An ankle sprain occurs when the ankle ligaments or the joint capsule are stretched beyond their normal limits and they tear. Sprains range from very mild to severe, depending on the extent to which this stretching occurs, which varies a great deal. The ankle is a paradoxical joint, taking the weight of the entire body without complaint for years and then suddenly painful and swollen if it gets turned in an unexpected way. This article is a deep dive into the best approach to treatment because things have changed a lot over the past ten years and the fix isn’t necessarily what you might think. (TL;DR it’s not RICE)

sprained ankle X-ray

X-ray of grade III sprained ankle

(copyright by the Author)

How common are they?

Ankle sprains are one of the most frequent injuries. They are more common amongst people who engage in sports involving running, jumping and rapid changes of direction, but they can happen to anyone.

A study published in the Journal of Foot and Ankle Research estimated that the annual incidence of ankle sprains in the general population ranges from 2 to 3 per 1000 people, depending on age and activity level. This is probably greatly under-reported because most sprains don’t take people to any kind of medical care so these occurrences aren’t counted in the figures.

 

Why do they matter so much?

Much of the time a sprained ankle just gets better. The body is great at healing itself and a bit of care and attention is all that’s needed. The issue is that some sprains don’t heal normally, which is sometimes because rehabilitation is missing entirely, or it’s inappropriate. These kinds of ankle sprains lead to future inactivity and compensation strains for the individual. This is what prompted me to write this article, so let’s get up to date with ankle rehabilitation.

The Ottawa Ankle Rules are a set of clinical guidelines that help healthcare providers to determine whether an ankle injury requires an X-ray to rule out a fracture. The rules were developed to make more efficient use of X-ray resources and reduce unnecessary X-ray imaging. They are based on a combination of clinical history and physical examination findings. The rules state that an X-ray is only necessary if there is pain in the malleolar zone (the bony part on the inside or outside of the ankle), and one or more of the following:

  • Inability to bear weight immediately after the injury and in the emergency department for four steps.
  • Tenderness at the posterior edge or tip of the lateral malleolus (the bony bump on the outside of the ankle) or at the posterior edge or tip of the medial malleolus (the bony bump on the inside of the ankle).
  • Tenderness along the distal 6 cm of the posterior edge of the tibia (the shin bone).

If none of these findings are present, an X-ray is not required to rule out a fracture.

The Ottawa Ankle Rules have been repeatedly shown to be a sensitive and specific tool for identifying ankle fractures in both adults and children, but they can only be used in conjunction with a competent case history and experienced clinical judgement. Additional diagnostic tests may be performed if there is a high degree of suspicion for a fracture despite negative Ottawa Ankle Rule findings.

Oh but don’t we just use RICE?

The internet is full of advice about sprained ankles, most of which focuses on the traditional approach: RICE. This is an acronym for rest, ice, compression and elevation. It’s a very good example of the danger of acronyms, especially when they’re catchy. The RICE protocol has been wheeled out for just about every musculoskeletal injury imaginable for decades, but it was never based on any real evidence.

Many more recent studies have challenged the RICE protocol and here are some examples:

  • A 2013 study published in the Journal of Athletic Training found that the application of ice to a muscle injury actually slowed down the healing process by reducing blood flow to the injured area.
  • A 2014 study published in the Journal of Strength and Conditioning Research found that immobilisation and extended periods of rest after ankle sprains lead to decreased muscle strength and decreased range of motion.
  • A 2015 study published in the British Journal of Sports Medicine found that a combination of rest, ice, and compression was no more effective in reducing pain and swelling after ankle sprains than rest alone. The researchers suggested that early mobilisation and functional exercises may be more effective in promoting healing and preventing long-term complications.

These studies, and many more like them, suggest a more active approach to treatment and rehabilitation and a move away from ice and anti-inflammatories. These ideas fit well with one of the key osteopathic principles: the general necessity of enhancing blood flow so that healing can be optimised.

 

PEACE and LOVE

The shift away from RICE has also been in response to a new approach which is more grounded in research. This formulation is called PEACE and LOVE.

PEACE stands for:

  • Protection: Protect the area against further damage.
  • Elevation: Elevate the area to reduce swelling (initially, and intermittently).
  • Avoid anti-inflammatories: don’t use non-steroidal anti-inflammatory drugs (NSAIDs) and ice as these have been seen to delay the body’s inflammatory processes.
  • Compression: Use compression to control oedema (swelling).
  • Education: Seek advice from a knowledgeable healthcare professional on the best course of treatment and rehabilitation for your injury and get as specific as you can about this process.

LOVE stands for:

  • Load: gradually load the injured tissues with weight-bearing and movement exercises as prescribed by the professional with whom you have consulted. There is no one-size-fits-all here; the approach has to be tailored to you.
  • Optimism: try to foster a positive outlook and confidence in your body’s ability to heal
  • Vascularization: promote blood flow to the injured area through movement, exercise and hands-on treatment if necessary.
  • Exercise: Perform rehabilitation exercises to restore function and prevent future injury.

 

 

Equally, because everybody is different and every injury is different, it’s important to note that the PEACE and LOVE approach may not be appropriate for all types of injuries, and it’s always a good idea to seek the advice of a medical professional to determine the best course of treatment for your specific case. In some cases, RICE may still be the right approach. It’s important to work with a healthcare professional to develop an individualised treatment plan based on the specific type and severity of the injury.

 

What happens to the rest of the body when an ankle doesn’t heal properly?

Most issues resulting from sprained ankles begin with limping. This puts a strain on the other foot, ankle, leg and the rest of the biomechanical chain which is involved with walking. Limping for a day or two tends not to cause issues, but if limping continues over weeks and months we develop compensation strains because the body attempts to compensate for the injured ankle by changing the way it moves and bears weight.

Some common compensation strains that may arise from an ankle sprain might include:

  • Calf strain: The calf muscles which run down the back of the lower leg become strained as they attempt to compensate for the injured ankle.
  • Achilles tendinopathy: the Achilles tendon, which connects the calf muscle to the heel bone becomes inflamed and painful as it is forced to bear more weight – and at a different angle – than usual.
  • Plantar fasciitis: the plantar fascia, a thick band of tissue running along the bottom of the foot becomes strained and inflamed as it compensates for the injured ankle.
  • Chronic ankle instability of the affected ankle.
  • Hip strain: the hip muscles and/or capsule may become strained as they try to compensate for changes in gait.
  • Knee pain: any of the structures in the knee can become strained as either knee compensates for altered movement.
  • Low back pain: the low back is the common point between both legs so it is logical that the low back experiences strains resulting from asymmetrical movement in the legs resulting from the sprained ankle.

The list goes on, but these compensation strains can be prevented or at the least minimised through appropriate management and rehabilitation of the ankle sprain, by a qualified healthcare professional such as an osteopath, physiotherapist, or sports medicine doctor. If your sprained ankle is not a lot better after a week, or if you think it might be in any way serious, get it examined.

Final thought: do kangaroos sprain their ankles?

Probably. Like humans, kangaroos (along with bears, raccoons, badgers, weasels, mice, rabbits and hedgehogs) are plantigrade. Other animals are either digitigrade (including cats, hyenas and dogs) or unguligrade (including horses, camels, giraffes and deer). This means that we walk with our toes and metatarsals (yellow and brown in the image below) flat on the ground. This is advantageous for stability but not so good for speed or jumping, and being digitigrade means that the ankle is a right angled joint as is clearly seen on the image below. This gives it a greater chance of being sprained than those of our relatives in the digitigrade and unguligrade families. A cat could never land from height if it were a plantigrade. Horses would never gallop at such pace were they not unguligrade. Food for thought.

Plantigrade left, digitigrade centre, unguligrade right

Plantigrade left, digitigrade centre, unguligrade right

In red the basipod, in violet the metapodia, in yellow the phalanges, in brown the terminal keratinized surface.

(Antoine Adam, CC0, via Wikimedia Commons)

 

Selected references

Bachmann, L. M., Kolb, E., Koller, M. T., Steurer, J., & Riet, G. ter. (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: Systematic review. BMJ, 326(7386), 417. https://doi.org/10.1136/bmj.326.7386.417

Bleakley, C. M., O’Connor, S. R., Tully, M. A., Rocke, L. G., MacAuley, D. C., Bradbury, I., Keegan, S., & McDonough, S. M. (2010). Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ, 340(may10 1), c1964–c1964. https://doi.org/10.1136/bmj.c1964

Bullock-Saxton, J. E. (1994). Local sensation changes and altered hip muscle function following severe ankle sprain. Physical Therapy, 74(1), 17–28; discussion 28-31.

Bureau, N. J., Cardinal, E., Hobden, R., & Aubin, B. (2000). Posterior ankle impingement syndrome: MR imaging findings in seven patients. Radiology, 215(2), 497–503.

Dubois, B., & Esculier, J.-F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine, 54(2), 72–73. https://doi.org/10.1136/bjsports-2019-101253

Eliasson, P., Agergaard, A.-S., Couppé, C., Svensson, R., Hoeffner, R., Warming, S., Warming, N., Holm, C., Jensen, M. H., Krogsgaard, M., Kjaer, M., & Magnusson, S. P. (2018). The Ruptured Achilles Tendon Elongates for 6 Months After Surgical Repair Regardless of Early or Late Weightbearing in Combination With Ankle Mobilization: A Randomized Clinical Trial. The American Journal of Sports Medicine, 46(10), 2492–2502. https://doi.org/10.1177/0363546518781826

Gabbett, T. J. (2016). The training—injury prevention paradox: Should athletes be training smarter and harder? British Journal of Sports Medicine, 50(5), 273–280. https://doi.org/10.1136/bjsports-2015-095788

Golano, P., Vega, J., de Leeuw, P. A. J., Malagelada, F., Manzanares, M. C., Gotzens, V., & van

Dijk, C. N. (2010). Anatomy of the ankle ligaments: A pictorial essay. Knee Surgery, Sports Traumatology, Arthroscopy, 18(5), 557–569. https://doi.org/10.1007/s00167-010-1100-x

Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of Ankle Sprains and Chronic Ankle Instability. Journal of Athletic Training, 54(6), 603–610. https://doi.org/10.4085/1062-6050-447-17

Hubbard, T. J., & Denegar, C. R. (2004). Does Cryotherapy Improve Outcomes With Soft Tissue Injury? Journal of Athletic Training, 39(3), 278–279.

Jansen, H., Jordan, M., Frey, S., Hölscher-Doht, S., Meffert, R., & Heintel, T. (2017). Active controlled motion in early rehabilitation improves outcome after ankle fractures: A randomized controlled trial. Clinical Rehabilitation, 026921551772419. https://doi.org/10.1177/0269215517724192

Kaminski, T. W., Hertel, J., Amendola, N., Docherty, C. L., Dolan, M. G., Hopkins, J. T., Nussbaum, E., Poppy, W., & Richie, D. (2013). National Athletic Trainers’ Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes. Journal of Athletic Training, 48(4), 528–545. https://doi.org/10.4085/1062-6050-48.4.02

Nester, C. J., Jarvis, H. L., Jones, R. K., Bowden, P. D., & Liu, A. (2014). Movement of the human foot in 100 pain free individuals aged 18-45: Implications for understanding normal foot function. Journal of Foot and Ankle Research, 7(1), 51. https://doi.org/10.1186/s13047-014-0051-8

Plisky, P. J., Rauh, M. J., Kaminski, T. W., & Underwood, F. B. (2006). Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. Journal of Orthopaedic & Sports Physical Therapy, 36(12), 911–919. https://doi.org/10.2519/jospt.2006.2244

Sidaway, B., & Trzaska, A. (Robinson). (2005). Can Mental Practice Increase Ankle Dorsiflexor Torque? Physical Therapy, 85(10), 1053–1060.

Stiell, I. G., Greenberg, G. H., McKnight, R. D., Nair, R. C., McDowell, I., & Worthington, J. R. (1992). A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Annals of Emergency Medicine, 21(4), 384–390. https://doi.org/10.1016/s0196-0644(05)82656-3