Ankle Sprains Are Common But Not Normal
Ankle sprains are the most common sports injury, & the pain, swelling & weight-bearing capacity usually settle fairly well in 1-2 weeks. Although this can be a positive thing, the downside is that ankle sprains are often seen as “normal”, & the quick reduction in pain means people often return to sport before adequate recovery has occurred. In a US study of high school athletes 75% returned to sports within 3 days & 90% within 10, giving very little time for recovery.
This premature return to sport has an impact on why recurrence rates are so high. A previous ankle sprain is the strongest risk factor for a subsequent sprain, with a recurrence rate of up to 70%2. Importantly, up to 72% of re-sprainers will go on to develop chronic ankle instability3.
Ankle Osteoarthritis Is Different To Hip & Knee Osteoarthritis
Unlike osteoarthritis (OA) in the hip & knee, ankle OA has a strong link to previous trauma. Up to 90% of those with ankle OA will have a history of ankle sprains4, compared to only 2-10% of hip & knee cases. The onset of ankle OA is also 14 years younger on average than those without a history of ankle sprains4.
So, while the vast majority of hip & knee OA is primary OA, i.e. simply due to the ageing process, ankle OA is much more related to previous trauma & sprains. This is called post-traumatic OA.
These future consequences of repeated ankle sprains mean that we need to start taking their rehabilitation more seriously. While they are common, & their acute symptoms may settle quickly, repeated sprains significantly increase the risk of developing early-onset OA several years or even decades down the line4.
When Does An Ankle Sprain Need An X-ray? The Ottawa Ankle Rules
Only 15% of ankle sprains result in a clinically significant fracture5. The Ottawa Ankle Rules are the gold-standard clinical tool to decide if referral for X-Ray is necessary. They avoid unnecessary imaging post-ankle injury6. You should see your GP or go to the emergency department at your hospital if you are concerned about your ankle injury, & they will use these rules to help decide if you need an x-ray. If you don’t have any of these markers you are less than 1% likely to have a fracture7.
How Do Physio’s Manage Ankle Sprains?
Ankle sprains are one of the most common sports injuries that we see as physios. While every sprain is different, & once the need for an x-ray or other imaging has been ruled out, the main areas of effective rehab after an ankle sprain are;
Range of Motion: Manual therapy & graded exercises restore full ankle range of motion (ROM).
Strength: It is critical to address strength deficits in the calf & peroneals. The ankle load in a single vertical jump is 1.5 x body weight, so restoring strength is essential.
Proprioception & Balance: Retraining ankle proprioception is critical for both static & dynamic ankle stability.
Agility & Sport-Specific Rehab: Progressive hops, jumps & sport-specific drills should be completed before returning to sport. We use the PAASS framework9 to make objective decisions on when a client is ready to return to sport.
What Happens If An Ankle Sprain Is not Treated Correctly?
As outlined above, the main risk of ankle sprains that are not treated correctly is an increased chance of developing osteoarthritis in the future. As well as being more common, this post-traumatic osteoarthritis also tends to come on at an earlier age4 (onset is 14 years younger in sprainers than non-sprainers).
Failure to treat ankle sprains properly can lead to recurrent sprains. Deficits in the above measures (ROM, strength, proprioception/balance, & sport-specific retraining) are attributed to 20% of those who go on to develop chronic ankle instability8. These people are at the highest risk of developing ankle OA in the future.
Have A Question About Ankle Sprains?
If you have any questions about how to treat ankle sprains, our physios are happy to help. You can click below to email us a question for some free advice, or book online to start your rehab with us.
References
1. Gribble et al. 2016 Consensus statement of the International ankle Consortium: prevalence, impact & long-term consequences of lateral ankle sprains. Br J Sports Med
2. Beynnon et al 2002 Predictive factors for lateral ankle sprain: lit.review. J Ath Trg.
3. Doherty et al 2016 Recovery from first-time lateral ankle sprain & the predictors of chronic ankle instability: a prospective cohort analysis. Am J Sports Med
4. Delco et al 2017 Post-traumatic OA of the ankle: A distinct clinical entity requiring new research approaches. J Orth Res
5. Brooks et al 1981 Inversion injuries of the ankle: assess’t & radiographic review. BMJ
6. Stiell et al 1993 Decision rules for the use of radiography in acute ankle injuries. JAMA
7. Kerkhoffs et al 2012. Diagnosis, treatment & prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med
8. Eechaute et al 2007 The clinimetric qualities of patient-assessed instruments for measuring chronic ankle instability: a systematic review. BMC
9. Smith et al 2021 Return to sport decisions after acute lateral ankle sprain injury: the PAASS framework—an international multidisciplinary consensus. Br J Sports Med
