A sprained ankle (twisted ankle, rolled ankle, turned ankle, etc.) is an injury where a sprain occurs on one or more ligaments of the ankle. It is the most commonly occurring injury in sports, mainly in ball sports (basketball, volleyball, and football) as well as racquet sports (tennis, badminton and pickleball). Ankle sprains are also among the most common acute dance injuries, often causing pain around the ankle and, in more severe cases, swelling and bruising.
Signs and symptoms Knowing the symptoms that can be experienced with a sprain is important in determining that the injury is not really a break in the bone. When a sprain occurs, hematoma occurs within the tissue that surrounds the joint, causing a bruise. White blood cells responsible for inflammation migrate to the area, and blood flow increases as well. Along with this inflammation, swelling and pain is experienced. The nerves in the area become more sensitive when the injury is suffered, so pain is felt as throbbing and will worsen if there is pressure placed on the area. Warmth and redness are also seen as blood flow is increased. There is also decreased ability to move the joint.
Cause Movements – especially turning, and rolling of the foot – are the primary cause of an ankle sprain. The risk of a sprain is greatest during activities that involve explosive side-to-side motion, such as tennis, skateboarding or basketball. Sprained ankles can also occur during normal daily activities such as stepping off a curb or slipping on ice. Returning to activity before the ligaments have fully healed may cause them to heal in a stretched position, resulting in less stability at the ankle joint. This can lead to a condition known as Chronic Ankle Instability (CAI), and an increased risk of ankle sprains. The following factors can contribute to an increased risk of ankle sprains:
Weak muscles/tendons that cross the ankle joint, especially the muscles of the lower leg that cross the outside, or lateral aspect of the ankle joint (i.e. peroneal or fibular muscles) Weak or lax ligaments that join the bones of the ankle joint – this can be hereditary or due to overstretching of ligaments as a result of repetitive ankle sprains Inadequate joint proprioception (i.e., sense of joint position); Slow neuron muscular response to an off-balance position; Running or stepping on uneven surfaces; Shoes with inadequate heel support; and Wearing high-heeled shoes – due to the weak position of the ankle joint with an elevated heel, and a small base of support. Ankle sprains occur usually through excessive stress on the ligaments of the ankle. This can be caused by excessive external rotation, inversion or eversion of the foot caused by an external force. When the foot is moved past its range of motion, the excess stress puts a strain on the ligaments. If the strain is great enough to the ligaments past the yield point, then the ligament becomes damaged, or sprained.
Diagnosis The diagnosis of a sprain relies on the medical history, including symptoms, as well as making a differential diagnosis, mainly in distinguishing it from strains or bone fractures. The Ottawa ankle rule is a simple, widely used rule to help differentiate fractures of the ankle or mid-foot from other ankle injuries that do not require x-ray radiography. It has a sensitivity of nearly 100%, meaning that a patient who tests negative, according to the rule almost certainly does not have an ankle fracture. If ankle pain is persistent 6–7 weeks after initial sprain, MRI imaging of the joint can be considered to rule out peroneal tendon, osteochondral, or syndesmotic injury.
Classification of severity Ankle sprains are classified as grade 1, 2, or 3, and, depending on the amount of damage or the number of ligaments that are damaged, each sprain is classified from mild to severe. A grade 1 sprain is defined as mild damage to a ligament or ligaments without instability of the affected joint. A grade 2 sprain is considered a partial tear to the ligament, in which it is stretched to the point that it becomes loose. A grade 3 sprain is a complete tear of a ligament, causing instability in the affected joint. Bruising may occur around the ankle.
Types
Inversion (lateral) ankle sprain The most common type of ankle sprain occurs when the foot rolls inwards, or has a force, typically one's body weight, causing it to internally rotate beyond its normal range, affecting the lateral side of the ankle. When this type of ankle sprain happens, the outer, or lateral, ligaments are stretched too much. The anterior talofibular ligament is one of the most commonly involved ligaments in this type of sprain, followed by the calcaneofibular ligament and posterior talofibular ligament respectively, the latter found in more severe ankle sprains. Approximately 70–85% of ankle sprains are inversion injuries.
When the ankle becomes inverted, the anterior talofibular and calcaneofibular ligaments are damaged. This is the most common ankle sprain.
Eversion (medial) ankle sprain A less common type of ankle sprain is called an eversion injury, affecting the medial side of the foot. This happens when, instead of the ankle rotating medially resulting in an inversion injury (the foot rolling too much to the inside), the ankle rotates laterally resulting in an eversion injury (when the foot rolls too much to the outside). When this occurs, the medial, or deltoid, ligament is strained.
High (syndesmotic) ankle sprain A high ankle sprain is an injury to the large ligaments above the ankle that join the two long bones of the lower leg, called the tibia and fibula. High ankle sprains commonly occur from a sudden and forceful outward twisting of the foot. This commonly occurs in contact and cutting sports such as football, rugby, ice hockey, roller derby, basketball, volleyball, lacrosse, softball, baseball, track, ultimate frisbee, soccer, tennis and badminton and horse riding.
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