Ankle Sprain
Among the most common injuries, an ankle sprain certainly ranks high: in Italy alone, about 10,000 cases occur every day.
It is primarily one of the most frequent traumas among sports practitioners, even at an amateur level. Indeed, an ankle sprain can happen after either a sporting or recreational run.
However, this injury is also common in everyday life, between high heels and recreational activities.
We have defined an ankle sprain as follows: [...] it is a temporary loss of contact between the two joint surfaces forming the ankle, with possible associated injury to the ligaments and articular cartilage.
Although very common, one should not make the mistake of underestimating it or failing to treat it with proper care.
The ankle sprain, or “twisted foot” as it is commonly called, can manifest with various levels of severity and, depending on these, the trauma will require a different intervention for optimal resolution.
Especially in cases where the sprain is mild, it may happen that the patient does not recognize it as such and, despite feeling pain, does not take the correct measures to address the injury.
Therefore, we want to focus on what the symptoms of an ankle sprain are and how to recognize it.
How an Ankle Sprain Occurs
An ankle sprain can occur in two ways:
- Eversion, when the foot rotates inward;
- Inversion, when it rotates outward.
After an ankle contusion, the injuries often affect the ligaments, but most of the time these are not injuries that have lasting consequences for the patient.
It is important to note that the ligaments in the ankle are extra-articular. This gives us an important advantage because it allows, in case of injury, the ligament itself to heal without particular consequences.
The ligament that is compromised in almost all ankle sprains is the “anterior talofibular ligament,” which is located on the outer side of the ankle.
A more complex consequence that can arise after an ankle sprain is an “osteochondral lesion” or “cartilage lesion” which, if it becomes chronic, can cause greater problems and more complex symptoms.
Classification of Ankle Sprains
“Classifying” has often helped medicine and doctors advance treatments by creating protocols as universal as possible.
Unfortunately, classifications are not always precise enough to truly help the doctor.
When talking about ankle sprains, we can find classifications such as:
- First-degree sprain: mild sprain causing stretching of ligaments and tendons without lesions
- Second-degree sprain: partial ligament lesion associated with swelling and pain
- Third-degree sprain: rupture of ankle ligaments with severe pain and marked swelling
The limitation of such a classification is that it tends to be very theoretical, impractical, and somewhat subjective.
Moreover, this classification focuses on ligament injuries without mentioning skeletal deformities and cartilage lesions, which can be equally serious and worthy of further diagnostic investigation.
Therefore, classifications often mentioned by patients are not always useful in clinical practice.
This is one reason why it is not possible to recommend a therapeutic path to a patient based only on their description or such classification: the physical exam is an important moment to assess the situation and discuss rehabilitation paths based on more advanced classifications useful in clinical practice, such as those developed by our group.
How to Recognize an Ankle Sprain
Sometimes the sprain does not cause severe pain or movement impairments, so it is easy to underestimate it and not take the right precautions to limit possible negative consequences.
Symptoms from this kind of trauma vary, which can cause confusion in patients and often lead to misinterpretation of their condition.
The Moment of Trauma
The situations in which an ankle sprain can occur are numerous, but some characteristic traits can be learned to identify these traumatic events.
Sprains typically occur during low-speed activities like walking or at most running.
Faster movements or those requiring significant weight bearing on the foot are more likely to cause a bone fracture rather than ligamentous or cartilage injury.
Patients generally report a sensation similar to tearing, sometimes accompanied by a popping noise.
Swelling and Bruising
Swelling and bruising are typical features of various foot and ankle injuries, including ankle sprains.
Usually, a sprain is accompanied by edema often localized not only at the injured area but extending throughout the ankle, which will appear stiff and painful.
In some cases, pain and swelling are accompanied by bruising, which, depending on the severity of the trauma, will increase in intensity and spread, concentrating in lower areas (such as the heel).
Pain
Pain is, of course, an inevitable symptom.
The intensity of the pain does not always correlate with the severity of the sprain, nor with swelling and bruising.
Sometimes the bruising is significant, but the patient cannot relate it to a specific cause and does not know how they got it.
In most cases, the most painful area corresponds to the anterior talofibular ligament, which is almost always tender on palpation.
Pain increases when putting weight on the foot or trying to keep the ankle at a 90-degree angle (horizontal position).
Often it becomes difficult to walk without limping; sometimes patients report stiffness related to swelling, other times a sense of instability related to a lack of proprioception in the affected ankle.
In milder cases, however, the patient can usually walk independently without crutches.
As we can see, the typical symptoms of an ankle sprain can be non-specific and affect the foot and ankle extensively.
For a correct diagnosis, the intervention of an orthopedic doctor through a thorough examination, even some time after the event, is essential.
A correct reconstruction of the traumatic event can help clarify whether only the ligamentous component is involved or also the cartilage, the latter being more serious, with a worse prognosis and requiring very specific treatment.
Without proper diagnosis and treatment, the symptoms of an ankle sprain can persist for long periods and tend to become chronic.
Symptoms patients should watch for include instability, meaning further sprains or a sensation of an unstable ankle, and pain that may indicate a cartilage lesion.
Clinical Diagnosis of Ankle Sprain
In the case of an ankle sprain, the specialist visit has a dual purpose:
- Evaluate immediate treatment
- Evaluate outcomes
First, a simple X-ray will help exclude a fracture.
Usually, the X-ray is performed directly in the emergency room.
Examination of ligaments and cartilage should happen later: ordering an MRI immediately after the sprain is absolutely useless.
Right after the injury, rest is recommended, keeping the limb elevated, applying ice, possibly bandaging for stability, and monitoring swelling.
If the pain is severe, the patient can use crutches, but they should not be used excessively.
The outcomes of an ankle sprain should be evaluated some time after the injury.
The patient’s symptoms—instability or pain—will guide the evaluation.
When instability is the main symptom, a ligament lesion is suspected.
The patient will report the ankle giving way, especially on uneven surfaces.
If pain is the main symptom, the patient feels limited and painful movement, which is more typical of cartilage lesions (osteochondral lesions).
The physical exam is fundamental, but a correct diagnosis cannot ignore instrumental exams.
The essential diagnostic tests are:
- X-ray
- MRI
- CT scan
X-ray
The X-ray must be weight-bearing and include the foot and ankle segments.
This allows analysis of the skeletal alignment of the foot and ankle as a whole.
MRI
MRI is fundamental for evaluating ligament status, particularly the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL).
MRI is also recommended to detect cartilage lesions, which may appear more extensive due to edema visible on MRI.
This is why CT scan examination is often necessary to deepen diagnosis.
CT Scan
CT provides much greater precision than MRI, especially in outlining the osteochondral lesion to understand its real extent and depth.
A major advantage today is the availability of a combined test: weight-bearing CT, which merges CT information with weight-bearing X-ray data.
The exam is performed with radiation doses similar to X-rays and allows 3D reconstructions crucial for surgical planning.
Treatment of Ankle Sprain
Treatment depends on the traumatic event.
It can vary widely depending on the damage caused by the sprain.
The trauma can occur in eversion or inversion, can be more or less severe, and may involve ligaments, bones, or both.
If the sprain caused a fracture, surgical treatment aimed at fracture fixation is necessary. If the sprain leads to ankle instability, surgery may involve ligament repair.
Less known but equally serious are cartilage lesions (talus dome).
In patients with symptomatic osteochondral lesions, surgery will focus on cartilage reconstruction.
Fortunately, in most cases, simple remedies like ice, rest, and proprioceptive rehabilitation are sufficient.
Prevention
Prevention means proprioception and appropriate physical exercise.
Proprioception means balance and coordination training focused on ankle function, like a rehabilitation protocol but planned as prevention.
Appropriate physical exercise means an activity compatible with any chosen sport but complemented by stretching. In short, preventing ankle injuries means taking care to train everything that supports the ankle: a well-trained lower limb and trunk will require less effort!
Frequently asked questions
What should you do if you sprain your ankle?
The first thing to do is to rule out the possibility of a fracture. Once you know that the sprain has not caused any direct damage, i.e. a fracture, keep the limb elevated, apply ice and rest. However, immobilisation should not be prolonged.
How can I reduce swelling from an ankle sprain?
Swelling is completely normal after an ankle sprain. Once you have ruled out a fracture, it is advisable to use common sense.
The rules are always the same, and we can use the RICE method to remember them:
- Rest,
- Ice,
- Compression,
- Elevation.
There are more innovative rehabilitation protocols (POLICE), but it is best that these are applied after receiving a diagnosis from a specialist.
How long does the pain last after a sprain?
The duration of the pain varies greatly. It can range from a few days to months. In this case, a specialist evaluation is recommended to rule out associated injuries, particularly cartilage injuries.
How can I avoid thrombosis if I have a sprained ankle?
Thrombosis can be avoided by simply bearing weight (walking), while in cases where this is not possible (due to a fracture or pain), heparin can be used for its antithrombotic properties. This should be done throughout the period of immobilisation, which, I would remind you, should not be excessively prolonged in the case of a simple sprain.
What happens if I don't treat my sprain?
It depends on “what I don't treat”. Most foot sprains do not leave any lasting effects.
In the event of ankle instability developing following a sprain, there is a risk of further sprains and damage to the joint cartilage.
If, on the other hand, I am ignoring an osteochondral lesion, I am depriving myself of the chance to stop the progression of osteoarthritis in the ankle.
What are the permanent damages caused by an ankle sprain?
As explained several times, excluding fractures, the most serious damage caused by an ankle sprain is osteochondral injury, i.e. damage to the articular cartilage.
This is permanent damage that can now be repaired using minimally invasive techniques that my team is proud to have developed and published (AT-AMIC).
Precisely because the problems associated with sprains are not limited to cartilage damage but also include the most common ligament injuries, we have worked on and developed new minimally invasive reconstructive techniques for the autologous reconstruction of damaged ligaments.