E. Protection, Rest, Ice, Compression and Elevation. This will greatly decrease the pain. Protection avoid hitting it or re injury to the ankle by using protective tape, bandage or brace. Rest the ankle and don’t perform anything that causes pain or puts the ankle at risk for re-injury. For example, If jogging doesn’t hurt start jogging short distances, use an ankle support and run on even surfaces or predictable routes you know well. Of course, if jogging does hurt, continue to rest and stick to walking or a non-painful activity. Ice with frozen veggies or a plastic bag with ice cubes and some water 15-20min. There are fancy ice packs out there but often not necessary. For Compression have a trainer or physical therapist tape your ankle or the local pharmacy probably has an ankle compression stocking. An old pair of tight hose or dress sock may do the trick if tight enough. Elevate by putting your foot up on a comfortable surface.
After PRICE if still painful and once the swelling is down, a medical practitioner will do ligament testing to make sure the ligaments are intact. There is much evidence to suggest that for lateral ankle sprains a short period of protection and early weight bearing should be followed by range of motion and neuromuscular training ASAP. Early functional treatment leads to the fastest recovery and least rate of reinjury.(2)
The risks for an ankle sprain are: a previous ankle sprain, weak ankles, shoes that are too small or worn down on one side, uneven sidewalks, sports that require side to side shifting (tennis, foot ball, basket ball…) and fatigue.
In order to prevent ankle sprains wear shoes that fit and aren’t worn out. The general rule of thumb is to replace sneakers every 6 months or alternate two different pairs over a years time. If you are very athletic you will need to replace your shoes more often or have more pairs, if you are less athletic or exercise bare foot (yoga, Pilates, GYROTONIC® exercise) then your shoes will last longer.
Keep in mind a previous ankle sprain puts you at risk for future sprains in the same ankle and in the other ankle. (1) It is important to re-train and strengthen your ankles.
Here is a program to prevent initial injury or to prevent re-injury. Many of these exercises will also be given in physical therapy to rehab an ankle sprain.
Ankle mobility:
Circles – For range and mobility put your foot up on a stool and circle the ankles in both directions. 5 slow large circles in each direction. Progress to circling your foot in a bucket of sand or rice.
Alphabet – For more of a challenge and to increase endurance draw the alphabet with your foot. Make big letters and perform exercise on both sides.
Retraining Balance – Stand on one foot, eyes open. Repeat with eyes closed make sure there is something to grab and prevent falling.
Repeat on pillow – To challenge your balance more, stand on pillow (uneven surface) first with your eyes open. Progress to closed eyes (make sure you are in a safe environment to prevent falls). Your ankle should fatigue with this above exercise. Your body is re-learning how to correct and weight shift to right your self and maintain balance.
Dynamic Balance-
Stand on the floor, on one foot and bend knee and hips to pick up an object from the floor.
To increase the challenge repeat on pillow. Make sure pillow is on a surface where it wont slide.
Repeat on thicker/higher pillow
Keep in mind a loss of balance is good for retraining the ankle and motor control centers to improve balance, falls are not. Choose an appropriate exercise to challenge your current level of coordination and balance.
Calf and ankle stretch and strength:
Eccentric Calf raises – On a step rise up to toes and slowly lower down, hold stretch, repeat rise up slowly lower down.
Theraband inversion and eversion – this is exercise is to strengthen the muscles and tendons around the ankle.
Wrap band around outside of working foot and under non working foot, hold band. Press working foot (in this picture the right foot) into band until muscle is felt on outside of ankle and shin. Start with 5 reps 2 sets and build to 10 reps until strength is restored.
This is a closer photo of the eversion exercise to strengthen peroneal muscles around were the ligaments were over stretched during the injury.
Directions wrap band around outside of working foot and under non working foot, Press top working foot into band until muscle is felt along inside of ankle and shin. start with 5 reps 2 sets and build to 10 reps until strength is restored.
Myofasical release/massage:
Take care of your feet massage them with lotion or oil and wiggle your toes.
Take good care of your feet. They are important for many daily activities including balance! Your ankles have a direct link to areas of your central nervous system responsible for knowing where you are in space so keep them happy.
Warmly,
Dr. Justine
1) Int J Sports Phys Ther. 2014 Oct; 9(5): 583-95.
Injury risk is altered by previous injury a systematic review of the literature presentation of causative neuromusclar factors.
Fulton J, Wright K, Kelly M, Zebrosky B, Zanis M, Drvol C, Butler R
2) Ortho Rev (Pavia). Jan 2, 2012; 4(1):e5.
Diagnosis and Treatment of acute ankle injuries: development of an evidence-based algorithm
Polzer H, Kanz K, Prall W, Haasters F, Ockert B, Mutschler W, Grote S.
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