Ankle Sprains: What should I do?

Eric-Olivier Sirois

Physiotherapist

May 8, 2022

Ankle sprains are very common, and most of us will, unfortunately, have to deal with one at some point in our life. They are the most frequent type of ankle injury and the most common sports injury. (1) For this reason, it is important to understand what they are and how we can treat them to limit their impact in the short and long term, which is the purpose of this article.

What is a Sprained Ankle?

A sprained ankle is what happens when the ligaments that support your ankles are overstretched and even torn sometimes in more severe cases. This is what people refer to when they say they have rolled, twisted or turned their ankles. With an ankle sprain, you will feel sharp pain at the site of injury. Depending on how you injured it, you might feel pain on the inside, outside, or the front of your ankle. 

What are Ligaments and Their Purpose?

Ligaments are a strong thick band of fibrous tissue that connect bones to other bones. The ligaments have the role of limiting how much our joints move to make sure the joints and the bones remain in proper and safe positions. When they are damaged, our joints and muscles become more at risk of sustaining injuries.

It is important to not confuse ligaments with tendons. Tendons are strong tissue ropes that connect muscles to bones. When a tendon is damaged, it is called a strain, not a sprain (2).  Here, we are talking of ligaments, and thus, we are talking of sprains.

Anatomy of the Ankle 

When we talk of sprained ligaments in the ankle, we usually refer to the lower seven ones. There are ligaments at the outer side of your foot, three of them (lateral collateral ligaments of the ankle). There are also ligaments at the inner side of your foot (medial collateral ligaments of the ankle), four of them. 

LCLs (Lateral Collateral Ligaments), (3) 

There are three main ligaments on the outside of your foot. Their purpose is to mainly limit how much your ankle can roll inward. When you sprain your ankle inward, these ligaments are the ones that are damaged. The lateral ligaments are the most commonly sprained. Roughly 85% of the time, they are the affected ones. (4) There are 3 of them, as mentioned earlier:

1.     ATFL (anterior tibiofibular ligament). This ligament is the weakest and unsurprisingly the most often sprained one. 

2.     CFL (calcaneofibular ligament). This is the second most affected ligament. It is usually affected 20% of the time. (4) 

3.     PTFL (posterior tibiofibular ligament). This one is rarely affected and requires a lot of strength to sprain.

MCL (Medial Collateral Ligaments) 

There are four main ligaments on the inside of your foot. Their purpose is mainly to limit how much your ankle can roll outward. When you sprain your ankle outward, these ligaments are the ones that are damaged. The medial ligaments are not as commonly sprained as the lateral ligaments since they are much stronger. They are sprained 15% (3) of the time. The name of the ligament often indicates which bones it connects to:

1. Tibiocalcaneal ligament
2. Talonavicular ligament
3. Anterior Tibiotalar ligament
4. Posterior tibiotalar ligament

How Can I Sprain My Ankle?

Ankles are usually sprained because of a specific wrong movement. Individuals with sprained ankles almost always know when the sprain occurred. They can remember the exact movement that led to it. It usually sounds like this: 

- I was walking on the sidewalk, I misplaced my foot and missed the sidewalk, falling on my ankle. 

- I was playing basketball, and when I landed from my jump, I felt my ankle rolling inside.

- I played basketball/tennis/soccer/football, and when I tried to cut and change directions, I felt my ankle going inside, and I knew something was off.

If you don’t know why your ankle hurts, it is most likely because you didn’t sprain your ankle.

What Does it Feel Like When I Sprain My Ankle?

Usually, you will feel that your ankle rolled or went “too far” in a specific movement, either inward or outward. You will usually feel a sharp knife-like pain just near your ankles. You might also feel that your ankle gave away, like it became unstable out of nowhere. The equivalent would be like when a knee buckles. During the first week, you will most likely experience pain with most movements of your ankle, no matter the severity of the sprain. This is mainly caused by swelling/inflammation. The more your ankle is sprained, the more pain and swelling you are likely to experience in the injured area. The following symptoms may be experienced:

1. Instability
2. Sharp pain
3. Pain in all directions
4. Swelling/inflammation
5. Difficulty walking in the first few days

After the first week, what you feel depends on the affected ligament and to what degree it has been affected. Typically, people will still have pain when walking and putting a good amount of their weight on their ankle when more they sustained a grade 2 or 3 sprain.

What Does it Look Like when I Sprain My Ankle?

Well, that depends on the severity of the sprain. The severity of the sprain is given according to how much damage was sustained by the ligament. The severity is divided into three subgroups, or  “grades.” 

Grade I: Mild Ankle Sprain 

The ligament integrity is preserved, meaning it didn’t tear. You only overstretched a minority of the ligament, which may induce minor inflammation. The big thing with grade 1 sprains is that the ligament can still fulfill its role. The ankle is still stable and functional but is weakened and thus more likely to injure itself further. With a grade 1 ankle sprain, your ankle will probably feel sore and may be slightly swollen. (5) 

Here are common signs and symptoms of a 1st-degree sprain:

1. There will be no bruising and, if any, only minimal swelling.
2. Pain when pressing on the injured area.
3. Moderately painful.
4. During the first few days, you might have limited movements in your ankle. Then as the days go by, it will be mainly one specific movement that will be limited.
5. You can still complete almost any activity that you do daily with moderate pain.

Grade II: Moderate Ankle Sprain 

At this stage, you have a partial tear in the ligament. It was stretched to the point of slight tearing. This will cause the pain to remain longer and induce more swelling. It might prevent you from putting your full weight on the ankle. You may also notice bruising.(5) The tissues in your ankle were stretched to the point that the tiny blood vessels in them and surrounding tissues were slightly torn, which is why there is some bruising. This isn’t dangerous, but it is usually a great indicator that you have at least a 2nd-grade sprain.

Here are Common Signs and Symptoms of a 2nd-Degree Sprain:

1. Hypermobility/Instability (feels like your ankle can move more than it usually does/should)
2. Marked tenderness
3. The swelling is pretty local, not widespread. It is only swollen below the ankle joint, not above it.
4. Significant pain
5. Painful when you touch over the ligament.

Grade III: Severe Ankle Sprain 

This is a full tear of the ligament. You may have heard a snapping sound when it happened. This level of sprain causes moderate pain, swelling and bruising. Because the ligament is no longer able to do its job, your ankle will feel unstable and will be unable to support you properly. (5) This is the most severe grade, but surprisingly, a grade 3 often doesn’t hurt as much as a grade 2. It might seem strange since the ligament is fully ruptured, but this is actually why it isn’t as painful. The signals of pain are somewhat disconnected from the ligament. The connection was interrupted because the two pieces of the ligament are no longer attached. 

Here are Common Signs and Symptoms of a 3rd-Degree Sprain:

1. Your ankle may feel as if it is unstable and feels unsafe to use in any way
2. Diffused swelling all over the ankle and the foot, not only to one side of the ankle
3. Minimal to moderate pain
4. Pain when touching the ligament
5. It is hard to pinpoint where the exact location of the pain is. You can’t show with one finger where it hurts the most.

How Long Will it Take Me to Recover From an Ankle Sprain? (6) 

Recovery time for an ankle sprain greatly varies according to the grade of the sprain. The important thing is to understand that a damaged tissue rarely gets back to 100% of the strength it had before. This is true for almost any tissue. This is why it is essential to understand that to be as stable and solid as before, you need to strengthen the muscles around the joint to compensate for the loss of strength from the injured ligament. You no longer can rely as much on your ligaments, thus you start relying more heavily on your muscles.

Grade 1 

Usually, mild sprains take between 3 and 5 weeks to fully recover, meaning (6) before you are ready to get back to sports for instance. This is the expected timeline when the rehabilitation process is taken care of by a health professional. This is the optimal timeline, if I can say. You might have some long-term consequences from it, particularly if you don’t properly take care of the stiffness of your ankle that may arise after you sprain your ankle. You might even experience stiffness in your ankle years after the sprain, which is usually not desired. It is important to mention that you will most likely feel just fine before 5 or even 3 weeks, but will not be back to where it was stability and protection wise pre-sprain usually before those 3 to 5 weeks.

Grade 2 

A 2nd-degree sprain will usually take anywhere between (6) 4 to 6 weeks to recover from. The ligament has sustained more damage and thus will take longer to heal fully.

Grade 3

3rd-grade sprains are much harder to fully recover (6) from, and they take much longer since the ligament was completely torn apart. These usually take months, between 3 to 6, to fully recover from and will sometime require surgery before rehab can begin. The potential need for surgery and referral to a doctor is one of the reasons why I believe seeing a health professional such as a physical therapist when you believe you sustained an ankle sprain is important. 

Other Factors 

As mentioned previously, sometimes we can be fooled by how much pain we are experiencing and the degree that our ligaments are injured. It can be difficult to know simply with the brief description that I gave earlier if you have a grade 2 or 3 sprain. It would be important to have a professional assess your ankle and determine what is the optimal way to get back to doing what makes you happy in a pain-free way. 

See the summary table at the end to better visualize the differences between the different grades.

Other factors come into play when determining how long it will take before fully recovering from an ankle sprain. The first one would be what you want to do after your injury, for instance, sports. Suppose you play a sport with a lot of changes in direction. In that case, the odds are that it will take you longer before going back to 100% simply because your sport is very demanding on your ankles. You will need to shield them more than someone, for instance, who plays a sport where they wear stiff boots, such as hockey or skiing. 

Another important factor is if you sprain the ligaments inside (MCL) or outside your foot. The ligaments in the inside of your ankle take longer to recover than the outside ones. 

A third factor will be if this is your first or if it is your 5th ankle sprain. Usually, the more ankle sprains you have, the longer it takes before regaining an acceptable level of strength and stability, as every sprain makes the ligament a little weaker. 

Summary Table

When Do I Seek the Help of a Physical Therapist Trained to Treat Ankle Sprains?

When you feel that your ankle is weaker. 

If you feel like your ankle is weak and shaky and doesn’t feel safe, it would be a great idea to consider seeking help from a health professional. If your ankle feels weaker, it likely is, which places you at greater risk of reinjury. Very often, the small muscles on the side of your foot are also stretched and strained when you sprain your ankle. If no one tells you how to strengthen and rehabilitate them properly, they will most likely stay weak and will not help stabilize your ankle as much. This means that not only is your ligament working at around 85% now, but so are your muscles. This isn’t good for the stability of your ankle.

When you can see bruising on your ankle.

Bruised ankles, as we saw earlier, usually mean that you have partially torn your ligament. If you don’t move your ankle the right way, you could easily worsen the situation. It is also important to move and strengthen in the right direction to ensure the new tissue in the ligament adapts correctly and not in a disorganized way. It will impact how good the new tissue is protecting your ankle.

If this isn’t your first ankle sprain.

Ankle sprains can become problematic in the long run. If this isn’t your first ankle sprain, it would be wise to seek professional help to make sure it doesn’t become a recurring theme in your life. Make sure to get it checked properly before there is little left to do to make your ankles stronger and safer. 

When you intend to go back to playing a sport.

It would be important to make sure the ankle is strong enough and ready to get back to work. If it isn’t, going back to sports may lead to more severe ankle sprains. Sometimes, even when you think it was only a minor ankle sprain, two weeks of treatment can have a significant impact in limiting reinjuries compared to freestyling your recovery process.

Prolonged pain (for more than two weeks).

Most of the time, if it is painful for more than two weeks, it means that there was tissue damage that needed a proper guided recovery process. The first week of pain can be blamed on the inflammation, but inflammation is no longer the main source of pain after two weeks. Thus, it becomes important to seek proper help to take care of it before it worsens and potentially becomes a chronic problem.

Why Should I Seek Long-Term Help For My Sprains?

The good news about an ankle sprain is that it is most of the time treatable without any surgery. The bad news is that if we are not careful with how we treat it, it might come back later in life, for instance, if the right exercises weren’t done. Unfortunately, up to 20% of people who sustain an ankle sprain will have what is known as chronic ankle instability. (5) 

Chronic instability is what happens when the ankle is unable to stabilize properly and protect itself with the normal protective mechanisms, even months and years after the ankle is no longer painful. This means that there is a very high likelihood that these individuals will re-sprain their ankles. This is caused by slowed-down reflexes (proprioception) and a lack of strength of the ligaments and muscles around it. (7) Unless proper measures and actions are taken, the likelihood of dealing with chronic instability increases.

 Individuals with a history of acute ankle sprains have an approximately 3.5 times greater risk of sustaining another ankle sprain than those with no such history. (8) This is why it becomes so important, even if the pain is no longer present, to seek help to bulletproof your ankles after sustaining an ankle sprain. It is always better to prevent than to treat. 

Exercises have been proven multiple times to be the go-to approach to prevent chronic ankle instability. (9)(10) For many of us, when we think about exercises, we think of having to do an hour and 12 exercises. The reality is that you will most likely never have to do more than 15 minutes per day and three exercises to benefit from training for most injuries. 15 minutes is a small price to pay to prevent having to put aside what makes us happy sometimes for up to multiple months. No matter how busy someone is, no one is busy to the point of not being able to multitask, moving their ankle and waiting for the coffee machine to make a coffee.

Who Should I Seek Help From?

The first professional that comes to mind is a physical therapist. They have the skill sets and the tools to help you with your ankle sprain. A physical therapist will begin with a thorough assessment to make sure that you indeed have an ankle sprain and then determine which ligament(s) out of the ones mentioned previously is or are the culprits. Once they know which ligament is at fault, they will be able to give you the proper exercises and the adequate restrictions to protect your ankle while you are re-strengthening it safely and soundly. Once the ankle is strong enough, certain activities will be brought back progressively to get you ready for the activities you used to do, whatever they may be. 

Another professional that could help you in this situation would be a physician. I wouldn’t recommend seeing a physician first. It may take some time before having an appointment, and they will most likely confirm that you have an ankle sprain and refer you to physical therapy unless you have a grade 3 sprain. In those cases, they might refer you to an orthopedist first.

What Can I Do If I Can’t See a Health Professional?

During the first week, using the RICE principle would be the best thing to do.  

1.     R for rest. You want to rest your ankle by using it as little as possible. This could mean using crutches or even just trying to walk as little as possible on it. However, the tricky part about ankle sprains is that even if at the beginning we’re avoiding temporarily using the ankle, very quickly we’ll need to start putting weight on it even if it’s somewhat painful. A physical therapist will be able to tell you when you should be restarting that.

2.     I for ice. You want to start putting ice on it after the 2nd day to help slowly decrease the swelling/inflammation and help control the pain. You can put ice on it for 15 minutes multiple times a day. Ice usually is no longer useful after the 5th day. You can still put ice on your ankle after the 5th day, but it will likely not have any impact on your recovery and might even hinder it.

3.     C for compression. You want to apply compression on your ankle with a bandage or an ankle brace initially. This will help control and reduce inflammation/swelling. When applying compression, it is still important to make sure that the bandage is not applied too tightly. It is still important to have an adequate blood flow going to the foot. To assess if it is too tight, make sure to assess the capillary refill of the toes. Capillary refill is the fancy way to explain how long it takes when you pinch the tip of your finger or toe nail to go from white to red again. It should take less than 3 seconds. If it takes longer, the bandage is likely too tight. Redo it, but lighter.

4.     E is for elevation. The goal is to have your ankle above the level of your heart. The reasoning behind it is that it helps drain your ankle and promotes fluid reabsorption better since all the fluids are pushed toward the heart in the body. That is what veins and the lymphatic system are for. This will help decrease the swelling.

Ankle Braces

Many people wonder if they should wear an ankle brace after injuring their ankle, for instance, with an ankle sprain. The reasoning being it will help make the ankle more stable and protect it from awkward movements. This is good reasoning at the beginning of the rehabilitation process when it is still too early to start retraining and strengthening the muscles that help stabilize the ankle. This would be a good idea, for instance in the first two-three weeks. After that, it can hinder the recovery process if we wear them too much everyday as it might stop the relearning of protective mechanisms (proprioception) and limit how much we engage and activate our ankle muscles to do their job of protecting the ankle. If we have a brace that does the job for our muscles, our muscles will stop working as hard, and your ankle, in a way, will become dependent on the brace to be stable, which is not something we want. The goal is to make the ankle as strong as possible to make sure we don’t have too many sprains in the future.

Seeking guidance

If you feel like you would benefit from an evaluation to identify and treat your pain from a health professional, you are welcomed to take an appointment with me. It will be my pleasure to guide you and answer your questions. 

For more information, make sure to read my other articles which you can easily find on my profile.  To discuss the information disclosed in this article, feel free to reach out and let me know, I am always eager to learn. To do so, you can contact me by email at ericolivier.physio@gmail.com

References 

1.     Mackenzie M. Herzog, Zachary Y. Kerr, Stephen W. Marshall, Erik A. Wikstrom; Epidemiology of Ankle Sprains and Chronic Ankle Instability. J Athl Train 1 June 2019; 54 (6): 603–610. doi: https://doi.org/10.4085/1062-6050-447-17

2.     InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. What are ligaments? 2018 Jul 26.

3.     Ferran, Nicholas & Maffulli, Nicola. (2006). Epidemiology of Sprains of the Lateral Ankle Ligament Complex. Foot and ankle clinics. 11. 659-62. 10.1016/j.fcl.2006.07.002.

4.     Cavazos GJ Jr., Harkless LB. The epidemiology, evaluation, and assessment of lateral ankle sprains in athletes. J Sports Med Ther. 2021; 6: 008-017. 

5.     https://www.webmd.com/fitness-exercise/what-is-an-ankle-sprain#2-6 

6.     https://www.healthline.com/health/how-long-does-it-take-for-a-sprained-ankle-to-heal

7.     de Vries, J. S., Krips, R., Sierevelt, I. N., Blankevoort, L., & van Dijk, C. N. (2011). Interventions for treating chronic ankle instability. The Cochrane database of systematic reviews, (8), CD004124. https://doi.org/10.1002/14651858.CD004124.pub

8.     Tsikopoulos, K., Mavridis, D., Georgiannos, D., & Cain, M. S. (2018). Efficacy of non-surgical interventions on dynamic balance in patients with ankle instability: A network meta-analysis. Journal of science and medicine in sport, 21(9), 873–879. https://doi.org/10.1016/j.jsams.2018.01.017

9.     Xue, X., Ma, T., Li, Q., Song, Y., & Hua, Y. (2021). Chronic ankle instability is associated with proprioception deficits: A systematic review and meta-analysis. Journal of sport and health science, 10(2), 182–191. https://doi.org/10.1016/j.jshs.2020.09.014 

10.  Doherty, C., Bleakley, C., Delahunt, E., & Holden, S. (2017). Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. British journal of sports medicine, 51(2), 113–125. https://doi.org/10.1136/bjsports-2016-096178 

Pictures 

1. https://heidenortho.com/wp-content/uploads/2018/03/degree-sprained-ankle.jpg
2. https://www.merckmanuals.com/-/media/manual/professional/images/f/x/l/fx_ligaments_ankle.gif?thn=0&sc_lang=en
3. https://orthofixar.com/wp-content/uploads/West-Point-Ankle-Sprain-Grading.webp
4. https://www.earthslab.com/wp-content/uploads/2017/07/Ankle-Joint-Medial-Ligament.jpg
5. https://upload.orthobullets.com/topic/7028/images/e1961b39-91b4-4468-a74f-28e0c9d29c84_ankle_sprain..jpg