Ankle Sprains

Ankle sprains occur when the ligaments that stabilize the ankle are stretched or torn as a result of a sudden and uncontrolled movement. This can range from mild ligament strains to complete ligament rupture.

Although often dismissed as a mere "strain" in the general public, ankle sprains account for 15–20% of sports injuries, and approximately 80% of all ankle injuries are sprains.

Sprains are divided into two main groups:

• Acute sprain: Occurs after a single traumatic event.

• Chronic ankle instability: Persistent looseness and a feeling of insecurity that develops after repeated sprains.

A sprain is not simply a "stretching" of ligaments. Microscopic tears, partial ruptures, or even complete ruptures can occur in the connective tissue. Therefore, not all sprains are the same, and their severity should be assessed clinically.

HOW DO SPRAINS OCCUR?

The vast majority of ankle sprains occur when the foot rotates inward (inversion) and simultaneously bends downward (plantar flexion). The foot rotates suddenly inward as it strikes the ground, stretching the ligaments beyond their capacity.

This mechanism is particularly observed in the following situations:

• Sudden change of direction during sports

• Misstep after jumping

• Walking on uneven ground

• Sudden loss of balance under load

Seventy-seven percent of sprains occur on the lateral (outer) side, and in most of these, the most frequently injured ligament is the anterior talofibular ligament (ATFL) .

The reason the ATFL is frequently injured is that it is anatomically the weakest lateral ligament and is subjected to the greatest tension in the plantar flexion position.

WHICH STRUCTURES ARE MOST AFFECTED?

The ligaments that stabilize the ankle are classified into three main groups:

1) Lateral ligament complex (most frequently injured)

• ATFL (Anterior talofibular ligament) – The most frequently torn ligament.

• CFL (Calcaneofibular ligament) – May be affected in moderate sprains.

• PTFL (Posterior talofibular ligament) – Strong, rarely injured.

The usual order of injury is: ATFL → CFL → (very rarely) PTFL.

2) Medial ligament (deltoid ligament)

It is injured by forceful outward movement of the foot (eversion) and is rarer than lateral sprains.

3) Syndesmosis

It is the structure that holds the tibia and fibula together at the top of the ankle. It is most often affected in severe hyperdorsiflexion traumas.

SPRAIN DEGREES

Not all sprains are created equal. Clinically, they are divided into three grades, and this classification reflects the severity of ligament damage and the stability of the joint.

• Grade 1 Sprain: There is stretching and microscopic tears in the ligament fibers. The ATFL (Atrial Ligament) is usually affected, but structural integrity is not completely lost. Swelling is mild, there is no significant laxity, and the patient can often walk. Therefore, it is often perceived as a "mild injury".

• Grade 2 Sprain: The ATFL is completely torn, and this may be accompanied by a partial tear in the CFL. Swelling and bruising are more pronounced. There is partial laxity in the joint, and the patient may feel insecure while walking.

• Grade 3 Sprain: This is the most severe form. Complete rupture of the ATFL and CFL occurs, with the PTFL also involved. There is significant edema, widespread ecchymosis, and severe mechanical instability. Most patients cannot bear weight on their ankle and may describe a "rupture" sensation at the time of trauma.

  
  

There is a significant misconception here: being able to walk does not mean the sprain is mild. Clinical grading is based not only on pain but also on ligament integrity and instability.

CLINICAL EVALUATION

Accurate diagnosis of ankle sprains is not based solely on swelling and pain. The goal is to determine the extent of ligament damage, rule out accompanying fractures or other problems, and assess the risk of future instability.

Assessment always begins with a detailed history. Important factors include how the foot was turned, the severity of the trauma, whether there was a "dropping" sensation at the time of injury, and whether the patient was able to walk after the injury. A history of previous sprains in the same foot is particularly significant in terms of chronic instability.

During the physical examination, the distribution of swelling and bruising is carefully examined. Local tenderness on the lateral side, especially in the ATFL and CFL regions, is indicative of ligament injury. If bone tenderness is present, the possibility of a fracture should be considered. The integrity of the Achilles tendon should also be assessed.

Certain specific tests are used to assess joint laxity (e.g., anterior drawer or talar tilt tests). These tests help reveal ligament laxity; however, they may not always be completely reliable due to the pain that follows a sprain.

In summary, clinical evaluation is based on understanding the mechanism, grading structural damage, and ruling out fracture.

OTTAWA REGULATIONS: IS AN X-RAY NECESSARY?

One of the most frequently asked questions about ankle sprains is: "Is an X-ray necessary?"

This is where the Ottawa Ankle Rules come into play. These rules were developed to determine when radiography is necessary and have reduced unnecessary X-rays by 30–40%.

X-rays are recommended in the following situations:

• If there is bone tenderness in the lateral malleolus or medial malleolus

• 5. If there is bone tenderness in the metatarsal area

• If there is tenderness in the navicular bone

• If the patient is unable to bear weight after the injury and during the examination

  
  

The aim of these guidelines is to evaluate suspected fractures clinically using objective criteria, rather than performing imaging for every sprain.

This approach shows that an ankle sprain is not a condition that requires "automatic X-rays".

X-RAY OR MRI?

The first-line imaging method is plain radiography. It is particularly used to evaluate conditions such as fractures, malleolus damage, or syndesmosis separation.

Magnetic resonance imaging (MRI) is not routinely necessary in the initial stages. MRI is more meaningful in the following situations:

• Pain that doesn't improve within 6-8 weeks

• Suspicion of accompanying osteochondral lesion (cartilage tissue)

• Unresolved instability

In high-energy traumas or situations where multiple structures may be affected, CT or MRI may be preferred. MRI is not always necessary in acute sprains. When a proper clinical assessment is performed, most patients can be managed appropriately without imaging.

TREATMENT

The vast majority of ankle sprains are treated conservatively, not surgically. The goal of treatment is to reduce pain, control swelling, maintain range of motion, and prevent the development of instability.

Conservative Approach

The most common approach in the acute (initial) phase is the RICE protocol: rest ( Rest ), cold application ( Ice ) , compression , and elevation . This method is applied within the first 48–72 hours to control edema and reduce pain.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to control pain during the inflammatory phase.

Immobilization varies according to the degree of injury. While elastic bandages may suffice for mild sprains, short-term supportive splints or braces are preferred for moderate sprains. In severe sprains, short-term, more rigid support may be applied; however, long-term plaster casting has been shown to negatively affect functional outcomes .

The joint should not be left completely immobilized; controlled mobilization should be performed.

Rehabilitation

One of the most critical aspects is rehabilitation.

Physiotherapy started in the early stages;

• It preserves the range of motion of the joint.

• It prevents muscle atrophy.

• It restores proprioception.

• Reduces the risk of chronic instability.

Functional rehabilitation typically lasts 3–6 weeks. The most important cause of recurrent sprains is loss of neuromuscular control. Therefore, treatment should aim not only at ligament healing but also at retraining nerve-muscle coordination.

IS SURGICAL INTERVENTION NECESSARY?

According to current literature, routine surgery is not recommended for acute ankle sprains.

A torn ligament can be repaired with a simple stitch, but studies have shown that surgery does not provide faster healing or reduce the risk of complications.

Surgery is most often considered in the following situations:

• Unstable ankle fractures

• Osteochondral defects

• Intra-articular free bodies

• Peroneal tendon ruptures

Therefore, surgery is considered not for the ligament sprain itself, but for any accompanying structural problems.

CONCLUSION

Ankle sprains are injuries that begin with a single moment of trauma, but their effects can have long-term consequences if not managed correctly. As we see in this article, the issue is not just about pain and swelling; underlying causes include biomechanical stress, connective tissue damage, loss of neuromuscular control, and potential instability.

Regardless of the severity of the sprain, the most important factors are accurate clinical assessment and a conscious recovery process. Avoiding unnecessary interventions is as crucial as not neglecting necessary rehabilitation. Proper management of the acute phase plays a critical role in preventing chronic problems.

In conclusion, an ankle sprain is not a "get-go" situation, but a condition that "needs to be treated correctly." When managed with a scientific approach, most cases show full functional recovery; however, if neglected, recurrent instability and loss of performance can become inevitable.

Taking an ankle sprain seriously doesn't mean being overly afraid; it means being sufficiently informed and prepared.

Reference:

• Al-Mohrej OA, Al-Kenani NS. Acute ankle strain: conservative or surgical approach? EFORT Open Rev. 2017 Mar 13;1(2):34-44. doi: 10.1302/2058-5241.1.000010. PMID: 28461926; PMCID: PMC5367574.