Lateral Ankle Sprains

The body’s joints get their static and dynamic stability through a combination of bony architecture, tightness and orientation of ligamentous structures (ligaments and the joint capsule), and muscular contractions. The amount of a joint’s stabilizing forces coming from each of these factors at any given time is dependent on the specific joint and the current position of that joint. Joints are most stable when the majority of the joint’s stability comes from the bony architecture, and they are often least stable when the ligamentous structures are left to contribute the most to the joint’s stability.

The ankle joint is most stable in a combined position of dorsiflexion (lift up your toes and front of your feet so you can walk only on your heels) and eversion (try to “aim” the soles of your feet as far away from each other as you can without rotating your legs) and least stable in a combined position of plantarflexion (point your feet and toes) and inversion (soles of the feet turned toward each other).

In the position of plantarflexion and inversion, the ankle’s stability comes primarily from its ligamentous structures. This means that if the ankle joint is stressed while in this position, the ligaments are the only structures that can resist these potentially injurious forces. The ligaments on the lateral aspect (“outside”) of the ankle are most at risk in this position because of the bony anatomy of the ankle joint. One of the three lateral ankle ligaments is pulled tight when the foot is fully pointed, and, therefore, is particularly susceptible to becoming injured.

One thing to note: tightness in the calf muscle group and/or Achilles tendon increases the risk of suffering a ligamentous injury like an ankle sprain. This is because the tight musculotendinous complex pulls the foot into a more plantarflexed position (remember, this is a less stable position), making the ankle more vulnerable to lateral ankle sprains.

Causes of Lateral Ankle Sprains

The most common mechanism of injury affiliated with lateral ankle sprains is an inversion mechanism. This is the technical term for “rolling” the ankle. Inversion of the ankle can happen when landing badly from a jump (either landing incorrectly or landing on someone or something), being stepped on (on the inside of the ankle), planting the foot to change directions quickly, or losing control while balancing or spinning on one leg.

In Performing Artists

Landing improperly and falling off of the leg are the two most common causes of lateral ankle sprains in dancers. Performers who must wear high heels on stage are at an added risk of spraining their ankles if they trip or fall while wearing these shoes. Marching band members are most likely to sprain their ankles while marching on uneven surfaces, like torn-up grass football fields with large clods of dirt/grass or big divots in the playing surface. Parades present their own challenges to performers, putting band and color guard members at risk of foot and ankle injury in the form of curbs, trash or giveaways from people ahead of the band in the parade, and uneven pavement or manhole covers in the street.

Re-injury

Roughly three quarters of people who have a moderate or severe ankle sprain (grade 2 or 3 sprain) will have an ankle sprain again in the future. Over half of the people who have a second ankle sprain note a residual decrease in physical performance. Among the factors that make someone more likely to have an ankle sprain are decreased muscular strength, a lack of muscle coordination, and decreased proprioception (the body’s ability to sense its spatial orientation and movement within its joints). All three of these factors are commonly found in people who have had multiple sprains of the same ankle.

Signs and Symptoms

The severity or intensity of the signs and symptoms associated with lateral ankle sprains varies based on the severity of the injury and the type of tissues that have been injured (Was just ligamentous tissue injured, or has the joint capsule been torn, too? Were any nearby tendons, nerves, or blood vessels injured, too?).

The most common signs and symptoms are:

• Feeling something tear or pop
• Pain centered around the ligaments on the lateral aspect of the ankle
• Tenderness over the injured ligament(s) (it hurts when you push on it)
• Pain with inversion or plantarflexion
• Swelling over the lateral aspect of the ankle
• Dysfunction of the ankle joint
• Limited range of motion

Since some of the ligaments that can become injured in a lateral ankle sprain are a part of the ankle joint capsule, the capsular tissue can become torn, too. This may produce rapid swelling throughout the ankle region.

One thing to keep in mind: if you sprain your ankle and you get some bruising, it’s completely normal for that discoloration to end up creating a “black line” along the side of the bottom of your foot within a few days (in fact, if you do an internet image search for “ankle sprain” you’ll see quite a few photos of this phenomenon). This line is simply the result of gravity.

At-home Treatment

***Be sure to see the section below about deciding when to go see the doctor and don't start self-treating your injury until you are certain that you do not have a bony or neurovascular injury.***

Regardless of the severity of the injury, all ankle sprains need to be rehabilitated in order to reduce the risk of re-injury upon return to activity.  Here are some simple steps to take to facilitate healing and limit further injury.

Let’s start with a very well-known injury treatment plan: RICE. This stands for Rest, Ice, Compression, and Elevation.

The rest limits further injury, reduces swelling and pain, and facilitates healing. Ice application reduces the amount of swelling your body is producing at the time you apply the ice. This can help limit excessive swelling that impedes healing. Compression does NOT mean that you should squeeze the heck out of your foot and ankle. When it comes to applying compression after an acute injury, an elastic bandage has enough elasticity in it to apply adequate compression with only a little stretch put on the bandage during application. If the bandage is stretched all the way before you put it on, it will end up squeezing your injured ankle WAY too much and it will be really uncomfortable; in fact, it can even restrict or cut off blood flow to your foot and toes, leading to tissue death. Elevation is used to limit the effect of gravity on the swelling that your body produces in response to injury. When the ankle is in a gravity-dependent position (below the rest of your body, like it usually is), it is significantly harder for your body to get the damaged cells and swelling out of the injured area. Keeping the ankle above the level of your heart by laying on the floor with your lower leg on the seat of a chair or the couch is one way to elevate your ankle while you are resting and/or icing.

As soon as you can do small arcs of motion without ANY pain, you should do so. Starting range of motion exercises early in the injury rehabilitation process decreases pain and swelling while increasing range of motion. Over time, increase the range of motion until you are returned to full pain-free motion in all directions.

Generally, when weight bearing is not painful and you have full pain-free range of motion, you can start strengthening and balance exercises. If you’re doing these exercises with pain (even a little bit) or restricted range of motion, you will likely end up doing them improperly. This can lead to further injury or the development of bad technique and movement patterns. If you can perform these strengthening and balance exercises correctly for a few days with no pain or setbacks, generally speaking, you can return to restricted activities (no jumping, cutting, or any other activities that put you at risk of inverting your ankle). When you return to your activities, you need to make sure that you have a really good warm-up, targeting your injured ankle and going beyond any warm-up you may have as a part of your rehearsal.

When to go to the emergency room or see a doctor

Go to the emergency room or see your doctor if any of the following situations applies to you.

Right after the injury

• If you can’t bear weight for at least 4 steps
• If you can’t feel any part of your foot, ankle, or lower leg, especially along the outside (lateral aspect) of these body parts
• If the majority of your pain is over the attachment site of the ligament, instead of over the length of the entire ligament, this may indicate an avulsion fracture
• especially when accompanied by a creaking or grinding sensation (crepitus)
• If you are extremely point tender (it hurts when you push on it) over:
• the back half of the bone on the lateral side of your ankle (distal fibula aka lateral malleolus) or
• the bone on the lateral aspect of your foot (5th metatarsal), especially the part of this bone that is closest to your ankle
• If one or more of the muscles in your lower leg or foot aren’t working properly
• If you have extreme point tenderness over the bottom of the bone that sticks out on the inside (medial aspect) of your ankle (medial malleolus on the tibia)

After you've been treating the injury for a while

• If your symptoms don’t start to get better or start to get worse during the first week after your injury (and you didn’t do anything to hurt it again)
• If you still have pain over the bony landmarks mentioned above after all of your other pain has gone away
• If you are pain-free during your strengthening and balance exercises, but your symptoms return when you return to activity
• If your pain or other symptoms get significantly worse at any time of your recovery or return to activity if you haven’t re-injured it