Ask a Sports Medicine Doc: Ankle sprains
April 7, 2014
Q: My 17-year-old son sprained his ankle in a basketball game recently. How long does it take for an ankle sprain to heal?
A: Ankle sprains are a very common sports injury. In one study looking at collegiate athletes, ankle sprains were the most common injury reported, making up 14.9 percent of all injuries. By comparison, ACL tears accounted for 2.6 percent and concussions 5 percent of all injuries. In 85 percent of cases, ankle sprains involve injury to the lateral ligaments or those on the outside of the ankle joint. These ligaments are the anterior talofibular ligament — ATFL, and the calcaneofibular ligaments — CFL. The ATFL is involved in most lateral ankle sprains.
The mechanism of an ankle sprain is typically "rolling" the ankle or having it invert and internally rotate. If an athlete can bear full weight on the ankle, and then comfortably run and jump on the ankle, they can return to their sport immediately. However, if they are unable to do this, they should be taken out of competition and more thoroughly evaluated.
CLASSIFYING THE SEVERITY OF SPRAINS
In the office, I perform a history and examination. Usually, the ankle has swelling and bruising. The athlete may complain of some numbness in the foot. An anterior drawer test is done to assess the amount of tearing of the ATFL, which is like checking the instability in a knee after an ACL tear. Like other ligament injuries, physicians classify the severity of the injury on a I-III grading system.
In grade I, there is stretching of the lateral ligament and there is pain and swelling, but the athlete is able to walk without crutches. In a grade II injury, there is pain, swelling and bruising, and the patient is usually only able to walk a few steps unassisted. Finally, in a grade III injury, there is a complete tear of the ligaments and there is significant pain, swelling and bruising, and walking is difficult. As part of the evaluation, orthopedists typically get radiographs to rule out an ankle fracture which can present like a sprained ankle at times.
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TREATING A SPRAINED ANKLE
A type I or II ankle sprain is treated with RICE (rest, ice, compression and elevation) and a lace up ankle brace. Physical therapy is also started to decrease swelling, improve range of motion, strength and proprioception. Proprioceptive training is critical to help avoid repeat ankle sprains. With this, a physical therapist leads the patient through a series of drills using wobble boards and Bosu balls to try to restore normal balance and postural control. Most athletes with grade I or II tears can return to play within six to eight weeks.
In a type III ankle sprain, the physician may choose to cast the ankle for several weeks to better protect and immobilize the ankle and then transition the patient out of the cast to a lace up ankle brace. The same rehabilitation program is then started but it progresses more slowly.
Most of these injuries should also fully recover. If there is persistent pain and lack of progress by eight weeks from the injury, then an MRI is warranted to rule out a cartilage injury or other injury such as a peroneal tendon tear. A high ankle sprain is a more serious injury than a lateral ligament injury and I can speak to that in a future article.
AVOID FUTURE SPRAINS
Athletes want to try to avoid having a second or third ankle sprain or else the ankle can go on to be chronically unstable with athletes having recurrent ankle sprains with minimal trauma and persistent ankle pain.
In an athlete with chronic instability, there is typically elongation and scarring of the ATFL and CFL. There can also be early arthritis and degenerative tendon tearing about the ankle. Some of these patients may come to surgical reconstruction of their chronically torn ankle ligaments to prevent further episodes of instability of further damage to the ankle joint.
Dr. Rick Cunningham is a knee and shoulder sports medicine specialist with Vail-Summit Orthopaedics. He is a physician for the U.S. Ski Team and chief of surgery at Vail Valley Medical Center. Do you have a sports medicine question you'd like him to answer in this column? Visit his website at http://www.vailknee.com to submit your topic idea. For more information about Vail-Summit Orthopaedics, visit http://www.vsortho.com.