Ankle Injuries: Causes Symptoms, Diagnosis, Treatments, Prevention

Ankle Injuries: Causes Symptoms, Diagnosis, Treatments, Prevention

What is Ankle injuries?

Ankle injuries are one of the most common reasons for emergency room and doctors' office visits. In fact, no fewer than 20% of all time-loss injuries in organized sports are ankle injuries. Ankle sprains and fractures may be difficult to distinguish since they share many of the same symptoms such as tenderness around the ankle ligaments and ankle bones. Localized swelling, discoloration and blister formation may be seen with more severe injuries. At the time of injury, you may have heard or felt a 'pop' followed by a wave of pain and nausea. This may indicate a vital ligament or bone has been injured. To avoid further damage, it is imperative that motion of the ankle should not be tested if a serious injury is suspected. Unfortunately, many ankle injuries are misdiagnosed and can lead to chronic problems including permanent disability.

Ankle injuries can happen to anyone at any age. However, men between 15 and 24 years old have higher rates of ankle sprain, compared to women older than age 30  who have higher rates than men. Half of all ankle sprains occur during an athletic activity. Every day in the U.S., 25,000 people sprain their ankle. And more than 1 million people visit emergency rooms each year because of ankle injuries. The most common ankle injuries are sprains and fractures, which involve ligaments and bones in the ankle. But you can also tear or strain a tendon.

The majority of people with routine ankle sprains can expect to return to their normal exercise programs within two weeks. Obviously, a more significant sprain can take longer to rehabilitate.

If the ankle continues to hurt after six weeks, see a physician. Also, if you’re unable to walk on the affected ankle within a day, you should see a physician. Unfortunately, many people refuse to take the ankle injury seriously. The more attention you pay to the sprain, the sooner the ankle is likely to heal and the less likely you’ll sustain another sprain.

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What Kinds of Ankle Injuries Are There?

Ankle injuries are defined by the kind of tissue -- bone, ligament, or tendon -- that's damaged. The ankle is where three bones meet -- the tibia and fibula of your lower leg with the talus of your foot. These bones are held together at the ankle joint by ligaments, which are strong elastic bands of connective tissue that keep the bones in place while allowing normal ankle motion. Tendons attach muscles to the bones to do the work of making the ankle and foot move, and help keep the joints stable.

A fracture describes a break in one or more of the bones. A sprain is the term that describes damage to ligaments when they are stretched beyond their normal range of motion. A ligament sprain can range from many microscopic tears in the fibers that comprise the ligament to a complete tear or rupture. A strain refers to damage to muscles and tendons as a result of being pulled or stretched too far.

Muscle and tendon strains are more common in the legs and lower back. In the ankle, there are two tendons that are often strained.  These are the peroneal tendons, and they stabilize and protect the ankle. They can become inflamed as a result of overuse or trauma. Acute tendon tears result from a sudden trauma or force. The inflammation of a tendon is called tendinitis.  Microscopic tendon tears that accumulate over time, because of being repeatedly over stretched, and don’t heal properly lead to a condition called tendinosis. Tendons can also rupture. Subluxation refers to a tendon that slips out of place.

What is structures are involved with ankle injuries?      

First the bones:  The ankle is comprised of three bones: the two leg bones--the tibia (shin bone) and fibula--(which most people inaccurately call the ankle bones) and the true ankle bone called the talus, which is the bone that lies between the tibia and fibula.

The soft tissues:  Surrounding all the joints is a thick envelope of tissue called joint capsule.  If you've ever seen the white, connective tissue that surrounds a the joint of a chicken or turkey leg--that's primarily the joint capsule.  It's quite strong, and it envelops all sides of these bones, just like you could place tape around two pencils placed eraser to eraser to hold them together.

Inside and outside the joint capsule are the ligaments--short, tough soft-tissue bands that reinforce and provide additional stability to the joint capsule.  The ligaments typically injured in ankle sprains are (in the order they're typically injured):  The Anterior Talofibular Ligament, the Calcaneofibular Ligament, and the Posterior Talofibular Ligament.

What Causes Ankle Injuries?

An ankle injury occurs when the ankle joint is twisted too far out of its normal position.  Most ankle injuries occur either during sports activities or while walking on an uneven surface that forces the foot and ankle into an unnatural position. The unnatural position of the ankle in high-heeled shoes or walking in unstable, loose-fitting clogs or sandals is also a factor that may contribute to ankle injuries. In addition to wearing faulty footwear, an ankle injury can happen as a result of:

  • Tripping or falling
  • Landing awkwardly after a jump
  • Walking or running on uneven surfaces
  • A sudden impact such as a car crash
  • Twisting or rotating the ankle
  • Rolling the ankle

Are There Different Signs for Different Ankle Injuries?

The symptoms of a sprain and of a fracture are very similar. In fact, fractures can sometimes be mistaken for sprains. That's why it's important to have an ankle injury evaluated by a doctor as soon as possible. The signs include:

  • Pain, often sudden and severe
  • Swelling
  • Bruising
  • Inability to walk or bear weight on the injured joint
With a sprain, the ankle may also be stiff.  With a fracture the area will be tender to the touch, and the ankle may also look deformed or out of place.

If the sprain is mild, the swelling and pain may be slight. But with a severe sprain, there is much swelling and the pain is typically intense.

Tendinitis and acute tears of the peroneal tendon result in both pain and swelling. In addition, the ankle area will feel warm to the touch with tendinitis. With an acute tear, there will be a weakness or instability of the foot and ankle.

Tendinosis may take years to develop. Symptoms include:

  • Sporadic pain on the outside of the ankle
  • Weakness or instability in the ankle
  • An increase in the height of the foot's arch
With the subluxation you will notice ankle instability or weakness. You also may notice sporadic pain behind the outside ankle bone and a "snapping" feeling around the ankle bone.

What tissues get injured in an ankle injury?

Any of the bones or soft tissues may be damaged in an ankle injury.  But most injuries begin as a simple strain to a ligament (usually the anterior talofibular ligament) on the outside portion of your ankle.  If the mechanism of injury progresses, the injury may progress to involve more ligaments (the posterior talofibular and the calcaneofibular ligaments) and the joint capsule.  As the mechanism of injury progresses, the injury may involve bone, in addition to the soft tissues.

The disruption of any of these structures may lead to dysfunction of the ankle joint, and recurring sprains may result, so a proper examination, appropriate diagnostic testing (X-ray, MRI, CT scans), accurate assessment and appropriate treatment by a qualified foot and ankle specialist is necessary to achieve the best return to normal function possible.

How Does the Doctor Diagnose an Ankle Injury?

The first thing a doctor will do is ask questions about how the injury occurred. Then the doctor will examine the ankle, noting the amount of swelling and bruising. The physical examination of the ankle may be painful because the doctor needs to move the ankle to evaluate the pain and swelling in order to make a proper diagnosis.

The doctor may order an ankle X-ray to determine whether there are any broken bones. In addition to an ankle X-ray, your doctor may ask for X-rays of the leg and foot to determine whether there may be other related injuries. If the doctor suspects a stress fracture, the doctor will ask for other imaging scans such as an MRI, which will show more detail about the injury. If there is a fracture, the doctor may also ask for a stress test, which is a special X-ray taken with pressure applied to the joint. This will help the doctor determine whether surgery is needed.

For most ankle injuries, pain is controlled by using an over-the-counter medication such as acetaminophen or other nonsteroidal anti-inflammatory drug such as ibuprofen. The specific treatment of the injury depends on the type of injury.

Treatment of Fractures

Fractures can be treated either surgically or nonsurgically. The doctor may treat the break without surgery by immobilizing the ankle if only one bone is broken, and if the bones are not out of place and the ankle is stable. Typically the doctor will do this by putting on a brace that works as a splint or by putting on a cast. If the ankle is unstable, the fracture will be treated surgically. Often, the ankle is made stable by using a metal plate and screws to hold the bones in place. Following the surgery, the ankle is protected with a splint until the swelling goes down and then with a cast.

It usually takes at least six weeks for the bones to heal.  Your doctor will probably ask you to keep weight off the ankle during that time so the bones can heal in the proper alignment. Ligaments and tendons can take longer to heal after a fracture is fully mended. It can take as long as two years to completely recover full painfree motion and strength after an ankle fracture, although most people are able to resume their normal daily routine within three to four months.

After the doctor has determined it is safe for you to start moving your ankle, you may need physical therapy to provide gait training, balance, strengthening, and mobility exercises.  The therapist will develop a home program  that you can use to regain your previous normal function.  It can take several months to return to a normal walking pattern without limping.

Treatment of Tendon Injuries

Options for treating tendon injuries are similar to options for treating sprains. They include:

  • Immobilization using a cast or splint
  • Oral or injected anti-inflammatory drugs to reduce pain
  • Physical therapy for range of motion, strength, and balance
  • A brace to provide support during activities
  • Surgery to repair the tendon or tendons and sometimes to repair the supporting structures of the foot

Treatment of Sprains

The treatment for sprains depends on the severity of the injury.  They are graded as mild, moderate, or severe. Surgery is not usually a treatment option unless the damage is extensive, involves more than the ligaments, or when other treatment options fail.

Mild sprains -- called grade 1 -- are treated with the RICE approach for several days until the pain and swelling improve. With a mild sprain, you won't need a splint or a cast. Your doctor will tell you to put weight on the ankle fairly soon -- within one to three days -- as long as you can tolerate it and will prescribe range of motion, stretching, and strengthening exercises.

If your sprain is classified as moderate, or grade 2, the doctor will use the RICE approach but allow more time for healing to occur. The doctor may also use a device such as a boot or a splint to immobilize the ankle. You will be given exercises to do first to improve range of motion and then to stretch and strengthen the ankle. The doctor may also prescribe physical therapy to help you regain full use of your ankle.

Grade 3 or a severe sprain involves a complete tear or rupture of a ligament and takes considerably longer to heal. It's treated with immobilization of the joint followed by a longer period of physical therapy for range of motion, stretching, and strength building. Occasionally, especially if the sprain does not heal in a reasonable time, surgery will be considered for reconstructing the torn ligaments.

On average, the initial treatment of a sprain, includes resting, and protecting the ankle until swelling goes down for about one week. That's followed by a period of one to two weeks of exercise to restore range of motion, strength, and flexibility. It can take several more weeks to several months to gradually return to your normal activities while you continue to exercise.

Ankle Injury Complications

Patients who develop arthritis as a result of an ankle injury generally receive anti-inflammatory drugs to relieve swelling and pain. However, the degenerative nature of the condition sometimes results in the need for surgery.

Surgery may involve trimming away damaged synovial tissue, smoothing out rough-worn cartilage, and removing fragments of cartilage or bone from the joint. Whenever possible, the procedure is performed arthroscopically, using a narrow, flexible, fiber-optic viewing tube called an arthroscope that enables the surgeon to see inside ankle and work with precision.

In severe arthritic conditions resulting from multiple fractures, bone fusion may be performed. Affected joints are fastened together with surgical screws or rods so they eventually grow together and become one larger bone. This procedure eliminates the joint and the motion that causes the pain. However, the patient is left with a noticeably stiff-legged gait. Trading limited mobility for pain reduction is usually a last resort.

When is Surgery Needed?

In more severe cases, surgery may be required to adequately treat an ankle sprain. Surgery often involves repairing the damaged ligaments.

After surgery, rehabilitation is extremely important. Completing your rehabilitation program is crucial to a successful outcome.

Can Ankle Injuries Be Prevented?

The National Institute of Arthritis and Musculoskeletal and Skin Diseases recommends the following steps for reducing your risk of an ankle injury:

  • Avoid exercising or playing sports when you are tired or in pain.
  • Keep muscles strong by eating a well-balanced diet.
  • Maintain a healthy weight.
  • Try to avoid falling.
  • Wear shoes that fit well and that are appropriate for the activity you are doing.
  • Don't wear shoes that have heels worn down on one side.
  • Exercise every day.
  • Maintain the proper conditioning for whatever sport you are playing.
  • Warm up and stretch before exercising or playing a sport.
  • Wear the proper equipment for whatever sport you play.
  • Run on flat surfaces.