Ankle sprains are among the most common musculoskeletal injuries in both the general population and among athletes. Their management, proper diagnosis, and understanding of when to seek further medical evaluation, such as imaging, are crucial in ensuring effective treatment and prevention of recurrence.

Types and Pathophysiology of Ankle Sprains

Ankle sprains are primarily classified based on the affected ligaments and the severity of the injury.

1. Lateral Ankle Sprains

• Pathophysiology: Occur when the foot rolls outward (inversion), overstretching or tearing the ligaments on the ankle’s outer side.

• Affected Ligaments: The anterior talofibular ligament (ATFL) is most frequently injured, followed by the calcaneofibular ligament (CFL), and less often, the posterior talofibular ligament (PTFL).

• Healing Timeline: Mild sprains (Grade I) typically heal within 1-3 weeks, moderate sprains (Grade II) take about 3-6 weeks, and severe sprains (Grade III) can take several months to heal fully.

2. Medial Ankle Sprains

• Pathophysiology: Result from an eversion movement, where the foot twists outward, stressing the medial side of the ankle.

• Affected Ligaments: The deltoid ligament complex is primarily involved, which is stronger and less commonly injured compared to lateral ligaments.

• Healing Timeline: The healing duration is similar to lateral sprains but may extend longer due to the complexity and strength of the deltoid ligament.

3. High Ankle Sprains (Syndesmotic Sprain)

• Pathophysiology: These occur from excessive external rotation of the foot or an outward twisting of the ankle, affecting the ligaments that hold the tibia and fibula together at the ankle.

• Affected Ligaments: Includes the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), and the interosseous membrane.

• Healing Timeline: High ankle sprains are more severe and take longer to heal, often requiring 6 weeks to several months.

Avulsion Fractures in Ankle Sprains

Avulsion fractures are a specific complication of ankle sprains, where a fragment of bone is torn away by the ligament or tendon attached to it.

Common Avulsion Fractures

• Fibular Avulsion Fracture: Commonly occurs with lateral ankle sprains.

• Medial Malleolar Avulsion Fracture: Happens when the deltoid ligament is forcefully stretched or torn.

• Fifth Metatarsal Avulsion Fracture: Often associated with inward rolling of the foot, though not directly part of the ankle joint.

Risk Groups and Long-Term Complications

• Age Groups at Risk: Adolescents and young adults are more susceptible due to their developing bones. Older adults are less likely to experience avulsion fractures but may suffer from ligament sprains.

• Long-Term Complications: If not treated properly, complications can include chronic pain, arthritis, decreased mobility, and improper bone healing (nonunion or malunion).

Chronic, Recurring Ankle Sprains

Chronic ankle sprains are characterized by the recurrent spraining of the ankle, often due to a previous injury that hasn’t healed properly or has resulted in weakened ankle stability.

Causes

• Ligament Laxity: Initially sprained ligaments that don’t heal properly can become lax, providing less support and increasing the risk of further sprains.

• Proprioceptive Deficits: Ankle injuries can impair the body’s ability to sense its position, leading to poor balance and a higher chance of re-injury.

Complications

• Increased Reinjury Risk: The weakened ankle is more prone to sprains, even with minimal force.

• Chronic Pain and Swelling: Continuous sprains can lead to persistent discomfort and swelling.

• Altered Gait: To compensate for the instability and pain, individuals may alter their walking pattern, leading to additional stress on other joints like the knees, hips, lower back, and feet.

• Arthritis Development: Frequent sprains can escalate the risk of developing osteoarthritis in the ankle joint.

Importance of Rehabilitation

Proper treatment and rehabilitation, including exercises to strengthen the muscles around the ankle and improve balance, are crucial. A structured return-to-sport program ensures the ankle is adequately healed and strong enough for specific activities, preventing chronic issues and maintaining overall joint health.

The Ottawa Ankle Rules for Imaging

The Ottawa Ankle Rules are a set of guidelines used by healthcare professionals to determine whether a patient with an ankle injury requires an X-ray to rule out a fracture.

Criteria for Imaging

• Pain in Specific Areas: Tenderness at the posterior edge or tip of the lateral or medial malleolus, base of the fifth metatarsal, or the navicular bone.

• Weight-Bearing Capability: Inability to bear weight both immediately after the injury and during the examination (i.e., walking four steps).

Benefits and Limitations

These rules are designed to reduce the need for unnecessary X-rays, ensuring efficient use of resources while also providing a quick method to identify potential fractures. However, they are not foolproof and should be used in conjunction with clinical judgment.

Conclusion

At Movability, we understand the intricacies of all the different types of ankle sprains. We use the latest scientific evidence to treat and rehabilitate ankle sprains effectively. Our team of chiropractors and physiotherapists work with both athletes and non-athletes alike, ensuring tailored treatment plans for optimal recovery and care. Understanding ankle sprains, their potential for chronic recurrence, and the importance of appropriate diagnostic measures like the Ottawa Ankle Rules highlight the need for careful management and rehabilitation. Our commitment is to provide the highest standard of care to ensure a successful return to daily activities or sports.