The scenario is very common. Whether it be from uneven ground, falling from a stair or from participation in a sporting event, “rolling” the ankle is actually a ligament tear. Approximately 20,000 ankle “sprains” occur each year. The term ‘sprain’ is a misnomer. What really occurs is that the ligaments that stabilize the ankle tear and are disrupted. This results in pain, swelling, bruising and most likely a limp.

Physiology

Usually, the ankle inverts or rolls inward. Less commonly, the ankle can evert or roll outward. Nonetheless, if the severity is enough, the ligaments that normally stabilize the ankle are disrupted. The more severe the ligament disruption, the more the swelling, pain and limping. There are 3 ligaments on the outside or lateral aspect of the ankle and 1 large ligament on the inside of the ankle that normally provide stability. The more severe the injury, the more ligaments that can be injured.

Treatment

Initial treatment consists of RICE. Resting the ankle, applying Ice, a Compression wrap and Elevating the extremity is helpful as initial treatment. It is important to reduce the swelling as this results in a feeling of tightness, pain and a loss of motion.

With more mild injuries, symptoms can improve over a few days allowing weight-bearing. With more severe injuries, bearing weight may not be possible initially. With these more severe injuries, evaluation is needed and radiographs can be obtained to exclude a fracture. If weight-bearing is difficult, crutches can be helpful to offload the affected extremity. Additionally, a boot brace can provide support and stability allowing earlier weight-bearing and mobility.

There are 2 goals with initial treatment. These 2 objectives would be initiated and performed when the initial pain and swelling have been reduced. This may take from a few days to a week. The 1st goal is to improve motion. Some people like to perform up/down movements and circular movements of the ankle. Another useful way to regain motion is for the great toe to draw letters of the alphabet. Achieving normal motion is essential to achieving proper function of the injured extremity.
The 2nd goal is to normalize gait. The goal would be to walk without a limp. Again, crutches and a boot may be useful in order to accomplish this.

Once walking has been normalized and motion has been improved, the crutches can be discontinued. The boot can be taken off to bathe, sleep, shower and perform the exercises above. If possible, anti-inflammatory medication can be utilized in the 1st week to reduce swelling and pain.
Depending on the severity of the injury, crutches are usually used for the 1st week and the boot is used for the 1st month.

Once the 1st 2 goals have been reached, treatment revolves around strengthening and regaining stability of the ankle. It should be noted that swelling can take up to 3 months to fully resolve. It is not so important that swelling is present, but that swelling improves on a weekly basis.

At this point, rehabilitating the injured ankle is very important as up to 20% of ankle sprains can lead to “instability”. This occurs when the ligaments heal in a “stretched out” position. This can result in pain and a feeling of looseness or giving way in the ankle which can impede progress and future function of the ankle.

Strengthening of the ankle can involve resistance training with the use of a band and will help to limit the loss of muscle bulk and function while the ankle is healing. It may be appropriate at this point to seek evaluation from a healthcare provider as to whether this rehabilitation can occur at home or whether formal physical therapy is needed. Full strengthening of the ankle may take up to 1 month to regain full muscle tone.

Next, the 3rd phase of rehabilitation will begin. This involves regaining stability of the ankle. This can occur on the patient’s own training with appropriate direction or involve the use of a qualified physical therapist. The goal is to regain one’s balance with subsequent progression to sport-specific activities. This may involve the use of single-leg activities such as step-ups or training on a tilt board to simulate cutting and twisting and uneven ground. Additionally, an agility ladder or cones with specific exercises can be utilized. This phase can take up to 1 month to regain proper stability of the ankle and limit the possibility of future injury.

At this point, the patient/athlete should be tested to simulate possible future demands of the ankle such as sporting events or walking on uneven ground. This can involve rapid cutting or twisting, jumping and/or pivoting which would simulate the future demands placed on the ankle.

Once the ankle has healed sufficiently and a return to sports is contemplated, it is generally recommended that the ankle be taped or braced for 1 month while returning to normal activities. Care should be taken with uneven ground and pivoting sports due to the increased stress placed on the ligaments.

Most initial ankle sprains heal uneventfully if the rehabilitation is properly followed. However, as mentioned, if the injury is neglected, and the ligaments heal in a “stretched out” position, instability may occur in the future.

Complications

As mentioned, ankle instability occurs in approximately 20% of patients who have had an initial ankle ligament tear. On the contrary, ankle stiffness, and limited movement, is usually the result of inadequate rehabilitation.

Ankle instability presentation

The ankle can give way, feel loose or give out when cutting or twisting, even with the slightest amount of stress while pivoting. Repeated injuries are to be avoided because cartilage damage in the ankle joint can occur with repeated giving way events. This may lead to small chip fractures called osteochondral lesions or may lead to stress on the tendons that also provide support to the ankle and result in tearing. The problem with these sequelae of ankle instability is that they do not heal and may result in ongoing dysfunction in the ankle and lead to future degenerative changes, i.e. arthritis.

Ankle instability treatment

If the ankle is found to be unstable, an initial course of formal physical therapy and brace wear can improve function and allow the patient to return to their sought-after activities. However, should this form of conservative treatment fail, surgical intervention can restore the ankle to normal or near normal function.

Surgical intervention is considered for patients that have recurring ankle instability events or chronic pain from loose ankle ligaments. An orthopaedic or podiatric evaluation would be recommended to confirm the diagnosis and assess the ankle for other injuries such as those mentioned above.

Ankle instability surgical treatment

Surgical treatment revolves around restoring normal anatomy. This usually consists of an ankle arthroscopy. This is when a camera is placed into the ankle to assess the joint surfaces and soft tissues for any damage is found. Any abnormality can be treated during this assessment.

Restoring the ligaments usually revolves around a “tightening” procedure. This is called a lateral ankle ligament reconstruction or if on the inner side, a medial ligament repair/reconstruction. If the ligaments are in a relatively sound condition, they can simply be ‘reefed’ or imbricated to restore the native/usual tension. At times, a synthetic strong suture is used for reinforcing these ligaments and allowing a faster rehabilitation. With some patients, the ligaments are too thin to “repair” and need to be augmented with a tendon graft. All of these procedures have the goal to restore the normal tension in the ankle ligaments.

The rehabilitation following surgical procedures for ankle instability occurs similarly in the above-mentioned phases. That is, an initial phase of swelling reduction and ankle motion return. This would be followed by gait training and strengthening. A stability program and return to sports is the final phase of the rehabilitation process.

In general, surgical treatment for ankle instability has a very high success rate of around 90% in allowing patients to return to their previous activity level. There is a rehabilitation time required following the procedure, however, results have been excellent in most cases.

The most important part in a discussion of ankle injuries is to properly rehabilitate even the mildest ankle “sprains” initially, in order to limit the possible long-term adverse effects.

Dr. Christopher Stroud specializes in Orthopaedic Surgery, and is board certified by the American Board of Orthopaedic Surgery. He received his medical degree from Wayne State University School of Medicine in Detroit, Michigan, and completed his residency at the Detroit Medical Center.

Dr. Stroud has also completed his fellowship in advanced training in Foot/Ankle at the Medical College of Wisconsin. His clinical interests include foot and ankle, arthritis surgery, deformity correction, sports related injuries, cartilage repair techniques, arthroscopy.

Dr. Stroud is affiliated with Corewell Health (FKA Beaumont Health) Troy, and performs outpatient procedures at Oakland County’s premier surgical facility, UnaSource Surgery Center.

Learn more about Dr.Christopher Stroud here and learn more about his practice Southeast Michigan Center for Orthopedics.