Ankle sprains are one of the most common injuries in sports and are a frequent reason patients, athletes and non-athletes alike, present for medical care with primary care providers, urgent treatment centers, emergency departments and orthopedic surgeons. Despite the high prevalence of ankle sprains and the frequency of clinical evaluations for these injuries, many patients may be misdiagnosed or undertreated, potentially leading to chronic disability. The notion among many patients, family members and healthcare providers that “it’s just a sprain” is simply not true.
The same twisting or “misstep” mechanism that can result in a classic sprained lateral ankle, where the anterior talofibular ligament (ATFL) and sometimes the calcaneofibular ligament (CFL) are torn, can also cause injury to other surrounding structures. Peroneal tendon tears and syndesmosis injuries involving the distal tibiofibular joint (“high ankle sprains”) laterally, ankle cartilage injuries, deltoid ligament tears medially, and subtle fractures in and around the ankle, heel and foot are possible and may be overlooked when patients initially present for treatment. Detailed attention to the patient’s clinical history, an anatomically focused exam and if necessary, radiographic imaging in the appropriate settings, can result in timely diagnosis of a patient’s injury pattern, referrals when necessary, fewer treatment delays and a decreased potential for long-term foot and ankle problems.
Fortunately, most patients who sustain tears of the lateral ankle ligaments, regardless of the severity of the initial sprain, can have positive outcomes with non-operative treatments. The well-known formula RICE (rest, ice, compression, elevation), should be coupled with a course of ankle immobilization, in a neutral or slightly dorsiflexed position, allowing the ligament to heal with the correct amount of tension. A functional rehabilitation program concentrated on regaining motion, strength and proprioception should follow this early phase of treatment. Despite positive results in most patients following this treatment regimen, up to 20 percent of patients may still experience recurrent ankle sprains and ankle instability, which is associated with chronic disability and in some patients, the development of ankle arthritis.
Surgical treatments for ankle instability vary, but most frequently involve outpatient procedures, such as a modified Broström-Gould procedure, to repair the torn ligamentous tissue in a tightened position. Depending on the degree of ankle instability, the chronicity of the problem, and other patient-related factors such as associated injuries, limb alignment, body size and activity level, more extensive procedures may be necessary. For instance, patients who do not have sufficient tissue strength or quality to stabilize the ankle or in whom an initial attempt to repair the ankle ligaments has failed, may require anatomic ligament reconstruction procedures using tendon grafts (autografts or allografts, similar to ones used in common knee ligament surgeries) to reestablish ankle stability. A focused rehabilitation program is typically employed following surgery to maximize the functional results of surgical treatment and get the patient back to their preferred activity level.
Although ankle sprains are common and most patients will have positive clinical outcomes, resist the temptation to say it is “just a sprain” when patients roll or twist an ankle or take an awkward step. Ankle sprains can be serious injuries with multiple long-term sequelae, even when appropriately treated. Consider the patient’s injury an opportunity for an anatomically based diagnosis centered on the patient’s history and physical examination, and to facilitate timely treatments and referrals based upon the true pattern of injury.
By Nicholas A. Viens, MD