Ankle Sprain

You stepped off a kerb at the wrong angle, or landed on someone's foot at padel, and felt the ankle roll under you. By the evening the outside of the ankle is puffy and starting to bruise, and putting your full weight on it feels like a bad idea. A few days later it is better, but not quite right, and you are not sure how hard to push it.

Most sprains involve the ligaments on the outside of the ankle, which stretch or tear when the foot turns inward under load. They are graded by how much ligament damage there is, from a mild stretch to a complete tear. In the first day or two, swelling and pain make that hard to judge. An evidence-based clinical guideline notes that the severity of ligament damage is assessed most reliably with a physical examination 4 to 5 days after the injury (Vuurberg et al., 2018), which is why we often reassess once the first swelling has settled. Ankle sprains sit within our wider ankle and foot pain work, and the same principles apply to other muscle strains and ligament sprains.

The first question is usually whether anything is broken. The Ottawa ankle rules answer this with a short bedside check: whether you can walk four steps and whether there is tenderness at the back edge or tip of either ankle bone (Halabchi and Hassabi, 2020). A review of 66 studies found the rules picked up 99.4% of ankle fractures (Beckenkamp et al., 2017), so when they are negative a fracture is very unlikely and most sprains do not need imaging. When they are positive, including when you cannot take four steps on the ankle, we refer you for an X-ray directly. Chiropractors in South Africa are primary contact practitioners, so you do not need a GP referral first. Checking feeling and circulation in the foot is a standard part of examining an ankle injury (Halabchi and Hassabi, 2020). If the foot looks out of shape or feels numb or cold, go straight to an emergency department rather than waiting for an appointment.

Once a fracture is ruled out, the aim is to protect the ankle without keeping it still for longer than it needs. An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise and manual therapy techniques in improving pain, swelling and function after an acute sprain (Doherty et al., 2017). The guideline recommends tape or a brace combined with an exercise programme after a ligament tear and recommends supervised, exercise-based rehabilitation (Vuurberg et al., 2018). It is the same thinking behind the move from RICE to PEACE & LOVE for soft tissue injuries.

Hands-on treatment plays its part. Many people are left with an ankle that will not bend fully as the knee travels forward over the toes, which shows up on stairs, in a squat and when running. In people with ongoing problems after a sprain, a meta-analysis found that joint mobilisation improved dynamic balance immediately after treatment and weight-bearing ankle bend in the short term (Weerasekara et al., 2018). We combine mobilisation and soft tissue work with a graded rehabilitation programme that builds from range of motion to strength, balance and hopping.

For many people the first sprain is not the end of it. A history of ankle sprain is linked to roughly 3.5 times the risk of spraining the ankle again, and in one prospective study 40% of people had chronic ankle instability a year after their first sprain (Herzog et al., 2019). Chronic ankle instability is the ankle that rolls on uneven ground, feels weak or unreliable and swells after sport. Many people never have the first sprain assessed at all. The good news is that this is where rehab earns its place: exercise therapy and bracing are both supported for preventing chronic instability, and balance and control training has moderate evidence for preventing repeat sprains (Doherty et al., 2017).

If you have already sprained the same ankle several times, it is still worth rehabilitating properly. The guideline suggests considering an ankle brace to help prevent recurrent sprains and reserves surgery for ankles that do not respond to thorough exercise-based treatment (Vuurberg et al., 2018). In one prospective study, difficulty with jumping and landing tasks two weeks after a first sprain was predictive of who went on to develop chronic instability, as were poorer balance reach and lower self-reported function at six months (Doherty et al., 2016). So we test your balance, single-leg landing, hop control and ankle range, including how the hip, knee and ankle move as you reach and land. The programme is built around what we find. For athletes, return to sport is guided by functional tests such as single-leg hop and balance reach tests (Halabchi and Hassabi, 2020), progressing to the cutting and landing your sport asks of it.

If your ankle still feels swollen, stiff or unreliable a week or two after a sprain or keeps rolling over, getting assessed early helps you start the right rehabilitation sooner.

Located on Rivonia Road in Morningside, we treat patients from Sandton, Bryanston, Rivonia, Fourways and across Johannesburg.

Book an appointment at our Sandton practice and let us help you get your ankle strong and stable again.

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