Question

    Ankle Sprain (Sprained Ankle)

    Ankle sprain is a condition, characterized by usually an inversion-type twist of the ankle, which causes significant amount of injury to the ligaments of the affected area. This is one of the most common injuries of emergency department.

    This disorder is related to the following process: Trauma.

    Presentation

    The ankle affected by sprain may show the following signs and symptoms:

    • Development of swelling accompanied by pain 
    • Bruising
    • Bone tenderness and stiffness
    • Inability or difficulty to bear weight depending on extent of injury
    • Discoloration of skin
    • Difficulty and pain while walking

    musculoskeletal
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  • Workup

    A thorough physical examination of the affected ankle will be carried out. Imaging studies such as X-rays will be required to rule out fractures. In addition to plain radiograph imaging, stress–view radiograph tests may also be performed, to get better insights about the ankle sprain [7].

    MRI is seldom indicated in such cases. However, when certain unusual characteristics features are present, such as acute pain, ecchymosis or excessive swelling, then MRI can be performed. In such situations, MRI studies may reveal osteochondral lesions, which are usually not revealed on plain radiographs [8]. CT scan is indicated in conditions of complex injuries and to determine osteochondritis dissecans.

    Imaging

    X-ray
  • more...
  • Treatment

    Treatment regime for ankle sprain is designed with the major goal of pain reduction, and restoration of lost motion. While mild cases of ankle sprain can be treated at home, moderate to severe cases may require more rigorous intervention.

    According to the National Institute of Health, application of ice on the affected area for at least 10 to 15 minutes is utmost necessary for reducing the swelling. This should be repeated every hour. Pain relieving medications are also administered. Thereafter, the affected ankle is supported with braces so that there is limited motion.

    Individuals are also not allowed to put weight on the ankle, and rest as much as possible. In many cases, the affected area is covered with ACE bandage to restrict motion, and reduce the pain [9]. Surgery is indicated only in cases when there is severe damage to the ligament.

    Prognosis

    Ankle sprains which are adequately treated have an excellent prognosis. Time taken for complete recovery would majorly depend on the extent of severity of the condition. In about 36 to 85% cases of acute ankle sprain, affected individuals recovered between 2 weeks to 36 months with proper treatment [6].

    Individuals, who participate in competitive sports, are at an increased risk of developing recurrent sprains. However, even in such cases, when the treatment is initiated with appropriate rehabilitation program, then the prognosis of the condition is extremely favorable.

    Etiology

    Ankle sprain occurs when the ankle undergoes an inverted twist due to sudden movement, which causes ligament tear. This may further lead to swelling and pain in the ankle, and it would get difficult for the individual to bear weight. Individuals can develop ankle sprain at any age. However, there are certain risk factors that can increase the chance of developing ankle sprain. These include [2]:

    • Lack of proper physical conditioning, poor muscle tone, contraction of joint capsule and lack of training in the activity being performed all lead to ankle sprain.
    • Accidents and other trauma conditions. 
    • Obesity can cause increase in kinetic energy, which may exceed the joint stress limits.
    • Individuals who participate in athletic activities are thrice as more likely to develop ankle sprains [3].

    Epidemiology

    The exact prevalence rates of ankle sprains are not known, because many cases are self treated, and therefore go unreported. With the available data, it can be estimated that about 23,000 individuals of United States per day seek medical intervention for ankle sprains [4]. In addition, it has also been reported that, female athletes are 25% more likely to develop ankle sprains, than their male counterparts. Along with basketball players, ankle sprain is a common occurrence amongst those individuals who play soccer, football and volleyball.

    Sex distribution
    Age distribution

    Pathophysiology

    Ankle sprain develops, when the ankle moves out its normal position, due to certain activities or actions. This causes the ligaments of the ankle to tear, leading to swelling and pain [5]. Ankle sprains are classified into 3 different grades which include:

    • Grade I characterized by minor injuries that causes the ligament to stretch, with little swelling and pain. In such cases, the individual is able to stand and bear weight.
    • Grade II injuries, wherein there is partial tearing of the ligament, followed by considerable amount of swelling, accompanied by moderate to severe joint instability. In this, the affected individuals have grave difficulty in bearing weight.
    • Grade III characterized by absolute rupture of the ligament, severe swelling and severe joint instability. Individuals, who have suffered grade III ankle sprain, are unable to bear weight without pain.

    Prevention

    The following steps can be taken to prevent occurrence of future sprains:

    • It is necessary to avoid high heels and not overuse the affected ankle.
    • Post recovery, the affected ankle can be bandaged and braces can be used if required.
    • Strengthening exercises are necessary to strengthen the muscles and ligaments of the affected area.
    • Individuals are also advised to wear comfortable footwear and external support while playing [10].

    Summary

    The resulting symptoms that occur usually due to inversion-twist of the ankle are pain, accompanied by swelling of the affected area. The fact that the affected area has undergone inflammation, but the individual can still walk, excludes all chances of occurrence of fracture. Ankle sprain is classified into 3 grades depending on the severity of the condition [1].

    Patient Information

    • Definition: Ankle sprain is characterized by ligament injury that occurs due to an improper twist, and turn of the ankle. It is a common occurrence amongst athletes, and females are more prone to contract the condition, than males.
    • Cause: All actions and activities that cause the ankle to improperly twist and turn can give rise to ankle sprain. Several factors such as accident, injury or wearing uncomfortable footwear, and playing sports can predispose an individual to develop ankle sprains.
    • Symptoms: Symptoms of ankle sprain include bruising, swelling, discoloration and pain in the affected region. Individuals are also unable to bear weight, due to which, they experience difficulty while walking.
    • Diagnosis: Physical examination of the ankle can be done at the preliminary level. This should be followed by X-rays to rule out fractures. MRI is indicated only when serious and complex injuries are evident.
    • Treatment: Application of ice immediately on the affected ankle for 10 to 15 minutes on hourly basis is strongly recommended. Medications to relieve pain and swelling are also given. The affected ankle is covered with ACE bandage, and braces are given for support and to restrict mobility. Surgery is indicated only when there is severe injury to the ligament.

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    References

    1. LeBlanc KE. Ankle problems masquerading as sprains. Prim Care. Dec 2004;31(4):1055-67. 
    2. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med 2001; 35:103.
    3. Waterman BR, Belmont PJ Jr, Cameron KL, Svoboda SJ, Alitz CJ, Owens BD. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med. May 2011;39(5):992-8.
    4. Mahaffey D, Hilts M, Fields KB. Ankle and foot injuries in sports. Clin Fam Pract; 1999:1(1):233-50.
    5. Ivins D. Acute ankle sprain: an update. Am Fam Physician. Nov 15 2006;74(10):1714-20.
    6. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. Apr 2008;121(4):324-331.e6.
    7. Frost SC, Amendola A. Is stress radiography necessary in the diagnosis of acute or chronic ankle instability? Clin J Sport Med 1999; 9:40.
    8. Saxena A, Luhadiya A, Ewen B, Goumas C. Magnetic resonance imaging and incidental findings of lateral ankle pathologic features with asymptomatic ankles. J Foot Ankle Surg. Jul-Aug 2011;50(4):413-5.
    9. Cooke MW, Marsh JL, Clark M, Nakash R, Jarvis RM, Hutton JL, et al. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technol Assess. Feb 2009;13(13):iii, ix-x, 1-121.
    10. Garrick JG, Requa RK. Role of external support in the prevention of ankle sprains. Med Sci Sports. Fall 1973;5(3):200-3.

    • Ankle inversion injury and hypermobility: effect on hip and ankle muscle electromyography onset latency - SM Beckman, TS Buchanan - Archives of physical medicine and , 1995 - Elsevier
    • Acute ankle sprain: an update. - D Ivins - American family physician, 2006 - ncbi.nlm.nih.gov
    • Arthroscopic assessment for intra-articular disorders in residual ankle disability after sprain - M Takao, Y Uchio, K Naito, I Fukazawa - The American Journal , 2005 - ajs.sagepub.com
    • Foot and ankle injuries in dancers - WG Hamilton - Clin Sports Med, 1988 - ckynde.dk


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