Ankle injuries are very common injuries we see in the physio clinic. Only half of all ankle sprains occur during athletic activity which means you don’t necessarily need to be playing sport to hurt your ankle. These typically manifest with rolling or twisting the ankle out of its normal anatomical position and can be caused by stepping on uneven surfaces, tripping or falling or even landing awkwardly.
There are many structures of the ankle and therefore many things that can become injured. Here we will talk about the most common ankle injuries we see in the clinic, what to be aware of if you encounter it and how you would manage these.
The ankle is a hinge joint which consists of the bones of the leg (tibia and fibula) meeting the foot (talus). These are connected by ligaments which hold the joint together which are surrounded by tendons (muscle to bone) which allow the ankle and foot to move.
On the inside of the ankle we have thick ligaments called the ‘deltoid ligaments’ and injury to these accounts to about 20% of ankle injuries.
On the outside (lateral) of the ankle, the joint is stabilised by three ligaments: anterior-talofibular ligament (ATFL), calcaneofibular ligament (CFL) and the posterior-talofibular ligament (PTFL). Injuries to these ligaments accounts to about 80% of ankle injuries. This occurs when the ankle is rolled inwards; this is called an ‘inversion injury’.
The most common ligament we see injured is the ATFL ligament. If the injury is significant enough, we can see further injury to the other ligaments or even an ankle dislocation.
Ankle injuries are defined by the tissue injured. This can be either: bone, ligament or tendon. A fracture is a break of one or more of the bones, a sprain is an injury to the ligaments and a strain is an injury to the tendon.
Types of ankle injuries:
Injury of ligaments. These are the most common ankle injuries we see, in particular on the outside of the ankle. These are caused by inversion injuries when the ankle is rolled inwards and occasionally we see eversion injuries when the ankle rolls outwards. These are grouped into three different grades: Grade 1, 2 and 3. Grade 3 being the most severe.
- Grade 1 Sprain (Mild)
- The ligament is stretched with no significant tear. Symptoms include: mild swelling around the ankle, swelling, bruising, tender to touch, sore to walk.
- Grade 2 Sprain (Moderate)
- The ligament is stretched with some (partial) tearing of the ligament fibres. Symptoms include: bruising, swelling, sore to walk, sore to move, tender to touch
- Grade 3 Sprain (Severe)
- The ligament is ruptured or completely torn. Symptoms include: severe pain followed by minimal pain, bruising, swelling, pain to touch, pain on walking, pain to move, poor balance.
- Grade 1 Sprain (Mild)
As you can see, the symptoms of each grade are very similar in presentation, this is what makes the diagnosis of the exact grade very difficult. With the use of imaging such as ultrasound or MRI, we are able to see clearly what exact level of injury has occurred.
This occurs when there is a break to a bone. Typically, the symptoms are very similar to that of a sprain: sore to walk, excessive bruising, sore to touch over the bone, swelling, heat. If your medical professional is suspecting a fracture they would either send you for an Xray or a CT scan.
This occurs when there is an injury to the tendon. These can also be graded from mild, moderate to severe with severe being a complete rupture of the tendon. The symptoms are very similar to that of ankle sprains. Accurate diagnosis of this can be with an ultrasound or MRI.
What makes me at a higher risk of getting an ankle injury?
There has been much research into why some people are more likely to get an ankle injury over others. Here are the proven risk factors:
- Previous or existing ankle injury (especially if these are poorly rehabilitated)
- Lack of strength or stability related to the ankle
- Lack of flexibility or extreme flexibility of the ankle
- Poor balance
- Foot posture
- Type of sport
The first point is the most important point. People who have had ankle injuries are at a higher risk to having another ankle injury of about 40-70%! This is why ankle rehabilitation after your injury is so important if you want to get back into sport as this can significantly reduce your risk of re-injury.
Treatment and Rehabilitation
The goals of treatment are to restore normal function back to an ankle and the person injured in the appropriate time-frame.
If this is the first time you have had an ankle injury, or this is a recurrent injury but have not had previous treatment, we strongly recommend you see your health care professional. They will be able to properly diagnose your injury and provide the best management for you especially with return to sports.
Below we have outlined the general phases of Grade 1 or Grade 2 ankle injury rehabilitation as this is the most common ones we see. There is no clear time-frame for each phase as this is usually under the discretion of your health-care professional.
Time-frame of Grade 1 and Grade 2 ankle injury: 4-6 weeks.
When we initially see ankle injuries, they are very puffy, swollen and very sore. Usually these ‘acute’ symptoms settle very quickly within the first two weeks.
Phases of ankle rehabilitation
Phase 1: Injury Protection, pain relief and inflammation.
The initial management of an ankle injury is very important and can help reduce the length of recovery time.
Remember the term RICE? This is an important acronym which is easy to remember which is essential in an acute injury. This is what it stands for:
Try to stay off your ankle as much as possible. This is usually symptom-guided, i.e. if it is very sore, listen to your body and try not to walk on it too much.
Apply ice for 20 minutes, maximally every hour for the first 48 hours. Try not to go over 20 minutes and more frequent than every hour as this could damage your skin.
Apply a compression sock or bandage which can help decrease and control the swelling.
Keep your leg elevated when resting, especially when sitting. This will be to help get the swelling back up to the heart and better circulated through the body.
Phase 2: Regain full range of movement
Mature scar formation takes at least six weeks and it is therefore important to restore and maintain full range of movement of your ankle to allow for optimal healing. This will involve exercises that keep your ankle moving including moving your ankle up and down repetitively.
Research has shown that a history of a sprained ankle predisposes you to a ‘stiff ankle’ which can increase your risk of further injury associated with this including sprains, foot pain, calf pain and leg injuries. If you are concerned about your ankle range of movement, you should seek a professional opinion.
Phase 3: Muscle Strength
The calf, ankle and foot muscles will need to be strengthened following an ankle injury. This will be important to restore normal functioning of the ankle and specially to prepare for more dynamic-based rehab which focuses towards sports.
Strengthening the ankle is also very important to prevent re-injury of the ankle. This is because the ligaments have weakened as well as the muscles which puts you at a higher risk (as mentioned before) of reinjuring your ankle. Strength is essential.
Phase 4: Balance (Proprioception)
Balance or proprioception is knowing the relative position of your body. In an ankle injury stability of the ankle is compromised due to injury the ligaments where their job is to stabilise the ankle. Therefore, working on balance is essential to prevent re-injury of the ankle as having poor balance is a big predictor for future ankle injuries.
Phase 4: Sport-Specific Training
This will include challenging your balance through more dynamic exercises. This will involve jumping, hopping, skipping etc which are few of the many demands required in sport. As sport is unpredictable and can have quick changes on your ankle, ensuring your ankle is strong enough for this demand is important to prevent injury.
Phase 5: Return to Sport
This will include a thorough time-line and program from your therapist ensuring you meet the sufficient training demands for your game. This includes participating in drills, endurance, and scratch matches. Once your therapist is satisfied you can tolerate this load then they can give you a clearance to play in your game, whether it be one quarter, half, or a full game.
Throughout these phases and in the first few weeks of your injury, your therapist may choose to tape your ankle. This helps to off-load and support your ankle which can help with pain when walking. This is important in the first 2-3 weeks and can help speed up your recovery time.
Medication such as anti-inflammatories can have a role to play in the initial stages of an ankle injuries to help reduce pain. You can seek guidance from your healthcare professional for further advice on this.
If you have any further queries or questions about your old or new ankle injury and are not sure where to begin, you are more than welcome to call our clinic on 9274 1482 and speak to one of our physiotherapists.
Izabela has been dancing for over 12 years and has travelled nationally to perform. She also enjoys the field of performing arts and has participated in a few stage shows within community theatre.
- Rehabilitation of Sporting Injuries
- Treatment of Chronic Pain