Managing Ankle Sprains

Twenty years ago, my family lived in a split-level house, a fixer-upper in which we had just replaced all the carpet due to a recently burst water pipe.  Because we had purchased this house with the idea of fixing it up and not with the intention of staying long-term, especially with three young children and more planned, we selected a very light-colored carpet, almost white.  And one evening after putting the children to bed, I grabbed the last piece of fresh blackberry pie and a little bit of vanilla ice cream and headed downstairs to check my email before heading to bed myself.  Halfway down the flight of stairs, with my view obstructed by the pie and my thoughts of enjoying it, I stepped on one of Becky’s little toys and started descending way more quickly than normal.  (In case you are wondering whether those stories of people having their lives pass before their eyes when they’re about to die, or fall down the stairs, are really true, I can attest that they most definitely are.)  In that moment, I recognized that I had two choices:  I could save the last piece of blackberry pie and the vanilla-white carpet, or I could save myself. 

Naturally, I chose the pie and carpet. 

I landed very soundly on my ankle.  Now, I had experienced ankle sprains several times, but this put all my past experiences to shame.  My sister-in-law just happened to arrive a few minutes later, and she and my husband both determined that my ankle was probably not broken.  But I was definitely in shock, shivering like crazy, and very mad about it.  It felt like a character flaw to go into shock over a stupid little fall.  Anyway, my husband got me up to bed that night (after I finished the pie and ice cream, of course), and we applied ice and I’m sure I took some anti-inflammatories.  But the next morning my ankle was still quite swollen and there was no way I could put any weight at all on it.  That merited a trip to the urgent care where an x-ray revealed nothing.  No fracture.  So that was the good news.  But the bad news was that I had a bad second-degree sprain.  I had three young children, lived in a split-level house, both of our cars were stick-shifts, and the boys needed to be driven to and from school (several miles away) each day.  Curses.

Recovery was long and painful, and about three days into this ordeal I wondered if it was time to re-think my choices of that fateful evening.  Maybe I should have sacrificed the pie and the carpet.

Classification

Ankle sprains classified as first-, second-, and third-degree sprains. 

• First-degree.  With these most common of sprains, the vast majority of patients don’t seek treatment.  First-degree sprains resolve within minutes to hours.  They may cause some pain but generally there is little difficulty with walking.
• Second-degree.  These sprains range widely in the amount of damage and pain.  The ligament (ligaments connect one bone to another) is partially torn, whether a few fibers are affected or many.  The most common symptoms are pain and swelling of the outer ankle, and usually there is bruising and tenderness.  If only a few fibers are torn, there will be little difficulty walking. If many are torn, taking even one step may be impossible.
• Third-degree.  The ligament has been completely torn apart.  Interestingly, a third-degree sprain often doesn’t hurt as much as a second-degree sprain because the ligament isn’t under tension anymore.  But the joint will be very unstable.  These sprains necessitate prolonged immobilization or surgery.  In an austere situation, prolonged immobilization will be the only choice. 

Differentiating between a bad second-degree sprain and a fracture.  Differentiating between the two is difficult even for physicians, so much so that a protocol called the Ottawa Ankle Rules was developed to help determine when an ankle injury is more likely to be a fracture and whether an x-ray is warranted. 

The Ottawa Ankle Rules provide a good reference point for determining whether an ankle injury might be a fracture instead of a sprain:

• Bony tenderness over the lateral malleolus (the bony mound that is the outside of your ankle)
• Bony tenderness over the medial malleolus (the bony mound that is the inside of your ankle)
• Bony tenderness at the base of the 5^th metatarsal (the most lateral, or outside, bone in the foot, extending from the pinky toe)
• Bony tenderness at the navicular (extends from the big toe straight back to the ankle)
• Inability to bear any amount of weight and walk at least 4 steps at the time of injury or at the time of evaluation. 

If there is no bony tenderness in the ankle and the patient is able to bear some weight and take a few steps or hobble around, the ankle is much more likely to be sprained than broken.  However, if there is any bony tenderness in the ankle and any of the other criteria is met, a fracture is more likely. 

The Ottawa Ankle Rules are nearly 100% accurate when used with individuals over the age of 18.  They should not be used with patients with a head injury, those under the influence of alcohol or drugs, pregnant women, or children.

Because the tip of the fibula is often weaker than the ligament it is attached to, if the ligament is stretched too much too fast, the bone may break instead of the ligament.  In this situation, the gap is usually less than ¼” inch, and the body will bridge the gap with new bone formation if the ankle is immobilized.  Without an x-ray, you won’t know if the tip of the fibula has broken off or if the patient has just a bad second-degree sprain.  However, in an austere situation, it doesn’t really matter because, as far as treatment goes, it is the same as for a severe second-degree sprain.  Recovery normally takes 6-8 weeks. 

Treatment

For all second- and third-degree sprains, the initial treatment is the same and involves the RICES protocol:

Rest.  Rest is a must.  In challenging circumstances, this may not be possible.  However, without rest, chronic problems—lifelong—should be anticipated. 

Ice.  Ice or cold packs should be used as soon as possible for the first 24 hours, for 20 minutes every hour.

Compression.  After the ankle has had ice applied for twenty minutes, the injury should be wrapped very snuggly with an Ace bandage, wrapping from the top down to the bottom and back up again.  Wrap well, taking care not to cut off circulation.  Numbness or tingling is not good.  Whenever a body part is wrapped, circulation in the fingers and toes should be checked. 

Elevation.  The injured body part should be elevated above the level of the heart to reduce swelling.

Stabilization.  The ankle must be immobilized to prevent further injury. 

So how is this supposed to be performed? 

For the first 24 hours and with a mild second-degree sprain, have the patient get comfortable and elevate the ankle above the heart.  Apply ice packs or cold, damp cloths over affected joint for 20 minutes every hour to reduce swelling and pain.  Then apply a compression bandage.  After the first 24-48 hours, instead of ice packs, apply heat several times a day to promote blood flow and healing.  Do not massage a sprain or broken bone.[1]

Moderate sprains will require more of the above a few days longer.  A more moderate ankle sprain will also necessitate immobilization and the use of crutches. Because ligaments have a poor blood supply, sprains heal quite slowly. 

A severe sprain (third-degree) will be suggested by joint instability, deformity (the foot is twisted 90 degrees to one side), bony tenderness, and/or an inability to walk.  Prompt licensed care should be sought out if at all possible.  Barring that, the ankle will require prolonged immobilization, up to 8 weeks, with the patient on crutches most of the time.   

In all cases, patients may take NSAIDs to reduce pain and inflammation.  All patients should begin walking as pain and joint stability allow, when weight-bearing is tolerated without pain medication.  Walking too soon may cause additional injury.  Persons with moderate to severe sprains should continue to wear an elastic bandage or gel case when walking for at least a few weeks to prevent re-injury. 

References: 

Cynthia Koelker, Armageddon Medicine, 295-298.

“Ottawa Ankle Rules,” Physiopedia.org, https://www.physio-pedia.com/Ottawa_Ankle_Rules (accessed 6 January 2021).

E Papacostas, et al., “Validation of Ottawa Ankle Rules in Greek Athletes,”  British Journal of Sports Medicine, Volume 35 Issue 6, https://bjsm.bmj.com/content/35/6/445 (accessed 6 January 2021).

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[1] David Werner, Where There Is No Doctor, 102.

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