What is Acute Ankle Sprain?
Acute ankle sprains are often seen in regular healthcare facilities, sports medicine offices, and emergency rooms. They can cause considerable short-term discomfort, repeat injuries, and issues with maintaining balance. While non-surgical treatment often provides good results, it’s essential to accurately diagnose and treat the sprain right from the initial evaluation to reduce the chances of ongoing instability. The correct treatment can help prevent long-term problems like repeated ankle instability, progression to arthritis, and long-term disability.
What Causes Acute Ankle Sprain?
Ankle sprains mostly involve damage to two specific ligaments in the ankle: the anterior talofibular ligament and/or the calcaneofibular ligament. The severity and type of an ankle sprain can change depending on how the injury happened (like high- or low-energy accidents), the position of the foot during the injury, and the twisting force on the joint and its supporting ligaments.
Low severity injuries, known as grade I and II, cause either a stretching or very tiny tears in the ligaments that help to stabilize the ankle. A very severe (grade III) ankle sprain results in damage to the structures that join the two bones of the lower leg. With very high-energy injuries, the mechanism can cause the tendons to tear completely and even fractures of the ankle and foot.
Risk Factors and Frequency for Acute Ankle Sprain
Ankle sprains are a common injury, with over two million cases being treated in emergency departments in both the United States and the United Kingdom. These types of injuries occur most frequently in sports. The likelihood of an ankle sprain can vary based on the sport and whether the athlete is male or female. However, many studies suggest that the incidence of ankle sprains is similar in male and female athletes involved in comparable sports.
Some research has shown that male athletes tend to have a higher overall injury rate compared to female athletes in the same sports. For instance, a 2017 study on ankle sprain rates in elite soccer players found similar rates for both genders. It is also important to note that after the first ankle sprain, there is a high risk of further sprains and ongoing instability in the ankle.
- Over two million ankle sprains are treated in emergency departments in the United States and United Kingdom every year.
- Ankle sprains are the most common sports injury.
- The chance of getting an ankle sprain can depend on the sport and the gender of the athlete, but generally, the rates are similar for male and female athletes.
- According to a 2017 study, male athletes may have a higher overall injury rate than female athletes in equivalent sports.
- Another 2017 study found that male and female elite soccer players had similar ankle sprain rates.
- There is a high risk of repeated ankle sprains and ongoing ankle instability after the first sprain.
- Up to 40% of people with a lateral ankle sprain experience persistent symptoms, repeated sprains, and chronic lateral ankle instability.
Signs and Symptoms of Acute Ankle Sprain
If you have hurt your ankle, a healthcare provider will inspect it and ask about the incident that resulted in the injury. They will want to know whether the ankle was twisted inwards, outwards, rotated, or if it was hit directly. It’s also important for them to know if you’ve hurt your ankle before and how well you can put weight on it after the injury.
The next step is an examination of the ankle. The provider will look closely at your ankle, touch different parts of it to check for tenderness, and also do some tests to check how well it can function. Several ligaments on the side of your ankle will be checked, as well as your shin bone. A key part of the exam includes checking the top of your shin bone, as pain or a crunching feel may suggest a specific type of high-severity ankle injury called a Maisonneuve fracture. This fracture is often caused by a strong twisting force on the ankle and may involve a break in the shin bone depending on how the foot was positioned.
The provider will also check your foot for other potential injuries, especially focusing on the fifth metatarsal bone, the navicular bone, and the midfoot area. This is done to identify a potential Lisfranc injury, which is a serious foot injury. Signs of this injury may include bruising on the bottom of your foot that can be seen during the visual examination.
If the doctor suspects a strained area at the junction between two bones in your lower leg (known as syndesmotic sprain), they might do a squeeze test or external rotation stress test. A positive squeeze test would cause pain when your mid-calf area is compressed and released, while a positive external rotation stress test would cause pain when they rotate your foot. These assessments can be done using real-time X-ray imaging or just a stationary X-ray image. Another option for testing is called the gravity stress view, which is done with you lying down on your opposite side and the injured leg elevated.
The healthcare provider can also check the stability of specific ligaments in the ankle with the anterior drawer test. In this test, one hand steadies your lower leg while the other hand pulls forward on your heel with your foot flexed downwards. Excess movement may mean that the ligament is loose. another test called the talar tilt test can check for looseness in another ligament, this is done by stabilizing the lower leg and tilting the ankle while comparing with the uninjured side. But these tests may not always show accurate results immediately after an injury due to the pain and muscle spasm that might mask the true state of the ligaments.
Testing for Acute Ankle Sprain
The Ottawa ankle rules are a set of guidelines that help doctors decide if a patient with an ankle injury needs an x-ray to check for fractures. These rules can be used in both adults and children over five years old.
The Ottawa ankle rules suggest that an ankle x-ray should be done if the patient has pain in the ankle area and any of the following symptoms:
- Sensitivity over the back edge of the end 6 cm or tip of the outer ankle bone (lateral malleolus).
- Sensitivity over the back edge of the end 6 cm or tip of the inner ankle bone (medial malleolus).
- Unable to put weight on the ankle right after the injury and not being able to walk four steps during the check-up.
Also, doctors should consider doing a foot x-ray if a patient has pain in the middle of the foot and any of the following symptoms:
- Tenderness at the base of the fifth long foot bone (metatarsal).
- Tenderness over the navicular bone (a small bone in the top of the foot).
- Unable to put weight on the foot right after the injury and not being able to walk four steps during the check-up.
However, these rules should not be used if the patient is injured elsewhere, intoxicated, has decreased feeling in the lower legs or unable to cooperate due to a head injury or other difficult conditions. Despite not being very specific, the Ottawa ankle rules are highly sensitive in detecting ankle fractures. In fact, less than 2% of patients who were advised against having an x-ray based on these rules ended up having a fracture.
A typical ankle x-ray series would include front-to-back, side, and special ankle (mortise) views. Standard foot x-ray series include front-to-back, side, and angled (oblique) views.
Treatment Options for Acute Ankle Sprain
The first steps in dealing with ankle sprains often involve a process known as the PRICE protocol. This includes protection, rest, ice, compression, and elevation. Resting the hurt ankle for the first three days, then slowly starting to use it again depending on how it feels, is a good strategy. If necessary, you can use crutches to help with moving around. Studies have shown that letting the patient bear weight early with some support (this could be an elastic wrap or a certain type of boot or cast) results in quicker recovery times, less swelling, improved movement, and happier patients.
An elastic bandage, lace-up ankle support, or specific type of brace can be used to compress the ankle. To reduce swelling, you can lift the injured ankle above the heart as much as possible for 24 to 48 hours after the injury. You should start moving the ankle again once the pain and swelling have gone down. Pain can be controlled with nonsteroidal anti-inflammatory drugs or acetaminophen.
Rehabilitation should aim to restore motion first, then focus on balance and muscle control, followed by strengthening exercises (particularly for the muscles on the outer side of the ankle) to help avoid future injuries. Strength training should begin once the swelling and pain have lessened and the patient can move the ankle fully. Functional braces can be used in the early stages of this phase, as well as when the patient starts getting back into their normal activities.
Usually, mild to moderate ankle sprains completely heal in 7 to 15 days. If symptoms last longer than this, it’s a good idea to reevaluate the injury. All symptoms should have disappeared before the patient returns to sports. Highly competitive athletes should have all but mild sprains checked by a sports medicine physician before they go back to playing, in order to make sure they have fully recovered and to avoid repeat injuries or instability in the ankle.
Those with evidence of loose ligaments should not bear weight on the injured ankle, use crutches to get around, and see a sports medicine specialist or orthopedic surgeon. This is key because more severe injuries can often cause damage to the bone, tendons, and fractures, and can even cause loose bits of bone or cartilage inside the joint.
Patients who are suspected to have injuries to the syndesmotic complex (the group of ligaments connecting the two bones of the lower leg) should also be referred to a specialist. These injuries can take a long time to heal and may need surgery. Acute syndesmotic injuries that show separation and instability will need to be fixed with screws or a tightrope procedure. Any chronic, recurring instability in the ankle should also be referred to a surgeon for ligament reconstruction using a variety of accepted surgical methods.
What else can Acute Ankle Sprain be?
- Sprained ankle
- Serious sprain affecting the high ankle and connective tissue
- Broken ankle
- Dislocation of the joint below the ankle (subtalar dislocation)
- Injuries to the midfoot area, also known as Lisfranc injuries
Surgical Treatment of Acute Ankle Sprain
The frequency of tumors in the appendix in the United States is 1.2 cases per 100,000 people; nearly 30% of those affected have sudden intense stomach pain. The most common types of appendix cancer are gastroenteropancreatic neuroendocrine or carcinoid tumors (GEP-NETs), goblet cell cancer, colon-type adenocarcinoma, and mucinous tumor.
Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs)
GEP-NETs are the most usual type of appendix cancer. They seldom spread; if they do, it’s usually to the liver and lymph nodes. Because of this, if GEP-NETs are suspected, doctors must check the liver and nearby lymph nodes in the abdomen. The treatment depends on the size of the tumor. For very small tumors (less than 1 cm), removing the appendix is usually enough. For larger tumors (more than 2 cm), half of the right colon might need to be removed. The best approach for tumors between 1 and 2 cm isn’t definite. However, removal of part of the right colon is typically suggested if the tumor has spread to the fatty tissue that holds the intestines in place, or the lymph nodes, or if it isn’t completely clear whether all the cancer can be removed during surgery.
Goblet Cell Carcinoma
Goblet cell cancers are typical in appendix cancer, and they have similar characteristics to both appendix adenocarcinoma and neuroendocrine tumors. A complete review of the membrane lining the abdominal cavity should be done. Removal of half of the right colon could benefit patients with a cancer that hasn’t spread or is larger than 2 cm.
Lymphoma
Non-Hodgkin lymphoma, including a type that particularly impacts the lining of the digestive tract, may look like acute appendicitis at first. The most appropriate treatment for this rare appendix cancer is typically just removing the appendix. However, a complete review of the body should be done to rule out any potential spread of the cancer.
Appendiceal Adenocarcinoma
Adenocarcinoma of the appendix, a rare type of appendix cancer, often appears as acute appendicitis. The standard treatment is removal of half of the right colon. This approach is taken no matter the size of the tumor or whether the lymph nodes are affected.
Mucocele and Mucinous Neoplasm
Mucocele of the appendix can look like acute appendicitis. Mucoceles can occur from various harmless or cancerous processes involving excessive growth of the lining of the appendix and development of fluid-filled sacs within the appendix. Certain features observed through medical imaging, like a well-defined fluid-filled sac in the lower right abdomen, can raise the suspicion of mucocele. However, the final diagnosis depends on inspection during surgery and laboratory tests.
The best treatment for mucoceles is typically removing the appendix, done very carefully to avoid rupture. Checking for any spread to the membrane lining the abdominal cavity is important; taking of tissue samples should be considered. When there is suspected mucinous tumor in the appendix, a thorough exploration of the abdominal cavity and recording of any findings is crucial, especially when mucus is present. Patients chosen for a less invasive surgical approach in managing appendiceal mucocele should show signs of a solid, fluid-filled sac on medical imaging.
What to expect with Acute Ankle Sprain
Most ankle sprains can be successfully treated without surgery. However, in some cases – as much as 25-40% of patients – repeated instability and related problems can occur. It’s crucial to identify these possible additional injuries and make sure they’re referred to an orthopedic or sports medicine specialist. This is necessary to help reduce the chances of long-term negative effects.
Possible Complications When Diagnosed with Acute Ankle Sprain
There are several complications that can arise from ankle injuries. These can lead to chronic pain or disability, instability in the ankle, damage to the talus bone in the ankle, and injury to the peroneal tendon. Injuries can also harm the nerves and blood vessels, which may result in neurovascular injury. Long-term, these injuries can cause arthritis in the ankle, specifically in the tibiotalar and pantalar joints.
- Chronic pain or disability
- Recurrent ankle instability
- Damage to the talus bone in the ankle (osteochondral defects)
- Peroneal tendon injuries
- Neurovascular injury
- Arthritis in the ankle (tibiotalar and pantalar)
Recovery from Acute Ankle Sprain
Individuals who have a simple case of appendicitis and go through surgery usually get better without needing antibiotics. But if the appendicitis is more complex, they will likely need to take antibiotics for four days. If a patient deals with complications from their surgery wounds, like infections, these issues can be dealt with by making sure the wound is properly open and clean, and then packed appropriately. If more serious complications arise, like forming an abscess or deeper tissue involvement, it’s crucial that antibiotics are used to manage these effectively.
Preventing Acute Ankle Sprain
Input: “Individuals who have experienced an appendectomy can usually go back to their regular routines within a few days to a week post-surgery. Nevertheless, it is crucial for these individuals to avoid undertaking strenuous activities and heavy lifting during the first 4 to 6 weeks after the procedure. This careful approach encourages successful healing and minimizes the probability of encountering any complications.”
Output: People who have had their appendix removed can usually get back to their daily lives within a week or so of the operation. That said, they should avoid any heavy lifting or tough exercise for the first 4 to 6 weeks. Being mindful of this allows for better healing and lowers the chance of anything going wrong.
