The most common type of joint injury is a sprain. A sprain results from the stretching and tearing of small ligaments (fibrous bands connecting adjacent bones in a joint). There are many ligaments surrounding joints that can become damaged when the joint is forced into an unnatural position.

The most frequent type of sprain is an ankle sprain and it occurs when weight is applied to the foot when it is on an uneven surface, causing the foot to "roll in" or "turn inward" (inversion). This places the sole of the foot in such a position that it points inward as force is applied, so the ligaments stabilizing the outside part of the ankle become stressed. Many people report hearing a "snap" or "pop" when an injury of this type occurs. A less commonly occurring sprain is when the foot "rolls out" (eversion) and result in damage to the inside ankle ligaments. Following such an incident, one experiences difficulty walking and, in a short time, the injured aspect of the injured ankle begins to cause pain and swells, sometimes so excessively that people believe it is broken.

Upon physical examination, the ankle will exhibit swelling and discoloration (black and blue) over the injured part of the joint. Touching of the area will result in a variable amount of discomfort. Frequently, there is instability. The range of motion in the ankle generally will become limited due to pain and swelling, but strength well not be affected. X-rays are often required to rule out the possibility of a fracture.

SEVERITY OF SPRAINS

Grade I

• Mild sprain, mild pain, little swelling, and joint stiffness may be apparent
• Stretch and/or minor tear of the ligament without laxity (loosening)
• Usually affects the anterior talofibular ligament
• Minimum or no loss of function
• Can return to activity within a few days of the injury (with a brace or taping)

Grade II

• Moderate to severe pain, swelling, and joint stiffness are present
• Partial tear of the lateral ligament(s)
• Moderate loss of function with difficulty on toe raises and walking
• Takes up to 2-3 months before regaining close to full strength and stability in the joint

Grade III

• Severe pain may be present initially, followed by little or no pain due to total disruption of the nerve fibers
• Swelling may be profuse and joint becomes stiff some hours after the injury
• Complete rupture of the ligaments of the lateral complex (severe laxity)
• Usually requires some form of immobilization lasting several weeks
• Complete loss of function (functional disability) and necessity for crutches
• Usually managed conservatively with rehabilitation exercises, but a small percentage may require surgery
• Recovery can be as long as 4 months

TREATMENT

Many problems resulting from sprains are due to blood and edema (swelling) in and around the joint. Minimizing swelling helps the joint heal faster. Most sprains heal completely within a few weeks. With increasing injury severity, the rehabilitation process becomes more complex and extensive. Chronic or recurrent sprains often will receive some type of strengthening program and rehabilitation due to poor balance on the joint.

Phase I (Early Phase):

Goal:

• Decrease post-injury swelling, bleeding, and pain. Protect the healing ligament(s).
• Avoid for the first 24 hours:
  • Hot showers
  • Heat rubs (e.g. Ben Gay)
  • Hot packs
  • Drinking alcohol
  • Aspirin–it prolongs the clotting time of blood and may cause increased bleeding into the joint (Ibuprofen (Advil) may be taken to help with pain)

The so-called PRICE regimen is an often used program for the initial management of a sprain:

• Protection
  • Ligaments must be maintained in a stable position
  • Stay off your feet as much as possible if pain persists
  • Use a stirrup or brace if necessary
  • Limited weight bearing but early motion including walking is essential, since weight bearing inhibits the tightening of tendons, which may lead to tendinitis
• Rest
  • Allow injured joint to rest for approximately 24 hours after the injury
  • Caution should be taken against vigorous exercise
  • Exercise for the uninjured leg may be performed
• Ice
  • Ice the joint every 2 hours for 20 minutes to decrease pain, swelling, and spasticity for the first 48-72 hours
  • Do not place ice on the joint for over 30 minutes
• Compression
  • Done with ice
  • Place air or cold water within enclosed bag to provide pressure to decrease swelling
  • Ace wraps, which may be wet to facilitate the passage of cold, could be used - wrap distal to proximal
• Elevation
  • Elevate as much as possible with ice and compression
  • Elevate the joint higher than the waist to reduce swelling and pain
  • Keep the joint elevated while sleeping

Phase II (Rehabilitation Phase):

This phase begins when swelling stops increasing and pain lessens, so that the ligament(s) have reached a point in the healing process at which they are not in danger given minimal activity. Pain is the guide as to how much activity is enough.

Goal:

• To increase motion and strength, which will aid in circulation and help eliminate residual inflammatory agents.

Motion and strength may be recaptured by:

• Stretching
  • Do stretches before and after activity
  • Vigorous stretches,
    • For ankles - heel cord/calf stretches hold 20 seconds each, performed every 2 hours) - moderate pull but no pain
    • All activities should be done slowly without pain at high repetitions (3 sets of 20)
    • Toe curls–place a towel on the floor and curl your toes to pick up the towel
    • Marble pickups–pick up marbles with your toes
    • Perform alphabet exercise–rest heel on floor and write the alphabet in the air with your big toe, making the letters as large as you can
• Stationary bike
• Strength
  • Begin with isometric exercises with progression to isotonic exercises (with and without resistance) in a pain free motion
  • As the ligament heals further and ROM increases, strengthening exercises may begin in all planes of motion
  • Pain should be used as the basic guideline for deciding when to start isotonic exercises
  • Obtain a strip (about 2 feet long) of elastic belting material, surgical tubing (from a medical supply store), or a bike tire inner tube and work your joint in all directions. Pull the tubing taut, making sure for ankles that the tube is placed at the base of your toes, and do the exercises only with your foot and ankle, not the whole leg
    • Out and up:  sit on floor or chair, loop tubing over foot and around table leg, with heel on floor, work ankle out and up
    • In and up:  as above, but loop tubing to provide tension against an inward motion, with heel on floor, work ankle in and up
    • Straight up:  as above, but with heel on floor, work ankle straight up
    • Straight down:  hold tube loop against bottom of foot, with heel on floor, work ankle down
  • At the beginning of the rehabilitation process, use weights for light resistance in all directions described above (2-4 sets of 20)
  • Heel/toes raises–stand on a step with your heels slightly off the step and slowly rise up on your toes and equally slowly lower heel down; when this exercise becomes simple to perform, do the exercise using only the injured leg in a pain free motion
  • Single knee flexion exercises–stand on injured leg and bend that knee and straighten it
• Proprioception
  • Defined as the knowledge of where one's body is in space
  • Following joint sprains, the injury can cause balance deficits (from loss of proprioception), and therefore increasing the risk of reinjury and poor healing
  • The greater ligament disruption, the greater proprioception loss
  • Early weight bearing on the ankle (e.g. standing/walking) decreases proprioception loss - begin by standing with eyes closed and progress to standing on injured leg with eyes closed

Phase III (Full Functional Level):

• Goal is to return to prior level of activity
  • Must have full range of motion
  • Must have 80-90% strength in injured joint
  • Strengthen the uninjured leg
  • Run in a pool, using a floating device; swimming
  • Tape the joint if necessary
  • High-topped footwear to stabilize the ankle
  • Gradual progression of functional activities
  • Full weight bearing when you can walk without a limp
  • Lunges forward, on a 45° angle, and sideways with injured and uninjured leg
  • Pain-free hopping on affected side
  • Step on high step in pain free motion
  • Stand on toes of the injured joint for 20 seconds hop 10 times
  • Begin stairmaster, treadmill, biking
  • Running can be started upon pain free walking

When to Seek Medical Attention:

If the ankle is obviously fractured/dislocated or the injury is causing severe pain/disability, then medical attention should be sought immediately.