Although seen as minor injury, it’s very debilitating™
By: Diandra Schonyers
Ankle injuries are one of the most common pathologies seen in sports and other recreational
activities. Ankle sprains are the most commonly seen injury in the lower extremity. There are
two types of ankle sprains, eversion and inversion.
These sprains are more widely known as a lateral
ankle sprain and a high ankle sprain. The inversion
ankle sprain is the most recurring of the two; this is
because the lateral malleolus sits lower than the medial
malleolus. Although the lateral ankle sprain is more
commonly seen, the eversion ankle sprain is more
debilitating. Too many people think an ankle sprain is
not a very severe injury. These injuries are classified
or graded according to their severity from grade one to
grade three, three being the most severe. Grade two
ankle sprains are the most commonly reported because the patient begins to feel discomfort
performing everyday tasks such as walking and standing. When everyday tasks are impaired a
patient is more likely to become proactive and seek treatment for their injury, whether from
health professionals or from their peers.
The lateral malleolus is the boney protrusion on the outside of the ankle.
The medial malleolus is the boney protrusion on the inside of the ankle.
Inversion Ankle Sprains 
The most commonly described method of injury
for an inversion ankle sprain is an individual
planting, cutting, and rolling their ankle inside
(plantar flexion and inversion). This mechanism
causes injury to the structures on the outside of
the ankle. The main ligaments affected by this
injury are the anterior talo-fibular ligament
(ATF), the calcaneo-fibular ligament (CF) and
the posterior talo-fibular ligament (PTF). The
lateral ankle sprain is graded as follows:
Grade One No sounds at the time of injury, slight discomfort over the ATF, no swelling or
discoloration, no to mild pain when stretching in extreme plantar flexion
Grade Two May have heard a pop at the time of injury, moderate swelling, discoloration, will
have impaired gait (a limp), very tender over the CF and ATF, ability to move
will be reduced due to pain (the ATF may be ruptured and the CF injured)
Grade Three Will hear a pop at the time of injury, severe swelling, discoloration, very tender
over all lateral structures, will not want to move their ankle because it is too
painful (ATF and CF are most likely ruptured and the PTF is injured)
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Inversion ankle sprains are seen in any sport or activity that requires lower extremity weight
bearing or activities that require repetitive jumping, landing or cutting; a few examples are
football and basketball. Recently Miami Heat Guard/Forward Dwayne Wade sat out six straight
games with a lateral ankle sprain. This shows that although an ankle sprain seems like a minor
injury it can be very debilitating, even to professional athletes. If untreated ankle sprains can lead
to injury of other structures due to compensation from the original injury, causing further injury
to the ankle, and/or weakened muscles and ligaments of the ankle. While Wade sat out those six
games, he went through the rehabilitation process and gave his ankle time to heal. Following his
rehab he was able to return to play against the New York Knicks and scored 28 points in his first
game back and played as though his ankle was not bothering him at all.
Eversion Ankle Sprains 
An eversion ankle sprain occurs when someone’s foot/ankle
is forced up and out (dorsiflexion and eversion). This injury
is more commonly known in sports as a “high ankle
sprain”. Eversion sprains are more devastating and take
longer to heal because it causes injury to the deltoid
ligament and/or the anterior tibiofibular joint, which is also
known as the syndesmosis joint. To simplify, this “joint” is
a grouping of connective tissue between the tibia and fibula.
This connective tissue
is responsible for
holding the tibia and
fibula together and dissipating the force of our everyday
movements. This type of sprain causes a separation of this
joint, which is very painful and greatly affects the way the
patient’s gait, the way they walk. Injury to the deltoid
ligament following an eversion mechanism is usually
referred to as an eversion ankle sprain. An eversion
mechanism that causes injury to the syndesmosis joint, and
possibly the deltoid ligament, is referred to as a high ankle
sprain. Injury to the syndesmosis joint causes a very
unstable ankle joint. This is because the syndesmosis joint
is affected by every step we take. With every step, this joint spreads a little to allow for full range
of motion. This constant separation to an already injured structure causes the patient severe pain
and prolongs the recovery process. Recently New England Patriots Tight End Rob Gronkowski
suffered a high ankle sprain in the AFC Championship Game against the Baltimore Ravens. Due
to the severity of the injury Gronkowski’s playing status for Super Bowl 46 was uncertain for
much of the week leading up to the game. Although his status remained uncertain until about
game day, Gronkowski played in the game. He was clearly not playing at his full ability because
he was still affected by the injury.
Eversion ankle sprains account for only about 10% of all ankle sprains
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Rehabilitation of both ankle sprains
Inversion Ankle Sprains ↓
-Patient is placed in walking boot or on
crutches if they have a limp
-As a precaution, the patient is sent for x
rays to rule out any fractures
-Typical progression of treatment: (Grades
1-2)
~Rest, Ice, Compression & Elevation
(RICE)
~Therapeutic
modalities &
analgesics (ex.
Tylenol) to reduce
pain and swelling
~Mobilization using
an ace wrap/ crutches
may be necessary after the first 48
hours
~After the first 24 hours on crutches
the patient will begin weight bearing
with the crutches
~Strengthening exercises using a
theraband
~Balancing exercises
~Functional/Sport Specific Exercises
~Return to sport (only granted is
sport specific exercises
can be completed pain
free)
-Typical progression of
treatment (Grade 3)
~For the first 6 weeks:
patient goes through the
normal rehab
progression for Grade 1
and 2 sprains
~If the patient is able to perform
normal sport activities with ice, tape,
a brace, and without unrelenting
issues following activity the injury
will not require surgery
~If there is constant instability and
pain, the patient will require surgery
~Following surgery the patient will
follow the normal rehab progression
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Eversion Ankle Sprains ↓
-Patient is placed in a walking boot to
prevent weight bearing
-As a precaution, patient is sent for x rays to
rule out any fractures
-Typical progression of treatment:
~Rest, Ice, Compression &
Elevation
~Therapeutic Modalities and
analgesics to reduce pain and
swelling
~Mobilization using an ace
wrap/ crutches may be
necessary after the first 48 hrs
~After the first 24 hrs
on crutches, the patient will
begin weight bearing with the crutches
~Strengthening exercises using a
theraband
~Balancing exercises
~Functional/Sport Specific Exercises
~Return to sport (only
granted if sport specific
exercises can be completed
pain free)
-Typical progression of treatment (Grade 3)
~For the first 6 weeks the
patient goes through the
normal rehab progression
for Grade 1 and 2 sprains
~If the patient is able to
perform their normal sport
activities with ice, tape, a
brace, and without
unrelenting issues
following activity the injury will not
require surgery
~If there is constant instability/pain,
the patient will require reconstructive
surgery of the injured deltoid
ligament and the syndesmosis joint
~Following surgery the patient will
follow a strict rehabilitation program
including the same principles as the
first rehab program
Although the progression of treatment is the same for both types of sprains,
the recovery time for and eversion ankle sprain is much longer.
Why is this important?
It is important to have knowledge about ankle sprains because they
are the most common injury seen in professional and recreational
sports. Due to this fact, many times these injuries go unreported
and lead to further injury and weakened ankle structures. An ankle
sprain may present in many different ways. For example there can
be little to no swelling or discoloration and on the other hand, the
foot and ankle may look like a ball.
The severity of an ankle sprain cannot be judged by the amount
of swelling and discoloration present. There are a combination of
observations and tests that are required to determine the severity
of this injury. Therefore, in order to gauge the severity of the
injury it is important to report the injury to a medical
professional. While it is important to report these injuries, it is
also essential to have some knowledge about ankle sprains.
Do not underestimate the amount of discomfort an ankle injury can cause.
Name of
Site
URL
Acute Ankle http://www.sportsci.org/encyc/ankacuinj/ankac
Injuries
uinj.html
Sports
Shorts
http://www.orthonurse.org/portals/0/AAP%20
Ankle%20Sprains.pdf
Sports &
Spinal
Physical
Therapy
Sprained
Ankle
http://www.ssptdc.com/about/ankle-sprainarticle.asp
Managemen
t of ankle
sprains
The
Physician
and Sports
Medicine
http://www.aafp.org/afp/2001/0101/p93.html
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http://www.mayoclinic.com/health/sprainedankle/DS01014
http://www.chiro.org/LINKS/FULL/Acute_An
kle_Sprains.html
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