Have you ‘twisted’ your ankle playing sport?
Is it now swollen, bruised and sore to walk on?
Did you go to A+E and get told you have no fracture and you should be better after 3 weeks but are still limping and in pain?
What is an ankle sprain?
An ankle sprain occurs when the bands of tissue that hold the bones of your ankle together (ligaments), get forced beyond their zone of load tolerance and become damaged. The level of damage depends on the extent of the trauma and will consequently also influence the length of recovery.
- Grade 1:
The least damage occurs with a grade 1 sprain, which affects 1 or 2 ligaments. There can be minor swelling and pain, and sometimes a small amount of bruising and stiffness in the ankle. You will be able to weight bear (ie, put your full standing weight on the injured ankle).
- Grade 2:
Significant swelling and bruising develops. Weight bearing can often seem difficult to begin with but is possible. You are likely to walk with a limp. The ankle often feels unstable and vulnerable and depending on your daily activities and recovery goals, you may need an Aircast boot to ensure optimal ligament healing in the early stages.
- Grade 3:
This often involves a complete rupture of 1 or 2 ligaments and is often affiliated with bone bruising or fractures in more severe cases. Cartilage damage can also occur when significant force has been involved in the trauma. Imaging (ie. an x-ray) will be essential to confirm the extent of the damage and whether surgical intervention is required.
There are suggested time scales of recovery for the basic ankle sprain but I think we are all guilty of thinking we heal faster than the average person, and this is why I so commonly see people battle a ‘dodgy’ ankle for years! Pain, swelling and range of movement has to be restored in the early stages but there are many other factors that need to be considered before return to sport! Muscle patterning and joint proprioception (the ability to know where your joint is in space) are severely affected when you sprain your ankle no matter how mild the injury seems, and this must be restored. As the ligaments heal, new bonds are formed within the damaged tissue and these strengthen according to the loads we put across them. This is why progressive loading is essential. Your ability to walk pain free and limp free does NOT mean that the ankle can tolerate the high multidirectional forces applied to it during a game of football or tennis or even a 10K run! It is not rocket science. For some reason we ‘hope’ we will get away with it but believe me: the fastest recovery is the right one!
When should I be concerned?
- If you can not put any weight through your foot or ankle then this must be investigated.
- You may have been to A+E, had an X ray and been told you have no bony injury but are still struggling to weight bear 3-4 days later and pain is failing to ease or is worsening. At this stage I would still be concerned about other structural damage to the foot or ankle. Further investigation is warranted – this may be in the form of an MRI or other imaging. A specialist opinion is important to ensure the right investigations are ordered.
- Night pain or pain at rest. Offloading an injury should ease pain and certainly shouldn’t wake you at night. When a patient reports these issues to me it will make me question if we are dealing with a basic ankle sprain.
- The average, low grade ankle sprain takes AT LEAST 4 weeks to recover from if done right. If you are struggling past this time scale invest in a professional opinion.
- If you like to keep fit and active then any injury tends to cause concern. Do not ignore it. Seek a professional opinion, recover the right way and return to training the fast way.
COMMONLY MISSED INJURIES
- Syndesmosis Injuries:
This syndesmosis injury is a high ankle sprain and it involves the ligaments that bind the tibia and fibula (2 bones in your lower leg) above the ankle joint. The mechanism of injury often involves excessive external rotation of the foot and extreme dorsiflexion i.e. as the foot and ankle are forced up and out, often with the foot firmly planted on the ground. It is more difficult to diagnose than the standard lateral ankle sprain and is often missed leading to protracted recovery time.
Common signs and symptoms can include an inability to walk or hop, pointing the foot and ankle down (plantarflexion) is restricted and pressure around the bottom of the shin can be acutely painful.
If you suspect that this was how you injured your ankle, you are finding that you are not recovering as fast as you expected, are struggling to weight bear and the pain is more around the front and top of the ankle this may be the injury you have sustained.
These can be troublesome to treat and may need a period of offloading or in worse cases surgery, so be sure to get this looked at as early as possible to ensure the best recovery and fastest return to sport.
- Avulsion ankle injuries
Some ankle injuries involve such substantial force that the ligament damaged pulls a small piece of bone away from its attachment. Again, further investigation is necessary often in the form of an X ray or MRI, and though symptoms can be similar to the standard ankle sprain, return to full weight bearing can be delayed and pain can be prolonged.
As mentioned above, sports injuries can often involve huge forces. Multiple tissues are affected i.e. ligaments, muscles, tendons and often bone! Bones can become severely bruised or in some cases will fracture. If patients have localized, acute pain over bone it is a fracture unless proven otherwise and though further investigation can seem tedious and expensive isn’t it best to know what the injury is at the earliest possible time so you can manage your treatment and expectations accordingly? Be wary of you’re A+E x rays as I have seen many patients who have been told they have no bone damage only to find out the this is not the case at a later date when they have more detailed investigations in the form of a CT or MRI. Some fractures are also difficult to see unless you know what you are looking for and if missed delayed bone healing can be hugely problematic.
- Osteochondral defects
If you imagine your bone is like a malteaser then the chocolate represents the articular cartilage that lines the bone. Ankle trauma can often result in a focal area of this chocolate or articular cartilage being chipped away leaving the bone exposed and vulnerable to the loads applied to the joint. Locking and catching in the ankle can be common symptoms as well as restricted mobility and soreness when walking on the joint. Though rare it is important to pick them up to avoid further joint damage. Common treatment involves a period of immobilization and graduated mobility and strength programme but in some cases surgical intervention in the form of excision and microfracturing can be necessary to preserve the joint in the long term.