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).