Prevention and Treatment of Lateral Ankle Sprains (Rolled Ankle)

rolled ankle treatment

Rolled ankle physiotherapy. 

Article by Sydney sports physio, Chris El-Hayek.

A lateral ankle sprain is an injury to the outside ligaments of the ankle ​​and accounts for approximately 85% of all ankle sprains.1 These ligaments provide our ankle with stability, and allow for appropriate ankle motion. Unfortunately, if these ligaments are stressed beyond what they can tolerate, a sprain or tear can occur.

How does a rolled ankle / lateral ankle sprain injury occur?

Lateral ankle sprains are one of the most common injuries that occur in sports. These sports typically involve rapid change of directions such as in football, rugby league, netball and basketball. In the US, approximately 2 million people suffer this injury per year!2

rolled ankle treatment ATFL

Mechanism of a lateral ankle sprain

Lateral ankle sprains typically occur from a combination of excessive ankle plantarflexion (picture pointing your foot downwards) and inversion (picture pointing your foot inwards).3 This is commonly referred to as rolling your ankle in.

What is injured?

There are 3 ligaments on the outside aspect of our ankle that provide stability and a certain degree of motion. Going from front to back, we have the Anterior Talofibular Ligament (ATFL), Calcaneofibular Ligament (CFL), and the Posterior Talofibular ligament (PTFL).

rolled ankle treatments

The ATFL has an important role in restricting 2 motions; ankle plantarflexion (downwards motion) and inversion (inwards motion). The ATFL is the weakest of the 3 ligaments mentioned above, and is therefore most commonly injured. In fact, in lateral ankle ligament sprains, the ATFL is injured in approximately 85% of these injuries.3

The CFL has an important role in preventing ankle inversion (inwards motion) and is injured in approximately 35% of these injuries.3

The PTFL has a role in preventing ankle dorsiflexion (upwards motion) and is only involved in approximately 12% of these injuries.3

If the CFL and PTFL are injured, it is normally associated with an increased injury severity as there is likely more stress placed at the joint for them to be stretched beyond what they can tolerate.

rolled ankle treatment atfl cfl ptfl

Rolled ankle / lateral ankle sprain injury risk factors

Extrinsic

Type of Footwear – Appropriate footwear should be worn to cater for the surface and the sport/activity is on and the weather conditions. For example, with football boots, when playing on a surface like artificial grass, wearing artificial ground studs can minimise the chance of your foot getting caught in the ground as you turn.4

rolled ankle treatment shoes

Taping/Bracing – After your first ankle injury, this may be required for up to 6 months on top of your rehab program to reduce chance of re-injury.5

rolled ankle treatment bracing

Intrinsic

Conditioning/Fitness – There is an increased risk of injury when fatigued, so having an optimal level of fitness is important to maintain a certain level of performance without breakdown of technique.6

Exposure to movements and technique – If you are not exposed to the movements of your sport/activity regularly on a week-to-week basis, your risk of injury increases, particularly when in competition! Technique of these movements should also be looked at to see whether this may influence your injury risk (particularly when decelerating or changing direction quickly).7

Strength – This is a no brainer! Strength reduces injury risk and improves your muscle and ligament function. If you lack strength, you may be more at risk of injuring yourself.8

Instability – If you have injured your ankle more than once, there is a risk of ongoing instability which increases your chance of rolling your ankle again.9

rolled ankle treatment example

Injury Severity & Duration

Ligament injuries can be classified from grade 1-3 depending on their severity. If you don’t have a grade 1 injury, you may have just tweaked or irritated the ligament without causing any damage. These should still be monitored depending on pain and function, but you may be able to return to sport within a week or two.

  • Grade 1 – minimal ligament damage, can be painful and have minor swelling. Tender on palpation and most likely no laxity when assessed by physiotherapist. Generally out of sport for 2-4 weeks.10
  • Grade 2 – More significant ligament damage, pain and swelling. Very tender on palpation with laxity on testing. Generally out of sport for 4-6 weeks and may require wearing a cam boot for a period of time if there is significant pain and loss of function.10
  • Grade 3 – Complete rupture of the ligament with significant swelling and very lax on testing. May require crutches for a small period of time, and wearing a cam boot to manage pain and function. These injuries rarely require surgery, however an orthopaedic surgeon can review if non operative treatment is not successful, or there are issues with repeat injuries or chronic instability. Generally out of sport for 8-12+ weeks depending on level of competition and type of sport played.10,11

rolled ankle treatment grades of ligament sprain

Medical Imaging

More often than not, medical imaging is not required for a typical lateral ankle sprain as a physiotherapist should be able to diagnose the injury based on their assessment.

However, if there is significant trauma, a suspected fracture, or an unstable injury which may require further investigation, a referral can be made for imaging, and possibly for an orthopaedic specialist review.

Usual imaging modalities include X rays to rule out fractures, and ultrasounds to show the amount of ligament damage and swelling within the joint.

Magnetic Resonance Imaging (MRI) is gold standard when it comes to lateral ankle sprains, and gives us the most detail to the extent of ligament damage that has occurred, but can be expensive12.

rolled ankle treatment exray

Management of a rolled ankle / lateral ankle sprain

Management will ultimately depend on the severity of injury. Often, in the moment, the injury can be quite worrying and painful, and people will present to the hospital emergency department.

However, if there is no fracture, this can often be avoided. A physiotherapist can assess this using what is known as the Ottawa ankle rules to warrant whether an Xray is needed for a suspected fracture13.

Here are some general rules to follow to optimise your recovery:

Acute management

It is normal to expect some sort of swelling after a ligament injury, and this can cause pain, and restrict movement. To reduce swelling, the following can be done:

  1. Elevate your leg above the level of your heart as much as you can whenever you are sitting/lying down.14
  2. Wear a compression bandage/sock around the injured ankle, making sure you also cover below and above the area of injury. Ensure it is not too tight and restricting blood flow. You can assess this by squeezing one of your toes. When you let go, it should return to a reddish pink colour within a few seconds.14
  3. Gently move your ankle up and down (and side to side if not too painful) while in an elevated position, and keep wiggling your toes so you can encourage some gentle movement in and around the area so it doesn’t start to feel weak and stiff so early on.14
  4. Avoid Non-Steroidal Anti Inflammatories (NSAIDs) in the first 48-72 hours as this can potentially impair healing.15

If you are in a lot of pain, you can apply a cold pack/ice to the injured area for 15-20 minutes (every 3-4 hours). However, evidence shows that this does not reduce swelling much, contrary to what most people believe.14 Make sure you place a towel underneath to avoid burning your skin.

rolled ankle treatment strapping

Rolled ankle / lateral ankle sprain exercises and rehabilitation

Early-Stage Rolled Ankle Rehabilitation Exercises Ideas

Early mobilisation is generally encouraged to minimise loss of strength and mobility around the ankle complex. Light range of motion and theraband exercises can be done quite early on if pain is not excessive.

Here is an example of 2 quick and easy exercises that can be done:

  1. Writing alphabet with ankle (Complete regularly throughout the day)
  2. Resisted TheraBand exercises (perform 2-3 sets of 15-20 reps, 2-3x a day)

rolled ankle treatment exercise

Mid-Stage Rolled Ankle Rehabilitation Exercise Ideas

At this point, exercises should be progressed to more weight bearing, and there should be a focus on progressively building strength, mobility, and proprioception/balance

Here are 3 examples of exercises that target the above-mentioned qualities that need to be progressed:

  1. Single Leg Calf Raises (Complete 3 sets of 6-10 reps, once a day. Carry weight in hand if it becomes too easy).
  2. Walking Lunges (Complete 3 sets of 5-6 reps each leg, once a day. Carry weights in hands if too easy, ensure front foot stays flat on ground).
  3. Star Excursion Balance Exercise (Complete 3-5 rounds on each leg, 1-2x a day).

rolled ankle treatment exercises

Late-Stage Rolled Ankle Rehabilitation Exercises

Exercises in this stage need to be relevant to your sport or activity, and should gradually progress from non-contact to contact (depending on the sport), and incorporate the necessary movements required in your sport such as change of direction, hopping and sprinting.

Here are 2 examples of reactive agility exercises that can be incorporated at this stage:

  1. Numbered Square Reaction Drill (3×20-30 seconds, and incorporate your sports equipment or ball): Label each cone with a number. When you shout that number, the athlete has to quickly accelerate to that cone and touch it. You can include a ball pass in between each sprint. Accelerate to the Cone (9 reps of 5-10m sprints with 45-60 sec recovery between each):
  2. Athlete jogs, or does a ball drill to the first cone (green cone), then accelerates to whatever cone you point at or whatever colour you call. You can use multiple colours, or several cones to increase the complexity.

rolled ankle exercises 1

How a physiotherapist can help in the treatment and management of a rolled ankle / lateral ankle sprain

If you have suffered from a lateral ankle sprain, a physiotherapist can assess the severity of your injury, and design a comprehensive treatment plan and exercise program to rehabilitate you back to full function in a structured and progressive manner.

There is a high recurrence rate of lateral ankle sprains that can lead to chronic pain and instability. In fact, after the first sprain, 40% of individuals will develop chronic ankle instability.9 Often this is because of inadequate rehabilitation and delayed treatment. If you are looking to get on top of your injury and optimise your recovery and function, send through an email or give us a call to find out more.

Do you need assistance managing or treating a rolled ankle / lateral ankle sprain injury? 

Sports physiotherapist Chris El-Hayek has extensive expertise in offering physiotherapy services to athletes in a range of high-performance sports. He has been able to assess and treat multiple athletes with a wide range of sport related injuries.  He can successfully implement programs that will minimise injury rates and enhance your athletic qualities.

Speak to a Physio

 

References

  1. Ferreira, J. N., Vide, J., Mendes, D., Protásio, J., Viegas, R., & Sousa, M. R. (2020). Prognostic factors in ankle sprains: a review. EFORT open reviews, 5(6), 334–338. https://doi.org/10.1302/2058-5241.5.200019
  2. Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of Ankle Sprains and Chronic Ankle Instability. Journal of athletic training, 54(6), 603–610. https://doi.org/10.4085/1062-6050-447-17
  3. Li, L., Gollhofer, A., Lohrer, H. et al. Function of ankle ligaments for subtalar and talocrural joint stability during an inversion movement – an in vitro study. J Foot Ankle Res 12, 16 (2019). https://doi.org/10.1186/s13047-019-0330-5
  4. Fujitaka, K., Taniguchi, A., Kumai, T., Otuki, S., Okubo, M., & Tanaka, Y. (2017). Effect of Changes in Artificial Turf on Sports Injuries in Male University Soccer Players. Orthopaedic journal of sports medicine, 5(8), 2325967117719648. https://doi.org/10.1177/2325967117719648
  5. Doherty, C., Bleakley, C., Delahunt, E., & Holden, S. (2016). 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
  6. Barte, J., Nieuwenhuys, A., Geurts, S., & Kompier, M. (2017). Fatigue experiences in competitive soccer: development during matches and the impact of general performance capacity. Fatigue: Biomedicine, Health & Behavior, 5(4), 191-201. https://doi.org/10.1080/21641846.2017.1377811
  7. Harper, D. J., & Kiely, J. (2018). Damaging nature of decelerations: Do we adequately prepare players?. BMJ open sport & exercise medicine, 4(1), e000379. https://doi.org/10.1136/bmjsem-2018-000379
  8. Lauersen, J., Bertelsen, D., & Andersen, L. (2013). The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British Journal Of Sports Medicine, 48(11), 871-877. https://doi.org/10.1136/bjsports-2013-092538
  9. Hertel, J., & Corbett, R. O. (2019). An Updated Model of Chronic Ankle Instability. Journal of athletic training, 54(6), 572–588. https://doi.org/10.4085/1062-6050-344-18
  10. Lynch S. A. (2002). Assessment of the Injured Ankle in the Athlete. Journal of athletic training, 37(4), 406–412.
  11. Hubbard, T. J., & Hicks-Little, C. A. (2008). Ankle ligament healing after an acute ankle sprain: an evidence-based approach. Journal of athletic training, 43(5), 523–529. https://doi.org/10.4085/1062-6050-43.5.523
  12. Milz P, Milz S, Steinborn M, Mittlmeier T, Putz R, Reiser M. Lateral ankle ligaments and tibiofibular syndesmosis. 13-MHz high-frequency sonography and MRI compared in 20 patients. Acta Orthop Scand. 1998 Feb;69(1):51-5. doi: 10.3109/17453679809002357. PMID: 9524519.
  13. Wang, X., Chang, S. M., Yu, G. R., & Rao, Z. T. (2013). Clinical value of the Ottawa ankle rules for diagnosis of fractures in acute ankle injuries. PloS one, 8(4), e63228. https://doi.org/10.1371/journal.pone.0063228
  14. Bleakley, C.M., O’Connor, S., Tully, M.A. et al. The PRICE study (Protection Rest Ice Compression Elevation): design of a randomised controlled trial comparing standard versus cryokinetic ice applications in the management of acute ankle sprain [ISRCTN13903946]. BMC Musculoskelet Disord 8, 125 (2007). https://doi.org/10.1186/1471-2474-8-125
  15. Bryant, A. E., Aldape, M. J., Bayer, C. R., Katahira, E. J., Bond, L., Nicora, C. D., Fillmore, T. L., Clauss, T. R., Metz, T. O., Webb-Robertson, B. J., & Stevens, D. L. (2017). Effects of delayed NSAID administration after experimental eccentric contraction injury – A cellular and proteomics study. PloS one, 12(2), e0172486. https://doi.org/10.1371/journal.pone.0172486