Interviewer: What do you do if you've sprained your ankle? Dr. Chris Gee is a primary care sports medicine and emergency medicine physician at University of Utah Health, and he's diagnosed and treated ankle sprains for professional athletes and people just like you and me.
So you think you've sprained your ankle, or you're pretty sure you've sprained your ankle anyway, what does that mean? What are the signs and symptoms and what can you do about it?
Diagnosing Ankle Sprains: Signs and Symptoms
Dr. Gee, let's start first of all with the signs and symptoms. What are the typical signs and symptoms that indicate that I have a sprained ankle?
Dr. Gee: So basically what a sprained ankle is, is that you have stretched or torn some of the ligaments that connect the bones together in the ankle. And so because of that stretching and tearing, there's a lot of swelling, there's a lot of bruising, and oftentimes quite a bit of pain with that as well.
Interviewer: Okay. And if somebody sprains their ankle, how good are patients generally at self-diagnosing that? I mean, do they have a pretty good sense that that's what it is as opposed to maybe something else that they've done?
Dr. Gee: Honestly, I think they're pretty good. Most people understand what it is. The ones that aren't quite as good are the ones that have a higher level of trauma and they've actually fractured something in addition. But I think most people are pretty good at understanding and recognizing when they've got a sprain.
Interviewer: So if I said I sprained my ankle, you would trust that for the most part if a patient told you that?
Dr. Gee: Yeah, exactly. There are some simple or relatively simple physical exam things that you can do to try to rule out a fracture or a tendon injury with an ankle sprain as well.
Interviewer: Is that something a regular person could do, or is that something that's really left to somebody like you?
Dr. Gee: It's obviously better in the hands of somebody who's done it a lot, but you could also do it on yourself.
So for example, one of the areas that will oftentimes fracture or break in the ankle is the side bone, kind of the bone that sticks out on the outside of your ankle. The ligament actually attaches to the bottom of that bone. And so if you're sore just down on the bottom or on the soft area just below it, that's probably just a sprain.
If that tenderness or that pain is kind of up the bone for a few centimeters, then you start worrying that you might have a fracture there. It doesn't mean you have one for sure. It just means hey, you probably need an X-ray and that's something we'll use in the clinic all the time.
Grading Ankle Sprains Severity
Interviewer: So then when it comes to ankle injuries, I understand that there are different classifications that are used to determine how severe they are. Can you explain that to me a little bit, please? Because that will impact how somebody might need to treat it or if they want to actually see a professional.
Dr. Gee: Exactly. So the easiest grading system is sort of a three-grade progression.
Grade 1 Ankle Sprains
So Grade 1 is that you have just stretched the ligament. So if you were to cut yourself open and look at it, you'd see that little strap or that little ligament still attached to the bone, it's just stretched. You're going to have pain, but still, generally, you're able to do some activity. You're still able to walk on it. It may swell up a bit, but those are treated conservatively and they do really well.
Grade 2 Ankle Sprains
Grade 2 is when you've partly torn it. And so if you were to look at those fibers, you'd see some were torn, almost like a frayed rope. Not totally torn, so it should heal okay, but it can be a little more painful, a little more swollen, and sometimes hard to get around.
Grade 3 Ankle Sprains
Grade 3 is where you've totally torn it off. Now, believe it or not, those can still heal okay, you don't have to get those fixed, but it may lead to some instability down the road. And so those have oftentimes a lot more swelling, a lot more bruising, and most of the time people can't walk on them for a week or two sometimes. And sometimes those need to be followed up to make sure that they don't have ongoing instability in the ankle that's going to cause problems down the road.
Distinguishing Ankle Sprains Grades
Interviewer: And as a sports medicine physician, how do you tell the difference between Grades 1, 2, and 3? Is that just purely imaging or are there other things that you do to determine the grade?
Dr. Gee: Yeah, so you can do it with imaging. Ultrasound or MRI can definitely tell you that. History and physical are probably the big ones that we use.
So on a physical exam, what they may do is they may take your ankle and kind of pull on it, basically pull it forward, push it back, tilt it to the side. If that ligament is still intact, it's going to give a nice endpoint, meaning when you try to pull it, it just stops. It won't let it go. If it's totally torn, it will just open up as wide as you can pull it.
And then the ones in between, the Grade 2s, they're a little tougher. Sometimes you'll have just a little bit of weakness or a little bit of laxity there.
But yeah, those Grade 1s and 3s are pretty easy to determine on physical exam.
The Ottawa Ankle Rules
Interviewer: Okay. So a provider like you might not even recommend imaging then because the physical exam is so good? Or do you generally always recommend imaging?
Dr. Gee: Yeah, so there is something called the Ottawa Ankle Rules that a lot of providers will use. And what they did was they did this study where they took a bunch of people and they said, "Hey, all these people got ankle X-rays. Which ones actually had fractures?" And they looked for the findings of those things that indicated they needed an X-ray.
One of them was what I talked about, that tenderness along the end of the fibula, about six millimeters up. There's some tenderness. If you have tenderness elsewhere, like on the base of a certain metatarsal or on the navicular, then those things probably need to have an X-ray.
And then beyond that, it's kind of the level and comfort of the provider. If they decide this patient has ongoing instability despite trying to do therapy and bracing, maybe they need an MRI to determine if that's not going to heal, they have multiple ligaments torn, or maybe there's even tendon or cartilage damage as well.
Interviewer: You mentioned the Ottawa Ankle Rules and how they apply to if there's a fracture or not, but does that also detect whether or not that tendon's been torn?
Dr. Gee: Not necessarily. Yeah, that's really just for fractures. So there's not a good rule system for that.
Most ankle sprains, however, will heal and they'll do fine. The biggest risk is that you might have a little bit of instability there. So a lot of times what we'll try to do is have the patient go through some physical therapy, building up the muscle and the tendon and trying to get that stable so that then you can get back to activity. Sometimes if you continue to have instability or a high-level athlete, those may get repaired and they may have the ligaments fixed and tightened up.
Treatment Strategies for Ankle Sprains
Interviewer: So let's talk about treatment. Talk us through the treatment plans of the different classifications and how the different classifications might also play into other factors. So let's start with that Grade 1, the least of the worst.
Dr. Gee: Exactly. So with Grade 1, and actually with all of them, the biggest thing that you want to try to do is get the fluid out of that ankle.
Managing Ankle Sprain Fluid Accumulation: Elevation, Compression, and Ice
So one of the problems I'll see is somebody sprains their ankle and they baby it, or they put it in a brace and they don't use it, it's been sitting down on the floor, and it's just swollen and so painful.
If you can, keep it elevated, so keep your foot above the level of the heart. You can use some compression like an ACE bandage or a sleeve on that ankle just to keep it from swelling too much, and apply ice to that ankle for about 10 to 15 minutes, 3 or 4 times a day. And then also use ibuprofen.
All those things with any ankle sprain are going to significantly decrease the amount of swelling and bruising that you have. And that's where a lot of the pain comes from.
The more nuanced stuff is whether or not you need to be in a brace and you need to be off of it. Definitely, if there's any concern that it's broken, you probably need to use some crutches and stay off of it. So if you've got any significant tenderness on the bones, then you probably ought to stay off of it until you have an X-ray.
But for most of them, once you feel a little more comfortable after a few days or a week or so, you can start doing some range of motion exercises to get that ankle moving a little bit. That'll also help the fluid get back out of the ankle so that it'll feel better.
Interviewer: And what is that fluid?
Dr. Gee: So that goes back to, as I talked about when those ligaments tear or stretch, they actually rip blood vessels and they tear tissue. And so that's actually blood that will track into the tissues into those areas.
So a lot of times when you've got a bad ankle sprain, you'll notice bruising that'll not only happen around the ankle, but it'll track down into the toes and into the heel, and that's all that blood just kind of working its way by gravity down through your skin.
Interviewer: And how does that complicate the healing process? It sounds to me that elevating it, the ibuprofen, those things are all about getting rid of that fluid.
Dr. Gee: Exactly. It complicates it because the tissues don't like all that fluid. It's really irritating to them. So it's a lot more painful. It's harder to move because it is so swollen, and it just doesn't come back quite as quickly.
When to Seek Professional Help for Ankle Sprains
Interviewer: So it sounds like that possibly a patient could do these types of treatment on their own without the help of a professional, but at what point would you want to perhaps go see somebody more educated in ankle sprains?
Dr. Gee: So, first of all, you try to do all these things to decrease the fluid. If after a week or so you're still having difficulty moving it, it's still really painful, or the pain just isn't getting better, at that point, you should definitely be seen.
The other thing to be seen is that if you feel like the ankle dislocated, and that means it kind of popped out, the whole ankle popped out and popped back in. That's pretty uncommon, but when it does happen, it almost always goes with a fracture. And so those ones probably need to be seen right away and probably should not be putting any weight on them.
Interviewer: So what is the advantage of seeing a professional such as yourself if somebody thinks that they do have a sprained ankle?
Dr. Gee: So one of the things that I think can really help you if you're able to see somebody early is that they can rule out any kind of a fracture or significant tendon or bony injury to the ankle. The reason that's important is because you can start doing some more rehab stuff quicker.
You're going to be doing the ice and elevation and ibuprofen anyway, but if I were able to rule out a fracture, then we can say, "Hey, you can really start exercising this, moving it around. You can put weight on it." All those things actually help it to feel better a little bit faster, and that can help your rehabilitation kind of speed up instead of having to wait a few weeks to see which direction it goes.
So one of the things that's really important with the ankle and that I try to stress with all of my patients is that when you stretch the ligaments, you also stretch small little nerves in there.
We have something in our bodies called a proprioceptive sense, meaning we know what position our foot is in without looking at it. However, when those nerves get stretched, that position sense gets messed up a little bit.
So even if the swelling goes down and the ankle feels better and you're walking on it, that position sense isn't quite as good as it used to be. So if you were to go walk on uneven ground, it's a little more likely for you to twist the ankle again if you step on a little rock or something like that. That's where physical therapy really is helpful.
And what they do is they really retrain some of your balance. They work on single-step kind of balance exercises to retrain the quickness of the tendons' and muscles' response to perturbations in your balance and in your position. They're able to really strengthen the muscles that support the ankle.
So even if you do have a big ligament tear, those muscles are going to help to support that ankle and a lot of times you can get away without having to do surgery if you're able to go through some good physical therapy.
Surgical Considerations in Ankle Sprains
Interviewer: And you mentioned surgery. Surgery could be necessary for a sprained ankle, huh? I guess I never thought that sprained ankles could get that serious.
Dr. Gee: Right. Most of the time, they don't. It's probably only a few percent that needs it, and it's really when you've torn all the ligaments on one side or the other in the ankle and it just continues to be unstable.
So people that keep spraining their ankle over and over despite doing good therapy, despite using bracing, and things like that, sometimes they need to get that fixed so that it doesn't damage the joint over time.
High-level athletes will sometimes do it because in theory they can get a little more stability and get back maybe a little bit faster than having to go through multiple sprains. That's some of the thought with that.
Interviewer: So at the end of all of this, if somebody is listening to this and they do have a sprained ankle, what is your kind of final piece of advice to leave them with? How should they proceed?
Dr. Gee: Yeah, so first off, I would definitely do all those things we talked about: icing it, keeping it elevated, protecting it, starting to kind of do some motion.
If you have any concerns, it seems more painful, it's a little abnormal from maybe prior ankle sprains that you've had, definitely get in and see a provider. We can help you kind of determine if there's anything more wrong and we can help you get back a little bit faster and definitely get you into therapy where that can be key to not only getting back quicker but also getting back 100% so that you don't have any ongoing problems with it.
