If you sprain or twist your ankle, especially where there was significant force trauma involved, and experience severe acute pain and swelling, you may wonder if you have sustained a bad ankle sprain or a bad ankle sprain and bone fracture.
Here are some indications that you may have also sustained a bone fracture along with your sprained ankle:
- Pinpoint tenderness. If you palpate the tips and distal shafts of the tibia and fibula bones of the ankle, and the victim experiences severe pain at a specific point on the bone, this may indicate a fracture. However, because ligaments that have been sprained or torn during the injury attach to these bony landmarks (medial and lateral malleoli) there can be significant pain where the sprain/tear occurred. You will need to try and distinguish if the pain is in bone or soft tissue.
- Sensation of numbness and tingling. A severe ankle sprain hurts like crazy, but if there is associated tingling and numbness in the ankle, this can be a sign of a potential fracture.
- Loss of ankle stability. If you have a real loss of ankle stability, this can indicate that an ankle bone or bones may have been broken.
- Hearing the noise of a “crack” sensation. While a severe ankle sprain may present with a popping sound, a fracture will present with a “cracking” sound.
- Obvious deformity. There is a saying in sports medicine that you cannot declare a sprained ankle as having also sustained a bone fracture without obvious deformity. However, a dislocated ankle without any bone fracture can look quite ominous.
If you have a question as to if you may have fractured your bone(s) as part of your severe ankle sprain, you should see your doctor who may order an x-ray to verify suspensions of a break.
Ankle Sprains – Inversion Mechanism of Injury
Approximately 95% of ankle sprains are “inversion sprains” where the foot turns inward causing damage to the lateral ankle stabilizing ligaments. Those ligaments are:
- Anterior Talofibular Ligament
- Calcaneofibular Ligament
- Posterior Talofibular Ligament
Ankle sprains are common in jumping and landing sports like basketball and volleyball, but inversion sprains can also occur in literally any sport and may even occur while simply walking and stepping on an uneven surface that tips the sole of the foot inward. Most people I know have experienced at least one ankle sprain in their life, whether it be a mild or a more severe sprain. According to the National Electronic Injury Surveillance System (NEISS) reporting for ankle sprain injuries presenting to emergency departments (https://journals.lww.com/jbjsjournal/Abstract/2010/10060/The Epidemiology_of_Ankle_Sprains_in_the_United.3.aspx) the peak incidence of ankle sprain occurs between the ages of 15 to 19. Nearly half of all ankle sprains occur during athletic activity with basketball reporting the highest incidence at 41.1%, football at 9.3%, and soccer at 7.9%.
How are Inversion Ankle Sprains Graded or Categorized
Ankle sprains are graded according to severity of damage to the ankle stabilizing ligaments, amount of swelling that is present, the degree of resulting instability, and the amount of functional loss to the ankle joint.
- Sprain mechanism is limited in amount of inversion.
- Ligaments are stretched causing microscopic tearing
- Little if any swelling is present
- No ankle instability
- No loss of ankle functionality
- Sprain inversion mechanism is greater than grade 1, but not severe
- Ligaments are stretched with partial tearing
- Moderate to severe swelling is present
- Mild to moderate joint instability
- Functionality impaired making it difficult to bear weight
- Ecchymosis – discoloration of the skin from damaged capillaries and bleeding
- Significant inversion sprain mechanism
- Most or all ligaments are ruptured
- Severe swelling occurs immediately after injury
- Moderate to severe joint instability
- Loss of functionality, severe pain if try to bear weight
- Ecchymosis – discoloration of the skin from damaged capillaries and bleeding
Steps in the Rehabilitation Process of a Sprained Ankle
Immediately After Any Grade of Ankle Sprain (RICE)
- Rest: Avoid activities that reaggravated the injury and cause pain and swelling. The stabilizing ligaments of your ankle have been traumatized as have other soft tissues and need to begin the healing process without further injury which would only prolong healing.
- ICE: Apply ice in the form of an ice slurry. Fill a bucket with ice, add cold water, and submerge your foot. Yup, the initial minute or so may be a bit difficult to bear, but an ice slurry allows the individual to gently move their ankle through some range of motion in the sagittal plane – plantar flexion and dorsiflexion. Ice for approximately 20 minutes. Icing serves to help reduce swelling, pain, and muscle spasms. You should repeat icing 2-3 times during the day.
- Compression. After completion of icing apply a compression wrap (Ace bandage) to the ankle to help control swelling and to provide support. The wrap should be applied with sufficient tension to provide compression, but not so tight as to adversely restrict circulation. Wear the wrap as much as possible, but again, not to compromise circulation to the foot.
- Elevation. Whenever possible, sit in a way so that you can elevate your foot to allow gravity to help control swelling at the ankle.
Note: Continue ice, compression, and elevation as your circumstances permit for the next 24 to 72 hours.
Daily Rehabilitation Regimen with Progression as Improvements are Made
As with any injury where pain, swelling, and restricted movement are present, certain anatomical and physiological changes occur that if not properly addressed in a progressive rehabilitation program, can dramatically slow the healing process, and may yield some long-lasting deficits.
Specifically, 1) the ankle quickly loses range of motion (especially dorsiflexion range of motion as the calf muscles become tight), 2) a loss of proprioceptive sensitivity in the muscle spindles of the muscles that support and provide reflex contraction protection to the ankle and subtalar joint of the foot, and 3) a loss of muscular strength of all muscles that provide stabilization and support to the ankle and subtalar joint. A failure to address each of these during rehabilitation increases the chance of ankle sprain reinjury, a compensatory injury to other joints, and diminished athletic performance.
NOTE: As previously presented, there are three grades of severity of ankle sprains. As such, the appropriateness of the timing of initiation of treatment protocols and the progression of those protocols will be different. Therefore, as a general guide:
- Grade 1: Because there is little ligament damage, joint instability, or swelling, rehabilitation can begin immediately after pain is controlled, and the individual can usually return to activity in less than a week.
- Grade 2: Because of partial tearing of ligaments, some joint instability, and moderate to severe swelling, the joint should be somewhat immobilized for several days, delaying the initiation of some rehabilitation protocols.
- Grade 3: Because the ligaments are ruptured with gross instability to the ankle joint, and pain and swelling persists for an extended period of time, the initiation of rehab protocols is delayed as weight bearing may not be possible for two or more weeks.
To further guide your rehabilitation, apply the principle of “let pain be your guide”. If whatever rehab protocol you are performing produces pain, then scale back so as not to reinjury the healing tissue.
Also, if swelling returns during your rehabilitation, you need to scale back on the intensity of exercises.
Note: → = progress to
Initial/Non-Weight Bearing Rehabilitation →→→
- Passive Range of Motion (PROM) → to Active Range of Motion (AROM): Perform ROM exercises in the sagittal plane of motion, working to maintain or restore normal dorsiflexion and plantar flexion range of motion.
- Isometric Contractions: Perform isometric muscle contractions of the evertor muscles (Fibularis Longus, Fibularis Brevis) to build strength in these muscles.
- Stationary Bike: Aids in dorsiflexion and plantar flexion ROM while providing a cardio respiratory workout to help maintain conditioning during absence from sport or activity.
- Wobble Board: In a seated or only partial weight bearing position, perform ROM exercises in both sagittal and frontal planes of motion.
→→→Progression of Rehab /Weight Bearing
- Walking: Focus on achieving a normal gait pattern
- Stretching of Calf Muscles: Beginning with towel stretches progressing to standing/weight bearing stretching of calf muscles.
- Progressive Resistance Exercises: Perform resistance (manual, exercise bands, weights, body weight heel raises, etc.) exercises of ankle plantar flexors and dorsiflexors, then invertors and evertors to progressively build strength
- Proprioceptive Training: Incorporation of balance training. Progression=: *Double leg stance → single leg stance *Firm surface → foam pad → BOSU *Eyes open → eyes closed *Incorporating various perturbations
- Back to Sport Activities: jogging → sprinting → jumping → figure 8’s, etc. progressing in speed, angle, force
Evidence shows that the leading predisposing factor for spraining an ankle sprain is having had a previous ankle sprain, and it is estimated that 30% of individuals who have sustained a grade 2 or 3 ankle sprain will go on to develop chronic ankle instability.
Your ankle rehabilitation program is not complete until your ligaments have healed, you have regained full ankle joint range of motion, muscles that cross and act on the ankle have returned to full strength, and proprioceptive sensitivity has returned to normal. Until this is achieved, you are at greater risk for becoming one of the previously mentioned statistics.
About the Author
Lynn Perkes is a full-time faculty member at Brigham Young University-Idaho teaching courses in Kinesiology and Biomechanics, Applied Kinesiology and Assessment, Therapeutic Exercise, and other Physical Therapist Assistant classes. He writes part-time for ProhealthcareProducts.com, who sells healthcare, medical, therapy, fitness, and personal protective equipment and supplies.