Ankle Pain

Sprained Ankle

What is an ankle sprain or sprained ankle?

An ankle sprain is the most common injury to the ankle and the long term consequences of an ankle sprain is a common cause of chronic ankle pain. The most common type is the inversion ankle sprain, in which the ankle rolls over on the outside.

An ankle sprain is the stretching and tearing of ligaments – in the sprained ankle the most common damage is done to the talo-fibula ligament (if the ankle sprain is worse, the calcaneo-fibula ligament can also be damaged) – sometimes the tendons also get damaged.

Sprained ankle causes:

Anything that makes the ankle ‘tip over’ increases the chance of an ankle sprain – this can occur in sport (eg jumping and landing on someone’s else’s foot), walking on uneven surface, twisting motions etc.

A number of factors predispose to ankle sprains:

* poor rehabilitation of a previous sprained ankle

* poor proprioception (proprioception is the ability to sense where a joint is …. if you don’t know where your ankle is, the muscles will not be able to prevent the ankle sprain)

* some feet are very easy to ‘tip over’ – this is common in those who frequently ‘roll the ankle’, without actually doing any damage and spraining the ankle

* weak muscles (they are just not strong enough to prevent the sprain occurring)

Ankle sprain types:

The sprained ankle is often classified as to how severe it is:

First degree ankle sprain:

* Some stretching or mild tearing of the ligament.
* Little or no functional loss – the joint can still function and bear some weight (…but hurts!!!).
* Mild pain
* Some swelling
* Some joint stiffness.

Second degree ankle sprain:

* Some more severe tearing of the ligaments
* Moderate instability of the joint
* Moderate to severe pain – weightbearing is very painful
* Swelling and stiffness

Third degree ankle sprain:

* Total rupture of a ligament – there is a loss of motion
* Gross instability of the joint – joint function is lost
* Severe pain initially followed by no pain
* Severe swelling

What to do when it you get an ankle sprain or sprained ankle?

The sooner treatment starts for a sprained ankle, the greater chance to prevent chronic pain and long term instability.

For all grades of ankle sprain follow the R.I.C.E. principles as soon as possible:

* Rest your ankle – do not walk on it.

* Ice – this helps to keep the swelling down. Use ice on the injury several times a day for 15-20 minutes (more than 20 minutes is not advised)

* Compressive bandages are needed to immobilize the ankle sprain and to support the injury.

* Elevate the ankle above your heart level for as much as you can for 48 hours.

If the sprain is a 2nd or 3rd degree ankle sprain, seek professional advice immediately.

Sprained ankle treatment

If the ankle sprain is a 2nd degree sprain, then in addition to the R.I.C.E. principle, a more effective means of immoblising the ankle (splints) may be needed. Anti-inflammatory medication may also be used to help.

If the ankle sprain is a 3rd degree sprain, cast immoblisation is needed for at least 2-3 weeks. Surgery to repair the ruptured ligament is ont often needed.

Physical therapy modalities (such as ultrasound) and manual therapy modalities (such as friction massage) are often used when the acute phase is over.

As soon as treatment is instigated, consideration must be given to adequate rehabilitation:

* exercises to increase proprioception

* ankle braces and strapping to facilitate activity

* muscle strengthening and flexibility exercises

* gradual return to any sporting activities

* maintain fitness by doing alternative activities

Exercises after the first 48 hours play a major role in the in the rehabilitation of the sprained ankle and the prevent of ankle sprains.

Initially, start by using a towel to gently pull the foot towards you. Repeat this several times a day, Later use calf muscle stretches against the wall.

Initially, start by balancing on one foot – hold for as long as possible – repeat several times a day. Later a ‘wobble’ board can be used.

Initially start by pushing the foot outward against a wall. Hold for 3 seconds – repeat 20 times, several times a day. Later use an elastic band that is tied to a heavy object and move the foot outward against this.

This is not a comprehensive ankle sprain rehabilitation program, but gives an idea of the kind of exercises that are needed for the sprained ankle.

What causes long term pain after ankle sprains

The most common cause for long term pain after an ankle sprain is poor rehabilitation of a previous ankle sprain. All causes of chronic pain after an ankle sprain should be evaluation by a health professional.

The common causes are of chronic ankle pain are:

* poor rehabilitation

* a fracture that was not initially diagnosed

* congenital abnormality

* post traumatic arthritis

* osteochondritis dissecans (loose bit of bone in the joint)

* sinus tarsi syndrome

* syndesmotic ligament injury

* functional instability (a feeling of ‘giving way’)

* ankle impingement

The list is complicated and diagnosis of what is causing the chronic pain after the ankle sprain is not easy.

Prevention of the sprained ankle

A number of things can be done to prevent an ankle sprain, especially if there is a history of recurrent sprained ankles:

* continue to stretch the calf muscles, strengthen the muscles and the balance exercises

* use strapping or an ankle brace

* sometimes a wedge in the shoe will help prevent the ankle from ‘tipping over’ – this is particular helpful in those who ‘roll’ their ankle a lot

Those who chronically sprain the ankle on a regular basis usually need surgery to ‘tighten’ the ligaments or move a tendon to help stabilize the ankle.

Tarsal tunnel syndrome

Tarsal tunnel syndrome is a condition that is caused by the entrapment of the tibial nerve on the inside of the ankle.

There are some very tight structures in this area, so there is very little room for expansion if any of these structures becomes inflamed or enlarged. This inflammation or enlargement of the nerve in this area causes the entrapment.

When this entrapment compresses the nerve, it can cause pain, burning sensations, and tingling on the sole of the foot. This usually worsens as the day progresses and is usually relieved by rest, elevation, or rubbing the area. The diagnsis of tarsal tunnel syndrome is sometimes made using nerve conduction tests.

Cause of tarsal tunnel syndrome:

A number of factors are involed in the cause if tarsal tunnel syndrome:

the nerve ‘bends’ around behind the inner ankle bone (medial malleolus) – this bend in the nerve does make it more prone to damage in this area.

structures that are adjacent to the nerve can compress the nerve if they become swollen (eg tendon)

people with very flat or pronated feet are more prone to develop tarsal tunnel syndrome.

a cyst or other lesion may develop in the area

some systemic diseases, such as rheumatoid arthritis can cause a swelling in joints that may compress on the nerve.

trauma or fractures causing a malalignment or the development of scar tissue can also affect how the nerve functions and the pressures on it.

Treatment of tarsal tunnel syndrome:

Conservative treatment generally consists of the use of some sort of foot support, which can often help, especially if the feet are very flat. Anti-inflammatory drugs may be used. Sometimes steroid injections can be effective. Surgical treatment may be necessary if these conservative measures are ineffective. An incision is made into the tisses to allow room for expansion of the nerve or for remoeal of a cyst or other structure that is compressing the nerve.