I can’t tell you how many times in my practice I hear the expression. “Doc, I just twisted my ankle, but I could walk on it, so I thought it was just a little sprain”. Ankle injuries occur often to us, but not just when we are exercising or playing sports like volleyball, soccer, basketball, or lacrosse. They can also occur with just walking in our home. Like going down our stairs or playing with our friends or family in the front yard. When the ankle gets injured, we may experience some swelling and pain that let us know we injured ourselves. But when is a sprain not just something we can “walk off”?
The usual motion of how someone rolls their ankle is from the outside or “inverting” the ankle. The less common twist is when the foot/ankle “everts” and rolls outward. This injury is associated with a more severe type of injury. The more common inverted injuries is when the outside tendons and ligaments to our ankle and foot become stretched or torn to the point of triggering inflammation. Inflammation is the body’s natural mechanism when the body senses injury and needs to begin repair. The typical presentation you will see are signs of swelling, increase pain and even in more severe injuries, bruising and redness will occur. Just because you can walk on the injury after it occurs does not mean the injury is mild and should be ignored. The best approach is to first stop the activity you are participating in and address the injury. The body has three phases of healing and the first phase, the most common and important phase, is inflammation. This phase is when we are in the most pain and observe the most symptoms. It is a very important phase in healing and can last 14-21 days. In my opinion, it is the most important time for you to seek medical attention and find out the severity of the injury. X-rays may be needed to rule out if there is a fracture (broken bone) along the ankle or foot that is not always clear at the onset of the initial injury.
Sprains are technically a pull or tear of a ligament. Ligaments are fibrous tissue that connect one bone to another over a joint to provide stability. Injury to ligaments that are not properly addressed will result in an instability of that particular joint and potential for abnormal wear and tear on that joint. Abnormal wear and tear on joints can lead to progressive arthritis that can begin at an earlier age versus if the injury was addressed early and treated correctly. When not addressed, this usually leads to chronic pain and reduction in full function and performance.
The rule of “RICE” (Rest, Ice, Compression, Elevation) is the best way to treat the injury, initially. This will reduce the pain and swelling caused by the inflammation. If the injury is severe enough and you are having trouble weightbearing on the injured foot/ankle, then getting crutches or a knee scooter to help to get around is suggested. The next step in treatment would be to seek medical care with a foot & ankle specialist to get an x-ray and rule out any fracture and/or cartilage issue of the neighboring bones and joints. Once the fracture is ruled out, then a diagnosis of a sprain can be made and proper treatment and advise can be provided.
There are three degrees of sprains, no matter the location. Grade 1 is usually a pull of the ligament with maybe some micro tears, but the overall ligament is still intact. Healing occurs in about 1-3 weeks and return to sport is pretty quick. Grade 2 sprains are more partial tears that require immobilization for 2-6 weeks with a walking boot or cast. It is important to address them sooner than later as they will continue to be painful since there is usually a tear. Grade 3 ligament sprains are a complete rupture of the ligament and are normally treated like a fracture (broken bone) with immobilization with a cast or a boot for up to 6-8 weeks due to the severe instability created from the injury.
There are schools of thought that believe you need to try to treat sprains with immediate mobilization and range of motion. I have found in my practice that patient respond and recover better with an initial period of immobilization for a period that is correlated with the grade of injury. Initial motion tends to continue to disrupt the injury more and creates a delay in the recovery. Weight bearing with a boot or cast is dependent on the degree of the injury and the symptoms. So it is not uncommon for a patient to be in a walking boot for up to 4 weeks with a grade 2 sprain before it is stable enough to return to a regular shoe. Once the ligament has been given enough time to heal and continue through the 2nd phase of healing (healing phase), then it can be transitioned to an ankle brace and rehabilitation can begin. I cannot stress enough the importance of physical therapy and rehabilitation to provide complete healing of the sprain. Physical therapy is vital in providing instruction and guidance on strengthening, balance training, gait retraining and improving functional performance after an ankle sprain. Failure to completed or partake in physical therapy and rehabilitation once immobilization is completed will result in a delay in proper functional performance and even increases the risk of reinjury due to weakness of the neighboring muscles and lack of neurological biofeedback for the body to prevent another injury.
It is never a good time to get injured. It is inconvenient, creates temporarily changes of our lifestyle, changes our ability to work and play and is an overall hassle. However, not addressing the issue can lead to longer functional issues and pain that can go on for a number of months or even years. Even to the extent that the instability and pain caused by the lack of attention to the injury may lead to the need for surgical intervention, which makes one's recovery and inconvenience even longer. So, it is best to address the issue sooner than later. As an athlete, you cannot perform at 100% if you have something that is weighing you down and only allowing you to perform at 75%.