The ankle is the most commonly injured joint among athletes. This is primarily due to its weight bearing function and the many stresses placed on the ankle during athletics. It is estimated that up to 10 million ankle injuries occur in the US each year, with approximately 85% of those being ankle sprains. The sports most commonly associated with ankle sprains are basketball, football, soccer and running.

An ankle sprain is a soft-tissue (non-bone) injury to the ligaments surrounding the joint. Ligaments are tough bands of tissue that connect bone to bone and support the joints while allowing movement. The ankle is the most commonly sprained due to its many movements that are under constant stress. A sprain occurs when a sharp twisting or wrenching movement such as turning your ankle forces the joint beyond its natural limits. As a result, the ligament may be stretched to such an extent that it tears.

Ankle sprains in which the foot twists inward are called inversions injuries, damaging the lateral ligaments on the outside of the foot. Less common are pronation injuries, damaging the medial ligaments on the inside of the foot, caused by twisting the foot outward. Depending on the severity of the tear, appropriate treatment plans may include immobilization, physical therapy or even surgery.

On the lateral side of the ankle there are three ligaments that make up the lateral ligament complex. These include the anterior talofibular ligament (ATF), the calcaneofibular ligament (CF) and the posterior talofibular ligament (PTF). The very common inversion injury to the ankle usually injures the anterior talofibular ligament and the calcaneofibular ligament. The ATF ligament keeps the ankle from sliding forward and the CF ligament keep the ankle from rolling over on it side.

Ankle sprains have been characterized as either grade I (mild), grade II (moderate), or grade III (severe) reflecting the amount of tearing to the ligaments.

Treatment

In a grade I sprain, there is usually minimal loss of function, minimal pain, minimal swelling and the patient maintains the ability to weight bear. The integrity of the ligament remains intact, and typically x-rays are not needed. Treatment consists of Rest, Ice, Compression, and Elevation (RICE). Nonsteroidal anti-inflammatory medications are helpful to control both pain and swelling.

Grade II sprains produce symptoms including more functional problems such as an increase in pain, moderate swelling, bruising, and more difficulty with weight bearing. A grade II sprain is indicative of a partial tear in the ligament. Treatment consists of using RICE protocol and anti-inflammatory medications. Patients will need an ankle support, and crutches are recommended until walking is pain free. Physical therapy and rehabilitative exercises should be started. It is important to re-strengthen the ankle, since people with a previous grade II ankle sprain are more prone to re-injury and tend to have more laxity in the joint following the injury.

In a grade III sprain, a complete rupture of the ligament is diagnosed. There is a severe loss of function, severe pain, and diffuse swelling, bruising and an inability to bear weight. Treatment of grade III sprains can vary.

Stages of Healing

Most sprains heal in four to sixteen weeks; the time will vary depending on age and the severity of the injury. Your doctor may recommend an ankle brace, cast or boot to help the healing process. Immobilizing the joint in the proper position may be recommended so that the ends of the injured ligaments can heal together. During the immobilized period the body is working to heal the injured tissue. Special cells fill the gap in the ligament fibers left by the injury. The body then replaces the torn, damaged tissue with strong, healthy tissue. There are three phases to the healing process, they are

Phase I
Multipurpose cells enter the injured area. They quickly and randomly fill the gap and clean up the wound by removing injured tissue.

Phase II
These cells become fibroblasts (cells that build soft tissue). They line up along the direction of the ligaments fibers, forming a bridge and filling the gap temporarily. They begin to produce collagen, the framework for new ligament.

Phase III
Eventually, the new collagen fibers become interwoven with the old collagen in the ligament. Fibroblasts disappear. Over time the structure is strengthened and refined through rehabilitation exercises.

It is important to know that once an ankle sprain has occurred the joint itself has been weakened and is not as strong as it was before the injury. Continued ankle strengthening exercises are very important. For participation in athletics, it may be necessary to continue to wear a supportive brace. Traditionally, many athletes trying to help protect themselves from injury have used ankle taping. Although taping offers some protection, studies have shown that support breakdown can occur quickly. One study showed that 40 percent of tape support was lost after 10 minutes; therefore, we recommend the use of ankle braces to counter the forces being placed on the ankle.

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Recurring Sprains

Most people will usually heal after an initial ankle sprain with exercise and rehabilitation to stabilize the joint. Though it is not uncommon for people to complain of recurrent ankle sprains that "won't go away", this is usually due to the weakened or lax ligaments. In these reoccurring cases, physical therapy is required to restore the ankle to a normalized strength. In some cases the ligaments are damaged to the point that they will require surgery.

Surgery

Ankle sprains rarely require surgery. If, however continued pain and recurrent ankle sprains are present surgical repair of the ankle ligament may be necessary. A completely torn ligament may need to be surgically re-attached to the bone. A chronic unstable ankle can be strengthened by removing a piece of tendon from one side of the foot and attaching it to the weakened area for more support (Brostrom repair).

If chronic pain is the problem, an Arthroscopic procedure may be necessary to clean out the joint. Arthroscopic surgery is a less invasive surgery, with faster healing, less post- operative pain and a more rapid return to sports. Some common indications for arthroscopy of the ankle are:

Loose bodies Remove fragments of loose cartilage or bone from the joint (common after multiple sprains)

OCD: Osteochondritis Dessicans- damaged bone and cartilage of the talus bone of the ankle are treated by drilling deep into the bone to encourage bleeding and growth of healing cells

Arthritis: Loose debris and inflammation are cleaned out. Spurs are removed

Fusion: In severe cases of arthritis, the joint can be fused

Impingement: Painful scar tissue that pinches in the ankle is removed