Ankle
Injuries

What is an ankle injury?

Sprains to the ankle are one of the most common sporting injuries. A sprain is defined as a tearing of the ligaments that connect bone to bone and help stabilise the joint.

Sports requiring jumping, turning and twisting movements – such as basketball, volleyball, netball and football – and explosive changes of direction such as in soccer, tennis and hockey are particularly vulnerable to ankle sprains.

Following an ankle sprain, the ankle joint may become unstable and take longer to recover.

Anatomy: The ankle joint is a hinge joint formed between the tibia and fibula (bones of the lower leg) and the talus (a bone of the foot). It allows the foot to bend upwards (dorsiflexion) and downwards (plantarflexion), and also permits a small amount of rotation. Two bones of the foot – the talus and calcaneus (heel bone) – form the subtalar joint, which allows the foot to rock side to side (inversion/eversion).

The joint’s stability comes from the structural arrangement of the bones and the surrounding ligaments. Ligaments provide stability by limiting side-to-side movement.

On the inside of the ankle (medial side), the joint is stabilised by a thick, strong fibrous ligament called the deltoid ligament. Sprains to the deltoid ligament (eversion sprains, where the foot twists outward) account for less than 20% of all ankle sprains.

On the outside of the ankle (lateral side), the joint is stabilised by three smaller ligaments:

• Anterior talofibular (at the front)
• Calcaneofibular (at the side)
• Posterior talofibular (at the back)

Incidence

Sprains to these lateral ligaments (inversion sprains, where the foot twists inward) account for more than 80% of all ankle sprains. The most commonly injured ligament is the anterior talofibular. Injury to this ligament results in swelling and pain on the outside of the ankle. If the force is more severe, the calcaneofibular ligament may also be damaged. The posterior talofibular ligament is less likely to be injured, although a complete tear of all three ligaments may result in dislocation of the ankle joint and an accompanying fracture.

Occasionally, medial ligament injuries may occur in conjunction with a lateral ligament injury.

Ligament sprains to the ankle joint may also involve the ligaments between the tibia and fibula (the distal tibiofibular syndesmosis). These are termed high ankle sprains or syndesmosis injuries. These injuries may also involve a fracture, are often slower to recover, and may require surgery.

Risk factors

Acute ankle sprains result from a force being applied to the ankle joint that causes excessive movement at the joint. Players are usually immediately aware of the injury and may hear an audible ‘snap’ or ‘pop’ due to tearing or stretching of the ligaments.

Proven risk factors

• Previous or existing ankle injury, especially if poorly rehabilitated
• Lack of strength and stability in the ankle
• Limited or excessive flexibility (hypermobility) in the ankle joint
• Poor balance
• Sudden change in direction (acceleration or deceleration)
• Increasing age of the player

Suspected risk factors

• Poor condition of the playing surface
• Inadequate, inappropriate or no warm-up
• Wearing inappropriate footwear for the activity
• Lack of external ankle support (e.g. taping, bracing) for previously injured ankles

Signs and symptoms

Sprains are graded on a scale of 1 to 3 (mild, moderate and severe), depending on the extent of ligament damage. X-rays are commonly performed to rule out fracture or dislocation.

Grade 1 (mild)

• Minor tear
• Minimal pain
• Little of no joint instability
• Mild pain with weight bearing activities
• Slight loss of balance

Grade 2 (moderate)

• Some tearing of the ligament fibres
• Moderate to severe pain
• Moderate instability of the joint
• Swelling and stiffness
• Pain with weight bearing activities
• Poor balance

Grade 3 (severe)

• Complete tear of the ligament(s)
• Severe pain followed by minimal pain
• Gross instability of the joint
• Severe swelling
• Possible pain with weight bearing
• Poor balance

Management

Immediate treatment of soft tissue injuries should follow the RICER protocol – Rest, Ice, Compression, Elevation and Referral. This should be followed for 48–72 hours. The aim is to reduce bleeding and damage within the joint.

• Rest the ankle in an elevated position
• Apply ice for 20 minutes every two hours (never directly on the skin)
• Use a correctly sized compression bandage to limit bleeding and swelling

The No HARM protocol should also be applied – No Heat, No Alcohol, No Running or activity, and No Massage – to minimise swelling and bleeding.

A sports medicine professional should be consulted as soon as possible after the injury to assess its severity and guide treatment and rehabilitation. X-rays or other diagnostic tests may be required.

Most ankle sprains heal within 2 to 6 weeks. However, severe sprains may take up to 12 weeks.

A comprehensive rehabilitation program minimises the risk of recurrence. This includes flexibility, balance, stretching, strengthening and sport-specific exercises. During this period, ankle taping or bracing may be prescribed to support the joint until full function is restored.

If pain or discomfort is experienced during rehabilitation exercises, stop immediately and consult a sports medicine professional.

Players with significant ligament injuries (Grade 2 or 3) are advised to use bracing or protective taping for sport for a minimum of 6 to 12 months post-injury.

Ways to help prevent ankle injuries include:

• Undertaking training prior to competition to ensure readiness to play
• Gradually increasing the intensity and duration of training
• Including flexibility, balance, stretching and strengthening exercises in weekly training program
• Adding agility drills to help the ankle withstand high acceleration forces and quick directional changes
• Allowing adequate recovery time between workouts or training sessions
• Warming up properly so that surrounding muscles are ready to support the joint during activity
• Using ankle taping or bracing, especially for previously injured ankles
• Wearing sport-specific shoes that provide appropriate stability and support
• Checking training and playing areas for hazards and ensuring surfaces are flat and even
• Staying hydrated by drinking water before, during and after play
• Avoiding activities that cause pain. If pain occurs, discontinue activity and commence RICER