Sprained Ankle – Are they all the same??

Most ankle sprains involve “rolling” your ankle into what is now as an inverted position and spraining the ligaments on the outside of the ankle complex, causing pain, swelling and reduced mobility.  After a few days, most mobility is restored and with appropriate stretching, strengthening and balance work, you’re good to go on average, within 3-4 weeks. 

However, some ankle sprains can be much trickier, but might present in a similar way.  I’m talking about syndesmosis injuries or ‘high ankle sprains’.  These usually occur when the ankle is forced the other way into a position known as eversion, while the knee goes forward over the toes, putting the ankle into what is known as dorsiflexion.  This dorsiflexion with eversion mechanism is shown opposite. 

Whereas more common lateral ankle sprains heal quickly, often allowing a speedy return to normal activities, syndesmosis injuries can take 6-8 weeks or more to come right and often won’t heal properly, unless you’re placed in a protective boot and given a carefully constructed, progressive rehabilitation program. 
The key clues to look out for, that could mean you have a high ankle sprain are:

• Pain higher up the ankle, more on the front than on the side, as in the picture opposite.
• Pain and dysfunction lasting more than a week. 
• Inability to hop within a week. 

Below is a more in depth look at these two different types of ankle sprains described above, as well as the less common eversion ankle sprain.  Here I will explain how they arise, what is the difference between the three grades of sprain and what it takes to get you back on track, if you should suffer one of these sprains. 

Firstly, inversion ankle sprains predominantly involve damage to the anterior talofibular ligament (ATFL), but can also involve the calcaneofibular ligament (CFL), the posterior talofibular ligament (PTFL) and the anterior tibiofibular ligament, also known as the anterior inferior tibiofibular ligament (AITFL).  The mechanism that usually causes this type of sprain is an inversion of the ankle, as illustrated on the right, in the picture below.  The varying degrees of ligament damage associated with this type of injury are illustrated below, starting with normal appearance of the lateral ankle ligaments on the left and progressing to the right, firstly to a grade 1 sprain with minor damage to the ATFL and CFL, followed by a grade 2 sprain with more significant damage to ATFL and CFL, along with minor damage to the PTFL.  Finally, the grade 3 sprain picture on the far right shows a rupture of all three ligaments – ATFL, CFL and PTFL, as well as minor damage to the AITFL. 

The estimated rehabilitation times and requirements, for the different grades of inversion ankle sprains are as follows:

• Grade 1 – 1-2 weeks, involving simple stretches and strengthening exercises, with some balance work. 
• Grade 2 – 3-4 weeks, involving more rigorous stretches and massage to restore range, some moderately challenging strength work and balance exercises.
• Grade 3 – 6-8 weeks, involving immobilisation of the ankle in a cam walker otherwise known as a moonboot, followed by significant stretching, strengthening and balance work, to restore full function. 

 Next let’s look at a syndesmosis injury, otherwise known as a high ankle sprain.  Below you can see that the injury mechanism is a turning in or internal rotation of the shin, with a simultaneous turning out or external rotation of the foot, often associated with the dorsiflexion and eversion movements described earlier in the article.  The grades of this injury begin with minor damage to the AITFL – termed a grade 1 sprain, followed by moderate damage to both the AITFL and the interosseous membrane (IM) – termed a grade 2 sprain and finally a rupture of the AITFL and significant damage to the IM – a grade 3 sprain. 

The estimated rehabilitation times and requirements, for the different grades of high ankle sprains are as follows:

• Grade 1 – 2-3 weeks, involving simple stretches and strengthening exercises, with some balance work. 
• Grade 2 – 4-6 weeks, involving immobilisation in a cam walker, followed by significant stretches, strength and balance work, to restore full function in the foot and ankle. 
• Grade 3 – 8-10 weeks, involving immobilisation of the ankle in a cam walker and often a surgical opinion, to see whether surgical repair is appropriate, based on your functional and or sporting goals.  Whether you have surgery, or spend an extended time in cam walker instead, either would then be followed by significant stretching, strengthening and balance work, to restore full function. 

Finally, below is an eversion ankle sprain, which similarly to the high ankle sprain involves damage to the AITFL, but in the absence of as much rotation at the shin, tend to be less serious.  These types of sprains are rare and involve pure eversion as shown in the picture on the right hand side below.  A grade 1 eversion sprain involves minor damage to the AITFL, tibionavicular and tibiocalcaneal ligaments.  Grade 2 eversion sprains involve more significant damage to these ligaments and grade 3 sprains involve ruptures to these ligaments, along with minor damage to the rearmost ligament – the posterior tibiotalar ligament, as illustrated below. 

• Grade 1 – 1-2 weeks, involving simple stretches and strengthening exercises, with some balance work. 
• Grade 2 – 3-4 weeks, involving more rigorous stretches and massage to restore range, some moderately challenging strength work and balance exercises.
• Grade 3 – 6-8 weeks, involving immobilisation of the ankle in a cam walker otherwise known as a moonboot, followed by significant stretching, strengthening and balance work, to restore full function. 

If you suffer an ankle sprain or have suffered an ankle sprain and feel, after reading this article, it might be more serious than you previously thought, or if you just want to put your mind at rest, come and see us for an appointment at our brand new state of the art clinic, at 492 St Kilda Road.