Ankle Joint Sprain: Causes, Types, Symptoms, Treatment- Conservative, Specific, PT
What is Ankle Joint Sprain?
Ankle joint is made up of bones, cartilages, synovial membrane, tendon and ligaments. Ankle Joint Sprain is a painful ankle joint disease caused by injury or inflammation of the ankle joint ligament. Severity of ankle joint sprain is described as Ankle Joint Sprain of grade 1 to 3.
What Does Ankle Joint Comprise of?
Ankle joint is a cartilaginous and synovial joint. Ankle joint links foot to the lower leg at 90-degree angle. Several bones, ligaments, cartilages, and tendons are involved in maintaining normal ankle joint function. Ankle joint consists of three joints.
- Tibio-Talar Joint: Tibio-Talar joint is the upper or superior ankle joint. Joint is a link between lower end of tibia and upper end of talus bone. Lower flat surface of tibia lies on top of the upper or superior surface of talus bone.
- Subtalar Joint or Talo-Calcaneal Joint – The Subtalar joint is an inferior ankle joint. The joint is the link between talus and calcaneal bone. Talus bone lies on top of calcaneal bone.
- Tibio-fibular Joint- The Tibio-Fibular joint is a lateral ankle joint. The joint is between lower end of tibia and fibula.
What is Cartilaginous Joint?
In cartilaginous joint smooth cartilages cover the bones forming the joints. Smooth surface of the cartilages are lubricated by synovial fluid. Joint is meant for movements like flexion, extension and rotation. Smooth surface of cartilages allows smooth movements of ankle joint such as flexion, extension or rotation.
What is Synovial Joint?
Synovial membrane is a thin cellular membrane, which covers the articulating and lateral surface of the bone involved in forming a joint. Synovial membrane does not cover smooth surface of cartilages. Synovial membrane is spread from articulating surface of the bone to lateral surface of the bone within the joint. Synovial membrane produces thin viscous lubricating fluid, which helps to achieve smooth joint movements. All three-ankle joints are covered by synovial membrane.
How Many Ligaments Support The Ankle Joint?
Several ligaments support the ankle joint. Ligaments are divided into 4 segments as follows-
- Ligaments on Anterior Side of the Joint:
- Anterior Talo-Fibular Ligament- Fastens Talus and fibular bone.
- Antero-Inferior Tibio-Fibular Ligament- Fastens Tibia and fibula at the lower end above ankle joint.
- Ligaments on Medial Side of the Joint:
- Medial Talo-Calcaneal Ligament- Fastens talus bone with calcaneal bone.
- Deltoid Ligament- Fastens calcaneal and talus bone to tibia.
- Ligaments on Lateral Side of the Joint:
- Calcaneo-Fibular Ligament- Fastens calcaneal bone and fibula.
- Ligaments on Posterior Side of the Joint:
- Talo-Fibular Ligament- Fastens Talus bone to fibula.
- Posterio-Inferior Tibio-Fibular Ligament- Fastens tibia and fibula on posterior (back) side.
- Posterior Tibio-Talar Ligament- Fastens talus bone with tibia.
- Posterior Talo-Calcaneal Ligament- Fastens talus with calcaneal bone.
What Causes Ankle Joint Sprain?
Causes of Ankle Joint Sprain are as follows-
- Ankle Joint Ligament Injuries Following:
- Auto Accident.
- Work injuries.
- Slip and fall.
- Sport Injuries Causing Ankle Twist:
- Contact Sports like football, wrestling and ice hockey.
- Athletic sports like soccer and baseball.
- Competitive Cycling.
- Ankle Joint Inflammation Caused By:
- Cellulitis surrounding tissue.
- Bleeding and blood clots surrounding ligaments.
Describe The Severity of Ankle Joint Sprain?
Severity of Ankle Joint Sprain is described as follows-
- Grade I Ankle Joint Sprain- Grade I ankle joint sprain is caused by mild to moderate injuries resulting in superficial scratch of the ligament.
- Grade II Ankle joint Sprain- Intermediate injury caused by partial tear or deep laceration of ligament.
- Grade III Ankle Joint Sprain- Severe injury of the ligament results in complete tear of the ligament.
Symptoms of Grade I Ankle Joint Sprain are as follows:
- Acute Pain- Pain may last less than 3 months.
- Tenderness- Examination such as palpation of the joint on same side as injured ligament causes mild to moderate pain on superficial touch and moderate to severe pain on deep pressure.
- Joint Swelling- Joint swelling may be observed over the injured ligament.
- Joint Movement- Joint movements such as flexion, extension and rotation are not restricted but painful. Pain is less severe when joint is covered with ace or crape bandage.
- Muscle Spasm or Stiffness- Muscle spasm or stiffness of calf muscles and foot muscles are not observed.
- Muscle Atrophy- Is not common with grade I Ankle Joint Sprain.
What Are The Symptoms of Grade II Ankle Joint Sprain?
Symptoms of Grade II Ankle Joint Sprain are as follows:
- Chronic Pain- Pain may last less than 3 to 6 months. Intensity of the severe pain is reduced when leg is elevated in sitting or lying down position.
- Tenderness- Examination such as palpation of the joint on same side as injured ligament causes moderate to severe pain on superficial touch and severe pain on deep pressure.
- Joint Swelling- Joint swelling is observed over the injured ligament and swelling is spread around the joint.
- Signs of Bruises- Signs of skin bruises may be seen over the injured ligament.
- Joint Movement- Passive joint movements such as flexion, extension and rotation are restricted because of pain when patient is asked to move the joint. Active joint movement is extremely painful during the examination.
- Muscle Spasm- Active joint movements performed by examiner while patient is in pain results in muscle spasm of leg (calf muscle) and foot muscles. Muscle spasm and pain is often not seen when joint is covered with ace or crape bandage. Passive and active joint movement is accomplished with moderate to severe pain when joint is covered with ace or crape bandage.
- Joint Stiffness- Joint stiffness is rare. Joint stiffness is seen in Ankle Joint Sprain of Grade II if symptoms are ignored and disease is not treated for prolonged time. Joint stiffness is also observed with repeated injury causing grade II Ankle Joint Sprain.
- Muscle Atrophy- Muscle atrophy is rare and not observed unless repeat injuries results in grade III injuries.
What Are The Symptoms of Grade III Ankle Joint Sprain?
Symptoms of Grade III Ankle Joint Sprain are as follows-
- Chronic Pain- Severe intractable chronic pain secondary to grade III Ankle Joint Sprain may last over 6 months. Intensity of pain is always extremely severe at rest and with activities. Intensity of pain is reduced when leg is elevated in sitting or lying down position. Ankle joint swelling progressively gets worse if not treated appropriately like rest, restriction of joint movements, and treatment of inflammatory disease.
- Tenderness- Pain is extremely severe and continuous following palpation for prolonged period after examination. Patient avoids any touch or contact to ankle joint.
- Joint Swelling- Joint swelling is observed over the injured ligament and swelling is spread around the joint.
- Signs of Bruises- Signs of skin bruises may be seen over the injured ligament. Signs of hematoma and bleeding are observed under the skin.
- Joint Movement- Patient is unable to perform passive joint movements such as flexion, extension and rotation because of pain, hematoma and inflammation of the ligament. Active joint movement by examiner is extremely painful and associated with ankle joint muscle spasm. Pain is less severe when joint is covered with ace or crape bandage. Partial passive and active joint movement is accomplished when joint is covered with ace or crape bandage.
- Muscle Spasm or Stiffness- Muscle spasm or stiffness of calf muscles and foot muscles are observed at rest or following examination. Muscle spasm last for prolonged period and may not respond to muscle relaxants.
- Muscle Atrophy- After 4 to 6 months of chronic pain patient may develop muscle atrophy of calf and foot muscles.
What Are The Investigations or Lab Studies Done To Diagnose Ankle Joint Sprain?
Ligamental injuries are not observed on radiological studies or ultrasound. X-Ray, CAT scan, MRI and Ultrasound studies are done mostly to rule out osteoarthritis, fracture or dislocation of the ankle joint. White blood cell count and erythrocyte sedimentation rate study is done to rule out septic ankle joint arthritis. Rheumatoid arthritis, psoriatic arthritis, gout and Pseudogout are ruled out by specific blood test.
What Are The Treatment Options Available To Treat Ankle Joint Sprain?
Ankle Joint Sprain is treated differently for different grades of injury. The treatment choices are as follows:
- Restrict Joint Movements- Partial or complete.
- Total Rest.
- Ice and Cold Applications on Ankle Joint.
- Heat Treatment- Ankle joint is covered with of hot towel or local application warm bag.
Pain, inflammation, muscle spasm and infection are treated with medications.
- Inflammation- Treated with Anti-Inflammatory Medications (NSAIDs).
- Pain- Treated with NSAIDs or Opioids depending on severity and side effects.
- Muscle Spasm- Treated with muscle relaxants.
- Joint Infection- Treated with antibiotics.
Physical Therapy (PT) is indicated for following reasons:
- Joint Movement- Improve joint movement.
- Joint Stiffness- Prevent joint stiffness.
- Muscle Atrophy- Prevent muscle atrophy.
- Ligament inflammation- Reduced inflammation.
Interventional Pain Therapy:
Indications for ankle joint injection using corticosteroid and local anesthetics are as follows-
- Inflammation- Corticosteroid is an anti-inflammatory and injection of corticosteroid results in rapid reduction of inflammation.
- Pain- Corticosteroid mixed with local anesthetics or only local anesthetic injection in ankle joint results in rapid decrease of pain.
- Joint Function- Reduction in pain and joint swelling following cortisone injection results in improvement of joint movements.
- Assist Physical Therapy- Injection is performed to reduce pain so patient can performed aggressive physical therapy.
Surgical Intervention for Ankle Sprain
- Ankle Joint Fusion.
- Ligament Reconstruction.
Which Specific Treatment Can Be Considered For Grade I Ankle Joint Sprain?
Treatment Options for Ankle joint Sprain of Grade I is as follows-
- For Joint Swelling- Daily ice and cold treatment to reduce joint swelling.
- Joint Movement- Avoid total restriction, movement is allowed as tolerated.
- For Ligament Inflammation- Inflammation is aggressively treated with NSAIDs for 2 to 3 weeks depending on side effects.
- For Muscle Spasm- Muscle relaxants are prescribed for muscle spasm.
- For Joint Stiffness- Physical therapy is advised once inflammation and pain is subsided to prevent joint stiffness.
Which Specific Treatment Can Be Considered For Grade II Ankle Joint Sprain?
Treatment Options for Ankle joint Sprain of Grade II is as follows-
- For Joint Swelling- Restriction of ankle joint movements, daily ice and cold treatment to reduce joint swelling.
- For Skin Abrasion and Laceration- Antibiotic ointment is used for skin abrasion and laceration.
- For Joint Movement- Movement of the joint is restricted until inflammation is treated and pain is tolerable. Joint is wrapped with ace or crape bandage to restrict the joint movement. Joint movement often is restricted with braces.
- Inflammation of Ligament- Inflammation is treated aggressively with NSAIDs.
- Chronic Pain- Opioids are prescribed for chronic pain not responding to NSAIDs treatment. Opioids are also prescribed before physical activities and ambulation to treat severe pain.
- Muscle Spasm- Muscle spasm is treated with muscle relaxants, massage and physical therapy.
- Anxiety- Severe pain and restriction of activities may result in anxiety. Anxiety is treated with anti-anxiety medication such as Ativan, Clonazepam or Valium.
- Ambulation- Patient is encouraged to use crutches for ambulation. Crutches helps to prevent weight bearing and pressure on ankle joint and ligament.
- Interventional Pain Therapy- Series of Cortisone injection is advised if ligamental inflammation is not responding to NSAIDs. Ankle joint is injected with local anesthetics and cortisone to assist physical therapy.
- Surgery- Patient may not need surgical treatment.
Which Specific Treatment Can Be Considered For Grade III Ankle Joint Sprain?
Treatment Options for Ankle Joint Sprain of Grade II is as follows-
- Skin Abrasion and Laceration- Superficial skin infection is treated with antibiotic ointment and deep skin infection or cellulitis is treated with oral antibiotics.
- Joint Swelling- Grade III ankle joint sprain may not respond to conservative treatment. Daily ice and cold treatment to reduce joint swelling.
- Joint Movement- Joint movement is restricted with braces or cast.
- Ligament and Joint Inflammation- Treated with NSAIDs and series of corticosteroid injection.
- Chronic Pain- Opioids are prescribed for chronic pain not responding to NSAIDs treatment. Opioids are prescribed before physical activities and ambulation to treat severe pain
- Physical Therapy (PT) - PT is advised after all symptoms are subsided.
- Cortisone Injection- Patient is scheduled for cortisone and local anesthetics injection frequently in the beginning and later during aggressive physical therapy for every 3 to 4 months if necessary.
- Infection- Infection is treated with antibiotics if associated with Ankle Joint Sprain.
- Surgical Treatment- Patient may need surgical treatment such as ligament reconstruction.