Ankle Sprain

Anatomy – Understanding the Ankle

The ankle (often called the “ankle joint”) is made of two main joints:

• Upper ankle joint – allows your foot to move up and down.

• Lower ankle joint – allows your foot to move side to side.

Together, they make your ankle move freely in all directions. The upper joint is formed by the shinbone (tibia) and outer leg bone (fibula), which create a “fork” that holds the ankle bone (talus). This fork can slightly adjust its shape to allow smooth and stable movement.

To keep this area stable, strong ligaments (tough tissues that connect bones) surround it:

• On the outer (lateral) side:

  • ATFL (anterior talofibular ligament)

  • CFL (calcaneofibular ligament)

  • PFL (posterior talofibular ligament)

• On the inner (medial) side:

  • Deltoid ligament

    
    

These ligaments protect the ankle from moving too far. In most sprains, the ATFL or both ATFL and CFL get injured. The PFL is damaged only in about 10% of cases.

Causes

An inversion ankle sprain usually happens when the foot turns too far inward while the toes point downward.Typical situations include:

• Running and suddenly changing direction

• Landing awkwardly after jumping

• Missing a step on stairs

• Slipping or falling from a height

  
  

Symptoms

The severity of symptoms depends on how much the ligaments were injured:

• Grade I (Mild): Ligaments are overstretched but not torn.→ Mild pain, tenderness, small swelling.

• Grade II (Moderate): Ligaments are partially torn.→ More pain, swelling, bruising, warmth, limited movement, and slight instability.

• Grade III (Severe): Ligaments are completely torn.→ Severe pain, major swelling, large bruises, and strong instability.Sometimes a popping sound is heard during the injury.

  
  

Diagnosis

The description of how the injury happened plus where it hurts gives important clues. The physiotherapist or doctor performs manual tests to check the ligaments, comparing the injured ankle with the healthy one.

In some cases, tests are done right after the injury for accuracy (later swelling can hide signs). It’s important to rule out bone fractures, especially of:

• the fibula (outer lower leg bone)

• the 5th metatarsal (bone on the outer side of the foot)

If pressing on these areas causes sharp pain, an X-ray (RTG) is recommended. In serious or unclear cases, MRI gives the most detailed image of bones and ligaments.

First Aid and Protection

If someone sprains their ankle:

1. Stop activity immediately. Adrenaline can hide the true pain level.

2. Apply compression: Wrap the ankle firmly with a bandage, especially on the outer side. A sock or soft pad can add pressure.

   • Keep the tight wrap for about 20 minutes, then reapply more loosely for several hours.

3. Elevate the foot above heart level to reduce swelling. These two steps limit internal bleeding and help recovery.

Avoid:

• Excessive use of ice or anti-inflammatory drugs — they can slow down natural healing. Inflammation is a normal part of the repair process for ligaments. They can be used in mdoerate.
  

Treatment

In most cases — even severe (Grade III) sprains — treatment is conservative, meaning no surgery is needed at first.

Even mild sprains should be checked by a physiotherapist, because small compensations can cause long-term problems in:

• knees, hips, shoulders, neck, or jaw

• and even dizziness, headaches, or ear ringing years later.

If pain or swelling lasts more than 2 days, a visit is necessary.

Physiotherapy Includes:

• Assessment of swelling and movement

• Manual therapy and modern techniques such as:

  • Fascial manipulation (FM, FDM)

  • Deep tissue massage

  • Cross-friction massage

  • Dry needling

  • Flossing

  • Kinesiology taping

  • Lymphatic drainage

After manual therapy, exercises begin:

• Start with toe and gentle ankle movements

• Slowly add weight-bearing (standing or walking)

• Later: use elastic bands (minibands, therabands) to strengthen ankle muscles– especially the peroneal muscles, which prevent the ankle from rolling inward.

• Finally: balance and coordination training, progressing to functional and dynamic exercises that mimic everyday movements or sports.

If instability remains after conservative treatment, surgery may be required.

Surgical Treatment

When surgery is needed, the surgeon decides how to rebuild or replace the torn ligaments. If the original ligaments can’t be repaired, a tendon graft (taken from another muscle, like the gracilis or peroneus brevis) may be used.

Post-surgery physiotherapy focuses on the same goals:

• restoring strength, mobility, and stability

• while protecting the repaired area using a cast or ankle brace

Therapy also includes scar treatment (including graft sites) and a careful balance between stability and mobility — too much immobilization can weaken the ligaments again.

References

1. Brotzman S.B., Wilk K.E. Orthopedic Rehabilitation, Vol. II, Elsevier Urban & Partner, Wrocław 2009.

2. McGovern R.P., Martin R.L. Managing ankle ligament sprains and tears, Open Access J Sports Med, 2016; 7: 33–42.

3. Mirkin G. Why ice delays recovery. drmirkin.com

4. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athletic Training, 2002; 37(4):364–75.

5. Murphy D.F. et al. Risk factors for lower extremity injury: a review. Br J Sports Med, 2003; 37:13–29.