What is ankle pain?
Ankle pain and sprains are common injuries that affect the ankle joint. The ankle joint is primarily formed by the tibia and fibula bones of the lower leg, as well as the talus bone of the foot. Ankle sprains occur when the ligaments that support the ankle joint are stretched or torn, leading to pain, swelling, and instability. Below is a detailed explanation of ankle pain and sprains:
Anatomy of the Ankle
To understand ankle pain and sprains, it’s helpful to know the anatomy of the ankle joint. The ankle joint is made up of three bones: the tibia (shinbone), the fibula (smaller bone in the outer lower leg), and the talus (a bone in the foot). The ends of these bones are covered with cartilage, which allows for smooth movement within the joint. Ligaments, which are strong bands of tissue, help stabilize the joint by connecting the bones together.
The lateral (outside) ligaments of the ankle play a crucial role in providing stability to the joint and preventing excessive inversion (rolling inward) of the foot.
There are three main lateral ligaments:
- Anterior Talofibular Ligament (ATFL): The ATFL is the most commonly injured ligament in ankle sprains. It connects the lateral malleolus (the bony prominence on the outer side of the ankle) of the fibula to the talus bone. It runs diagonally from the front and lateral side of the ankle joint. The ATFL primarily resists excessive inversion and helps stabilise the ankle during plantarflexion (pointing the foot downward). It is the weakest of the three lateral ligaments.
- Calcaneofibular Ligament (CFL): The CFL is located just below the ATFL and runs from the lateral malleolus of the fibula back to the calcaneus bone (heel bone). It is positioned more horizontally than the ATFL and provides additional stability to the ankle against inversion forces. The CFL is typically injured in conjunction with the ATFL during severe ankle sprains.
- Posterior Talofibular Ligament (PTFL): The PTFL is the strongest and least commonly injured of the lateral ligaments. It connects the lateral malleolus of the fibula to the posterior aspect of the talus bone. The PTFL primarily resists posterior displacement of the talus and provides stability to the ankle joint during dorsiflexion (pulling the foot upward).
Together, these three ligaments form a supportive network on the lateral side of the ankle, providing stability and preventing excessive inversion movements. When a lateral ankle sprain occurs, it typically involves the stretching or tearing of one or more of these ligaments, with the ATFL being the most commonly affected.
The Varying Degrees of Lateral Ankle Sprains
The severity of a lateral ankle sprain can vary.
- Grade I sprain: Mild stretching of the ligaments or micro tears. This is considered a mild injury, and there is typically minimal swelling, tenderness, and joint instability. Recovery time for a grade 1 sprain is usually around 1-2 weeks.
- Grade 2 sprain: A grade 2 sprain involves a partial tear of the ligaments. This type of sprain presents with moderate swelling, pain, and difficulty walking or bearing weight on the affected ankle. Recovery for a grade 2 sprain may take approximately 4-6 weeks, and immobilisation or bracing might be recommended during the early stages of healing.
- Grade 3 sprain: Grade 3 sprains involve a complete tear or rupture of the affected ligament(s). These sprains cause significant pain, swelling, bruising, and marked instability of the ankle joint. The recovery time for a grade 3 sprain can vary but generally ranges from 8 weeks to several months. Treatment often involves immobilisation with a walking boot and intense physiotherapy. Following a thorough assessment, our physiotherapy staff may discuss the option of an orthopaedic referral if required.
Deltoid Ligament Complex in Ankle Stability
The medial side (inside) of the ankle also has important ligaments that provide stability and support to the joint. The main ligaments on the medial side of the ankle are the deltoid ligament complex. The deltoid ligament complex consists of several ligaments that work together to resist excessive eversion (rolling outward) of the foot. The four ligaments that comprise the deltoid complex of the medial ankle include the Tibionavicular Ligament, Tibiocalcaneal Ligament, Posterior Tibiotalar Ligament, and Anterior Tibiotalar Ligament.
Injuries to the deltoid ligament complex are less common than lateral ankle sprains but can occur, typically as a result of a significant force or trauma, such as a severe ankle twist or impact. Medial ankle sprains involve stretching or tearing of one or more of these ligaments.
Causes of Ankle Sprains
Ankle sprains typically occur when the foot twists or rolls forcefully, causing the ligaments to stretch beyond their normal range of motion. This can happen during activities such as running, jumping, or even simply walking on uneven surfaces. Common causes of ankle sprains include:
- Inversion sprains: These are the most common type of ankle sprains and occur when the foot rolls inward, stretching the ligaments on the outside of the ankle.
- Eversion sprains: Less common than inversion sprains, these occur when the foot rolls outward, stretching the ligaments on the inside of the ankle.
- High-impact sprains: These sprains are often the result of a significant force or trauma, such as landing awkwardly from a jump or during a car accident. They can lead to more severe ligament damage.
Symptoms of Ankle Sprains
When an ankle sprain occurs, several symptoms can manifest, including:
- Pain: Ankle sprains typically cause immediate pain around the affected area. The intensity can range from mild discomfort to severe pain.
- Swelling: Swelling occurs due to inflammation caused by the injury. The ankle may become puffy and tender to the touch.
- Bruising: Blood vessels may break due to the injury, resulting in bruising around the ankle.
- Instability: An unstable feeling in the ankle joint may be experienced, making it difficult to bear weight or walk normally.
- Restricted range of motion: Ankle sprains can limit the normal range of motion, making it challenging to move the foot up or down.
Treatment and Recovery Process for Ankle Sprains
The treatment and recovery process for ankle sprains depends on the severity of the injury. Common treatment options include:
- Rest: It’s essential to incorporate relative rest for the affected ankle, allowing the ligaments to heal. It may be necessary to avoid weight bearing and use crutches. Our team of physiotherapists at Any Stage Physiotherapy and Sports Medicine will be able to determine the level of injury and correct course of action. However, early weight bearing has proven to assist with healing. Our team is able to inform you of when this is appropriate.
- Ice: Applying ice packs to the injured area can help reduce swelling and pain. Ice should be applied for about 15-20 minutes every 2-3 hours for the first 48-72 hours after the injury.
- Compression: Wrapping the ankle with an elastic bandage can help control swelling and provide support. It’s important not to wrap it too tightly to avoid cutting off circulation.
- Elevation: Keeping the injured ankle elevated above the heart level can help reduce swelling. This can be done by propping the foot up on pillows or using a recliner.
- Pain relief: Over-the-counter pain medications such as ibuprofen may be recommended to manage pain and reduce inflammation. Please seek medical advice regarding pain medication.
- Rehabilitation exercises: Once the pain and swelling have started to subsided, our physiotherapists at Any Stage Physiotherapy and Sports Medicine will prescribe specific exercises to help regain strength, flexibility, and stability in the ankle.
Ankle Sprain Recovery and Prevention through Strength Training
Strength exercises are an essential component of ankle sprain rehabilitation as they help restore muscle strength, improve joint stability, and aim to prevent further injuries. Strengthening the muscles surrounding the ankle joint is crucial for supporting the ligaments and providing proper stability during movements.
Strengthening helps with:
- Muscle Stabilisation: After an ankle sprain, the muscles around the ankle can become weak and lose their ability to stabilise the joint. Strengthening exercises target these muscles, including the calf muscles (gastrocnemius and soleus), the peroneal muscles on the outside of the lower leg, and the muscles in the front of the leg (tibialis anterior). By strengthening these muscles, they can better support the ankle joint and provide stability during movements.
- Joint Protection: Strong muscles act as protective mechanisms for the joint. When the muscles surrounding the ankle are strong, they help absorb and distribute forces effectively, reducing the strain on the injured ligaments. This can decrease the risk of recurrent ankle sprains and promote overall joint health.
- Restoring Function: Strengthening exercises aim to restore normal movement patterns and functional abilities. By improving muscle strength and coordination, individuals can regain their ability to perform daily activities, sports, and other physical tasks without pain or instability.
- Improving Proprioception: Strength exercises often incorporate balance and proprioceptive components, enhancing the body’s awareness of joint position and movement. This integration of strength and proprioception helps improve joint stability and reduce the risk of re-injury.
Strength exercises for an ankle sprain typically include, but are not limited to:
- Ankle Alphabet (early phase range of motion): Sit with your legs extended or while seated in a chair, lift one foot off the ground, and trace the letters of the alphabet in the air with your toes. This exercise helps strengthen the ankle muscles and improves range of motion.
- Toe Raises (early phase): Sit with your feet flat on the floor, then raise your toes up while keeping your heels planted. This exercise strengthens the muscles in the front of the leg (tibialis anterior).
- Calf Raises: Stand with your feet shoulder-width apart, rise up onto your toes, and then slowly lower your heels back down. This exercise targets the calf muscles and strengthens the ankle plantar flexors.
- Resistance Band Exercises (early phase resistance for injured ligaments): Attach a resistance band around the forefoot and perform resisted dorsiflexion (pulling the foot upward), plantarflexion (pointing the foot downward), inversion (rolling the foot inward), and eversion (rolling the foot outward) against the resistance. These exercises target various muscle groups around the ankle.
- Balance Exercises: Stand on two feet and then just your injured foot when able, challenging your balance and stability by closing your eyes. This can also include the Y-balance test.
- Global strengthening: Following an ankle injury, strengthening of the entire leg is vital. Our physiotherapists will help guide you through exercises that target the calf muscle complex, quadriceps, hamstrings and gluteal muscle complex. Improving your overall strength and confidence when returning from an ankle injury.
The Importance of Proprioceptive Exercises in Ankle Sprain Recovery
Proprioceptive exercises play a crucial role in the rehabilitation and recovery process for ankle sprains. Proprioception refers to the body’s ability to sense its position, movement, and balance in space. After an ankle sprain, proprioceptive deficits often occur, leading to decreased joint stability and an increased risk of re-injury.
The Stages of Ankle Sprain Recovery
The timeframe of recovery following a significant ankle sprain typically follows the below stages:
- Acute Phase (0-72 hours): During the first 72 hours following an ankle sprain, the focus is on immediate management of pain, swelling, and inflammation. The RICE protocol is commonly recommended: Rest, Ice, Compression, and Elevation. It is important to protect the injured ankle during this phase. Physiotherapy assessment can help determine the severity and what the next course of action is. This is important to help provide education around weight bearing, scans and time frames.
- Subacute Phase (3 days – 3 weeks): As the acute phase subsides, the focus shifts to promoting healing, reducing swelling, and restoring range of motion. Range of motion exercises, such as ankle circles and toe scrunches, may be initiated. Physiotherapy interventions, including the initiation of early load through the joint is often indicated. This will be determined based on the severity of the injury and sensitivity of the joint. Soft tissue massage and taping can also be used during this phase.
- Early Functional Phase (3-6 weeks): During this phase, weight-bearing and functional activities are gradually introduced. Strengthening exercises for the muscles around the ankle, balance and proprioceptive exercises, and low-impact aerobic activities may be included in the rehabilitation program. This phase aims to improve strength, stability, and proprioception, gradually transitioning the individual back to normal activities.
- Intermediate Phase (6-12 weeks): The focus of this phase is on further increasing strength, range of motion, and functional activities. More challenging exercises and activities specific to the individual’s needs and goals are introduced. Physiotherapy may include exercises using dynamic movements, weights, inclines and declines to enhance ankle stability and function.
- Advanced Phase (12 weeks and beyond): In this phase, the emphasis is on returning to full activities, sports, and higher-level functional tasks. The individual engages in sport-specific training, agility drills, and more challenging balance and coordination exercises. Continued strength and conditioning exercises are important to prevent re-injury and maintain optimal ankle function.
There are a series of range of motion, strength and stability tests that are performed throughout the rehabilitation process. These assessments provide feedback to the individual and physiotherapist about when and if the individual is able to progress to the next stage and whether they will tolerate an increase in intensity.
Final thoughts on Ankle Sprain Rehabilitation
Recovery time can vary significantly based on the severity of the sprain. Mild sprains may heal within a few weeks, while more severe sprains, such as high-grade sprains or those with associated ligament tears, may require several months of rehabilitation. Each person’s progress may also differ, and it is crucial to work closely with your physiotherapist and healthcare team, who can provide an individualised treatment plan and monitor progress throughout the recovery process.
If you have experienced a recent ankle injury, or, you have persistent ankle pain, please do hesitate to contact our friendly and experienced team at Any Stage Physiotherapy and Sports Medicine. We are here to guide you back to a pain free lifestyle and help return you to sport.
Daniel Lee, DPT, B. Sc, APAM
Director / Principal Physiotherapist
Shannon Murray, DPT, B. HSc, APAM