eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Acute Ankle Sprains: Treatment

Author: Ray Foster, MD, FACS, Medical Staff Physician, Black Hills Health and Education Center
Contributor Information and Disclosures

Updated: Apr 30, 2009

Treatment

Medical Therapy

Most ankle sprains heal spontaneously with immediate application of ice locally, elevation for the first 24 hours after injury, the use of an ankle support as long as symptoms persist, and avoidance of activity that causes pain. Many immobilization devices are comfortable and conform to the ankle with air cushion pads (eg, air cast). Immobilization that allows movement until healing has taken place (3-6 weeks) is the criterion standard for ankle sprain treatment because the collagen fibers heal the fastest and orient along the lines of force where protected movement occurs. Early movement also helps in decreasing swelling and the danger of fibrosis that normally develops in chronic swelling.^{13,14,15,16,17}

The Collaborative Ankle Support Trial (CAST) in the United Kingdom was a randomized, controlled trial that compared the clinical effectiveness and cost-effectiveness of 3 methods of ankle support (below-knee cast, Aircast brace, and Bledsoe boot) with that of the double-layer tubular compression bandage (Tubigrip). At 3 months, the below-knee cast was shown to provide an advantage in terms of overall recovery (pain, activities of daily living, sports participation); the Aircast provided minimal advantage; and the Bledsoe boot provided no significant advantage.¹⁸

By 9 months, there were no significant differences in the 4 therapies in the CAST trial. Cooke et al concluded that the below-knee cast and the Aircast brace provided cost-effective alternatives to the tubular bandage in the treatment of acute severe ankle sprain. However, since no differences in long-term outcome were noted, practitioners should consider likely patient compliance and acceptability when choosing a brace.¹⁸

For acute third-degree ankle sprains, cast immobilization is indicated for 3 weeks, followed by a walking boot or other ankle immobilization device after the immediate swelling has subsided. Immediate icing and elevation are used to decrease the swelling and reduce the danger of long-term postswelling fibrosis.

Surgical Therapy

The 2 indications for surgical treatment of acute ankle sprains that are generally agreed upon are (1) a deltoid sprain with the deltoid ligament caught intra-articularly with widening of the medial ankle mortise and (2) an inferior tibiofibular syndesmosis sprain causing real or potential widening of the ankle mortise. Acute grade 3 tears of the interior tibiofibular ligament can have a normal radiographic appearance in patients not bearing weight; this is the standard of care in acute ankle sprains because of the discomfort associated with bearing weight. Thus, keep in mind that normal radiographic findings do not rule out the need for surgery.^13,14,15

Pain and swelling localized over the inferior tibiofibular syndesmosis should alert the clinician to tears in the syndesmosis complex that may best be treated with surgical fixation. There is still controversy concerning the surgical treatment of complete anterior talofibular and fibulocalcaneal tears (double ligament tears) and for the rare cases in which all 3 lateral ankle ligaments are torn. In a young patient with athletic requirements, surgical repair of a severe lateral ankle sprain is sometimes indicated.

Treatment of distal tibiofibular syndesmosis sprains consists of placement of a screw across the syndesmosis.¹⁹  The screw remains in place for 6 weeks; to avoid screw breakage, the screw is removed before weight bearing is allowed.

Surgical repair of the lateral ligaments is still debated. Exposure must be made carefully so as to avoid the sural nerve posteriorly and the lateral branch of the superficial peroneal nerve anteriorly. Nonabsorbable flexible suture is preferred for suturing the tendons and the capsule. The peroneal tendon sheaths are opened and the tendons retracted to access and repair the calcaneus fibular ligament. The peroneal tendon sheaths should be repaired along with the joint capsule. Careful skin handling and meticulous repair are indicated, as the skin is thin and fragile over the lateral ankle, even in young athletes.

Intraoperative Details

Open reduction of a deltoid ligament caught in the medial ankle is performed through a curved incision below the medial malleolus. For greater exposure, some surgeons prefer a vertical incision. (The physician should use his or her best judgment when choosing the type of incision that will result in the least skin problems and the best healing). Release the caught ligament, and either suture the ligament together or suture it to bone with a trocar needle using a nonabsorbable pliant suture. A standard postoperative course should be followed, including splinting in the same manner as for conservative treatment of ankle sprains.

Postoperative Details

Acute sprains that do not heal and become painless should alert the clinician to possible complications, such as a loose body, posttraumatic arthritis, or an occult fracture. An MRI could be helpful in defining a mechanical cause of continued symptoms that could be corrected surgically.

Follow-up

Follow-up care is very important because ankle sprains tend to recur and progress to ankle instability if neglected.²⁰ The goals of follow-up care are 3-fold:

• First, the range of motion must be restored completely. This is most important to help prevent a recurrence of an ankle sprain. The desired range of motion is 10-15° of dorsiflexion of the ankle with the knee extended and a full 90° of plantarflexion. Stretching exercises, particularly for the tendo Achillis and for both muscles that attach to the tendo Achillis, are needed. Home exercises after appropriate physiotherapy instruction are important.
• Muscle strengthening after immobilization for any length of time is the second goal. Muscle strength can be targeted specifically, with a physical therapist, or simply, with self-directed walking exercises; ideally, the individual should walk 2 miles a day for 5 days a week for life. Daily walking exercise affords many health benefits besides increased ankle strength and fewer recurrences of ankle sprains. Thera-Band exercises for all muscle groups around the ankle can be self-directed after instruction from a physical therapist or other office staff personnel. Exercising specific muscle groups lacks the synergistic effect obtained from activities such as walking or using a proprioceptive board as described below.
• The third goal is to restore, facilitate, or develop proprioception in the ankle joint. Proprioception is facilitated or developed with physiotherapy instruction and help, if necessary. A half-inch to three-quarter–inch thick piece of plywood, measuring as long and as wide as the foot, can be made and used economically at home for 6 weeks of self-directed exercises by a compliant and motivated patient. This proprioceptive board also helps with the stretching and strengthening exercises. Half of a 3-4 inch diameter plastic or wooden ball is fixed to the center of 1 surface of the board. This device affords 2 levels of range of motion. The patient steps on it with the half of a ball down on the floor to perform 10 sets of ankle motion in plantarflexion and dorsiflexion. Then the foot is placed on the wood cross-wise, and side-to-side motions are performed 10 times. These sets of exercises are performed once or twice daily with the patient’s attention directed to what the foot is doing in order to facilitate the cerebellar-foot neural connections.When these exercises are performed easily (after approximately 3 weeks), the range of motion is increased and the device is used in the opposite fashion; the plantarflexion and dorsiflexion motions can be performed with the foot sideways on the proprioceptive board, and the side-to-side movements can be performed with the foot on the board such that it fits the foot. Care must be taken with these exercises to avoid causing another ankle sprain, which is what the proprioceptive exercises are designed to prevent.

Following the criteria for the patient’s return to sports activities is important. When the athlete can run without a limp or hesitation or pain, the patient can be approved to return to sports. Figure-of-8 measurement around the ankle and midfoot, compared with the contralateral side, can be used to measure swelling accurately. The presence or absence of ankle swelling has been reported to correlate poorly with functioning; therefore, running without pain or limping is the preferred criterion for returning to sports. That is, assuming that the patient has regained proprioception, muscle strength around the ankle, and a full range of motion (or has reached a plateau for several weeks with range of motion, particularly for postoperative patients), and is pain free with a clinically stable ankle. Meeting all of these criteria is necessary to minimize the recurrence of ankle sprains and to minimize chronic symptoms following a severe ankle sprain.

Protective strapping and the use of an ankle support or high-topped footwear are strategies that may help reduce ankle sprain recurrence. There is no substitute for a full range of motion, ankle strength, and proprioception in decreasing the recurrence of ankle sprains.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.

Complications

The major complications of ankle sprains are recurrence, prolonged pain, and ankle instability. These complications are best avoided by rigorous early treatment with adequate immobilization. A rare complication is complex reflex pain syndrome (sympathetic dystrophy). Unrecognized osteochondral injuries are more common in patients with ankle fractures than in those with ankle sprains because higher forces result in fractures rather than in sprains.

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