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Disease Process
The ankle joint is formed by the tibia and fibula (the two bones in the lower leg) and the talus (one of the bones in the foot). The ankle joint moves upwards (dorsiflexion) and downwards (plantarflexion) and side to side (inversion – toes move to the inside and eversion - toes move to the outside).
The two bony prominences (the big bumps on the inside and outside of the ankle) are called the medial (inside) and lateral (outside) malleolus. Ankle joint stability comes from the shape of the bones that make up the joint and the ligaments on the inside and outside of the ankle.
A sprain simply means that the ligaments in a joint have been damaged. Ankle sprains are common in athletes, people walking over uneven surfaces and in people that already have instability in the ankle from a previous injury. When the ligaments in the ankle stretch beyond their normal range of motion, it is considered an ankle sprain. The ligaments can actually stretch so far that they tear.
There are three “grades” of ankle sprains:
Grade I: Minimal tenderness and swelling are noted. Possible microtear of the ligaments.
Grade II: Moderate tenderness and swelling are noted. Complete tear of some but not all of the ligament fibers is present, along with possible instability.
Grade III: Significant swelling and tenderness present. Complete tear / rupture of the ligament. Instability is present.
Causes
The foot and / or ankle turning beyond normal limits.
Symptoms
- Pain in ankle with swelling and bruising after twisting ankle to the inside or outside. Some bruising may be noted in ankle area or up side of the lower leg. Difficulty placing weight on the injured ankle.
- Decreased range of motion in the ankle.
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| Diagnosis
- Patient History Physical Examination X-Rays to rule out a fracture
- Possible MRI to check for instability or joint changes
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Current Treatment
- By Grade:
- Grade I: able to bear weight on ankle as tolerated (to level of comfort), no splinting is needed, isometric and range of motion (ROM) exercises and stretching.
Grade II: immobilization (air splint), isometric, range of motion and stretching exercises, and physical therapy.
- Grade III: immobilization (walking cast), physical therapy, possible surgery.
RICE:
- R: Rest – keep weight off of the ankle and avoid any activities that are painful.
I: Ice – use ice for 15 minutes at a time at least every two hours.
C: Compression – use of a pressure dressing (such as an ACE wrap) will help decrease swelling. The compression wrap should not be so tight that it cuts off blood flow. Remove it if there is a sensation of tingling or pain. The compressive wrap should be re-applied every 4 hours.
- E: Elevation – raising the inured area at least 12 inches ABOVE the heart also helps reduce swelling (and pain). The ankle should be elevated for 30 minutes at least 4 times a day (can Ice and Elevate at the same time).
- Medication:
- NSAIDS to help reduce pain and inflammation
- Surgery:
- Arthroscopy: to look for bone or ligament fragments in the joint.
- Reconstructive: to repair torn ligaments with sutures or stitches (may also use other ligaments in the area).
How Can Physical Therapy Help
Physical Therapy can help the patient reach their goals of decreased pain and swelling, increased range of motion, increased strength and return to function. The physical therapist will probably use a variety of modalities such as ultrasound or electrical stimulation, as well as ice to help with the pain and swelling. The physical therapist will perform an evaluation to determine how severe the sprain is and what limitations the patient has in order to determine which exercises that should be performed. The PT will progress the exercise program as the ankle heals in order to allow for return to full function. If a brace is needed, the physical therapist can provide the brace and make sure it is properly applied.
Patient Resources
American Academy of Orthopedic Surgeons
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