The Credit Valley Hospital

Sprained Ankle

The doctor who examined you has diagnosed a sprained ankle. This injury involves a partial tear of the ligaments that join together the bones of the ankle. Recent studies have shown that, if you are able to walk 5 steps on the injured ankle and do not have tenderness along the back half of the bones at the sides of the ankle, then it is very unlikely that a bone is broken. In this case the doctor probably did not order an x-ray. Pain and swelling will be maximum over the first 24-48 hours after the injury. The less swelling that you end up with, the faster your recovery will be. To improve your chances of a rapid and full recovery, follow the "PRICE" principles below:

Protection - During the first 1 - 2 weeks when the risk of re-injury is the highest, avoid activities which may cause further injury to the ankle. An air cast or similar ankle brace, or ankle taping will allow some movement but will help prevent you from going over on the ankle again.

Rest - For the first 1-2 days, you may have to stay off of your injured ankle completely. If you cannot walk heel-to-toe without pain, you should be on crutches until you can. You should gradually increase the amount of weight bearing you do based on the amount of pain and swelling around your ankle. Most people can walk without pain within 1 week of injury. If you can't stand at all on the ankle 3 days after injury, see a doctor again for a recheck.

Ice - Ice helps keep swelling down and also relieves pain. Use a zip-lock bag filled with ice and some water, or a bag of frozen peas. Wrap this with a damp towel or pillow case. Apply to your ankle for 10-15 minutes every 2-3 hours while awake. Continue icing until no more new swelling occurs after activity - usually 48-72 hours.

Compression - This also helps minimize swelling. It should be used for the first 2-3 days or until the swelling is gone. An air-cast, ankle brace or a horseshoe-shaped foam paid, held in place under the ankle bone with a tensor bandage, will provide appropriate compression. To make sure that the bandage is not too tight, you should easily be able to slide a finger down between the bandage and your skin. Never wear a tensor bandage on your ankle while you are sleeping. A pins and needles sensation or a purplish colour of the skin means that the wrap is too tight.

Elevation - Whenever possible, during the first 1-2 days, keep your ankle elevated above the level of your heart, to help minimize the amount of swelling.

Medication - Regular icing, rest and elevation, will usually relieve most of the pain from a sprained ankle. If you still have a lot of pain, try taking plain acetaminophen (Tylenol), at a dose of 650mg-100mg, every 4 hours, or buy an over the counter anti-inflammatory medicine such as Ibuprofen (Advil or Actiprofen). If your doctor has prescribed a stronger pain reliever, it may cause drowsiness. Be careful with any activities, such as driving, where you have to be alert, and avoid alcohol while on this medication. Codeine products may upset your stomach and may make you constipated. This can usually be relieved by taking the medication after meals and eating extra fibre such as bran cereals, bran muffins, prunes or by taking a bulk laxative such as Metamucil.

Activity - Recovery from a sprained ankle is faster in those people who follow an early, progressive, ankle rehabilitation program. One example of a step by step program is described as follows:

Range of motion exercises are very important to decrease stiffness and help get rid of swelling. After 48 hours or when the swelling has started to go down, start off by moving your ankle slowly through its full range of movement. Drawing the letters of the alphabet with your big toe is a good way to do this. In some cases, this might be easier to do if you heat the ankle up first in a hot bath (105 degrees F or 40 degrees C) or whirlpool. If this activity causes a lot of pain or more swelling, go back to icing for another day.
Stretching helps to decrease stiffness and muscle spasm which often accompanies a sprained ankle. Start these exercises when you can move the ankle comfortably. Stretch the heel cord by looping a belt around your foot while you are sitting with your legs straight, and then pull your toes as far as you can, up towards your chest. Hold for 20-30 seconds. Do the same stretch with your knee slightly bent. Next, try pointing your toes as far as you can and hold for 20-30 seconds. Finally, sit on the floor, with your knees straight. Turn the soles of your feet inward, so they face each other and hold for 20-30 seconds. Repeat these stretches at least 4 times per day during the first week.
Strengthening exercises are important to prevent future sprains. The muscles and ligaments around the ankle become weak if they are not specifically strengthened after a sprain. A piece of surgical tubing (available at a medical supply store) or an elastic bungee cord (available at a hardware store) is an inexpensive piece of equipment to help you do this. First sit down with the heels resting on the floor and knees slightly bent and touching each other. Wrap the tubing or elastic cord snugly around the front of the foot. Now pull both feet out to the side. Repeat 10 times, rest, then 10 times again. Next, hold one arm of the tubing in each hand and loop it around the bottom of the foot. With your leg straight, pull the tubing toward your chest while you push your toes toward the floor. Repeat 10 times, rest, and 10 times again. Finally, tie the tubing to something heavy on the floor. Slip one foot into the loop and move far enough back to have some tension on the tubing. Now pull the front of the foot up towards your chest. Repeat 10 times, rest, and 10 times again. Do this twice per day.
Proprioception in the joints helps us keep our balance. When you sprain your ankle, you damage some of the nerves in the joint which tell your brain what position the ankle is in at any given time. As you regain strength in your ankle, it is important to retrain this function in order to prevent future sprains. One way to do this is to make a balance board using a piece of wood large enough for you to stand on with both feet, and a 30cm (1 foot) piece of dowel or broom handle. Centre the dowel under the board, then try to balance on it, side-to-side, as long as you can. Repeat this with the dowel turned the other way and try to balance front-to-back. Another balancing exercise is to stand on your toes, one leg at a time, as long as you can. Keep your eyes open at first. Later try it with your eyes closed. You should eventually be able to balance for at least 10 seconds.

You are ready to return to full activities when: You can run pain-free; You can jump up and down on each foot 10 times without pain; You can balance on each foot for at least 10 seconds. If you are still having pain and swelling 1 week after the injury, see your family doctor to reassess your ankle and to see if you require further testing or a referral for physiotherapy.

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