What is it?
An inversion ankle sprain is a common injury in high intensity athletics
such as basketball, football, and soccer to name a few. It occurs
when the foot is forced into inversion (turned inward) beyond ligamentous
or muscular control. As a result of this excessive force, failure
of the involved ligaments may occur. Common reference to a cause
of this injury will be “I twisted my ankle” or “I landed on someone’s
It hurts where?
The area of pain will vary according to the severity of the injury.
Acutely there will be generalized pain throughout the medial and lateral
aspect of the ankle. Specific point tenderness will be along the
anterior and distal end of the lateral ankle. Active and passive
movement of the ankle joint in all planes will cause discomfort with
an increase in discomfort upon inversion and plantar flexion.
How does it happen?
As with most joints of the body, there are specific ligaments to prevent
excessive motion of that joint. The anterior talofibular ligament
(ATF) and the calcaneofibular ligament (CF) are the primary restraints
of ankle inversion. Because ankle sprains usually occur with the
foot in plantar flexion (foot pointed downward) the ATF is the most
frequently injured. With the foot in plantar flexion the ATF is
taught. With combined excessive inversion and plantar flexion,
tearing or complete rupture of the ATFL is the usual occurrence.
This exact mechanism may occur with any high intensity activity involving
lateral movement, jumping or running. It may also occur with leisurely
walking if the ground surface is uneven (stepping into a hole).
Occasionally, foot abnormalities may predispose an athlete to ankle
sprains. For these athletes orthotics may be required to reduce
the risk of further injuries.
Classification of inversion ankle sprains is done through a grading
system according to the amount of damage. Grade 1 is considered
to be mild stretching within the ATF with little swelling, tenderness
and laxity. Grade 2 may vary depending on the source. Some
sources will identify complete rupture of the ATF without CF involvement
and others will claim partial tearing of both. Descriptors of
this grade include mild-moderate laxity, moderate pain, moderate inflammation
and some loss of motion. Grade 3 sprains indicate rupture of both
the ATF and CF. Descriptors include severe swelling, an unstable
joint, loss of function, and abnormal motion. As with any injury,
improper rehabilitation and early return to competition may cause progression
from one grade to the next.
Upon occurrence of a suspected ankle inversion sprain, bony involvement
must also be suspected. Fractures to the distal end of the fibula
as well as avulsion fractures should be ruled out. Complete immobilization
of these fractures must occur for proper bone healing to take place.
The treatment process can be divided into three phases. Modifications
to these phases can be made depending upon the severity of the injury.
Phase 1 is usually one to two days with the focus primarily on the reduction
of inflammation utilizing the principles of RICE (Rest, Ice, Compression,
and Elevation), Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), and
crutches as needed to allow weight bearing as tolerated. Phase
2 (2-12 days) focuses on restoration of motion within the ankle complex
starting with active range of motion into dorsiflexion and plantar flexion.
Inversion and eversion may be too painful to tolerate actively and therefore
should be performed either passively or active-assist. Weight
bearing during walking should gradually be increased to allow proprioception
to return and an increase in ankle mobility. Phase 3 (12 days
and beyond) should focus on strengthening, agility and endurance.
Strengthening should primarily emphasize dorsiflexion and eversion,
as these muscles are responsible for resisting inversion-plantar flexion
sprains. Proprioception activities can be initiated utilizing
a BAPS / balance board or trampoline. Agility and endurance activities
should gradually be progressed to allow return to functional and athletic
activities. For certain athletes, the use of an orthotics may
help limit the vulnerability of a person to inversion sprains.
Returning to competition is dependent again on the severity of the injury.
Some general indicators that may be used as a guideline for return include
full muscular control of a painless joint with full active range of
motion and minimal to no swelling. Prophylactic taping and bracing
has proven effective in the prevention of ankle inversion sprains and
should be incorporated for some time after the initial injury.
Continued strengthening of the ankle musculature and proprioception
activities should be continued both in and out of season to allow continued
prevention of inversion sprains.