Sprains, Strains, and Breaks: Treating Ankle Injuries

Dr. Anthony A. Ferguson, Wisconsin Bone and Joint S.C.

At some point, virtually everyone will either personally suffer or know a close friend or family member who suffers from one of the many types of common ankle injuries. Ankle injuries can affect anyone, from professional athletes to couch potatoes and all ages, from kids to seniors. 

In many cases, treating ankle injuries is as easy as performing rest and rehab, but occasionally more severe injuries may require more 

extensive treatment. The good news is that most ankle injuries are minor and self-limited when given a little TLC and recuperation time. 

Dr. Anthony A. Ferguson, a board certified orthopedic surgeon and foot and ankle specialist at the Orthopaedic Hospital of Wisconsin, takes a look at a few common ankle injuries. He also discusses the basics of treating more severe ankle injuries to help you prepare in case an unfortunate injury occurs.

The Basics of Ankle Sprains

Tens of thousands of ankle sprains occur daily; most are minor and resolve quickly. The definition of any sprain is an injury to a ligament, which are the cords or sheets of tissue connecting one bone to another. Ligament sprains range from minor (over-stretched) to severe (completely torn). One of the most common ligament sprains occurs in the ankle.

As you well know, the normal function of the ankle is to provide most of the up and down motion for the foot. The ankle doesn’t move side to side. All the side to side motion (inversion and eversion) occurs below the ankle, inside the structures of the foot. An ankle sprain happens when the ankle, rather than the foot, is forced to turn sideways. Classic examples of harmful activities include stepping into an unexpected divot or hole, slipping on the ice, or landing on the edge of an object like another player’s foot during basketball. When the ankle turns abnormally, the ligaments get stretched and injured, resulting in a sprained ankle.

Symptoms of Ankle Sprains

Many of us also know the symptoms of an ankle sprain. The ankle feels like it gives way followed by pain, swelling, bruising, and often weakness. Sprains can really hurt! Sometimes it’s almost impossible to put weight on the foot. Other times “walking it off ” is easy. It all depends on the severity of the injury. 

Studies show early weight-bearing and a careful return to non-twisting activities are good, so start walking on your ankle as soon as possible. In some cases, an ankle brace can provide support and aid in getting up and going on the ankle again. You can usually manage minor sprains at home with this protocol and common sense, but more severe sprains may require physical therapy after being evaluated by your doctor or orthopedist. 

Be cautious when evaluating your ankle pain. It’s a myth that the ability to walk on the ankle rules out a fracture! I frequently see patients with fractures who have been able to walk since the injury, so it’s best to trust the little voice in your head. 

If the injury doesn’t seem right, have a professional evaluate the ankle and an x-ray taken, even if you are putting weight on the foot. Always remember, when in doubt, get it checked out! 

Treating Ankle Sprains

As far as treating ankle injuries, a sprain typically requires minimal attention. You can treat most ankle sprains with the standard RICE protocol: rest, ice, compression, and elevation. This protocol has worked for years. The only modification I recommend is to use caution about compression. Wrapping the ankle too tightly with an elastic wrap is never a good thing, so use a little common sense. 

Thankfully, only a handful of ankle sprains result in surgery. These patients have typically exhausted all other efforts, or they’re experiencing more serious structural issues caused by the injury. All ankle sprain surgeries involve repairing or rebuilding what was damaged. If the healing ankle forms too much scar tissue in the joint (called impingement), a doctor may use a camera called a scope to clean out the scarring and relieve the pain. If the ligaments heal too loosely or don’t heal at all, and the ankle is unstable, they may need tightening or rebuilding to restore stability and function to the joint.

I’d like to emphasize ignoring an old urban legend. More years ago than I’d care to admit, my football coach used to say it’s better to break an ankle than sprain it. He was taught broken bones heal, but sprains don’t. He’d often say an ankle was never the same after a sprain. Not true! They do heal. The vast majority of ankle sprains are manageable without surgery and recover completely. The few who eventually need an operation still typically heal well. Most return to full, or near full, function after surgery and therapy. Sorry coach, but on this one topic, I’m glad to say you were wrong!

Tendon Strains

Strains are slightly different from sprains. When a tendon or muscle is injured, we refer to it as a strain, but tendon injuries in the ankle are rarer than sprains to the ligaments. The two tendons most at risk are called the peroneal longus and peroneal brevis on the outside of the ankle. These are the primary evertors of the foot, meaning they resist the inward twisting force typical of the most common ankle sprain.

You can injure the two tendons by stretching them during an ankle sprain or when they contract forcefully in an attempt to restore balance to the foot. Fortunately, when they tear, they usually split in two—like dividing a ponytail into two parts—rather than completely failing.

Unfortunately, this split pattern makes tears challenging to diagnose. Most tendon tears will heal along with the ankle ligaments, but some don’t. The tendons that fail to heal usually require surgery, and you should take the situation seriously. Again, if your foot and ankle don’t feel right after an ankle injury, you should undergo a proper evaluation, including assessment of the peroneal tendons.

Ankle Fractures

Multivolume books and journals have been written on the topic of ankle fractures, so let’s stick to the basics. Ankle fractures result from various injuries. Examples include a direct blow to the ankle, a fall from a height, or a stress fracture overuse during exercise. However, the most common mechanism of injury is a twisting or angular force to the ankle.

In Wisconsin, we see this quite commonly during winter with a slip on the ice or snow. The foot slips, and as gravity pulls one’s body weight down over the ankle, the combination of forces results in a broken ankle. Coincidentally, most of these injuries begin with a sprain, but when the force continues, one or more areas of the bones also fail.

Fractures come in multiple types and various classification systems exist. I tell my patients these various fracture patterns are usually summarized quite simply. There are fractures needing surgery and those that don’t. Deciding what group your fracture is in and why is up to your orthopedist.

Each patient and each fracture are different, and doctors should take all the factors about the patient into account, not only the x-ray. Your orthopedist must consider your age, medical conditions, medications, job and sport demands, the health of surrounding soft tissues, as well as the fracture pattern itself when suggesting a treatment plan. 

Treating Ankle Fractures

Doctors often recommend treating ankle fractures that don’t need surgery with rest in a boot or cast. Crutches, walkers, and rolling knee walkers can help. Once the bone has sufficiently healed, physical therapy may follow. Remember, most common ankle injuries heal well, but listen to that voice in your head.

Surgery may be best for treating injuries that result in a fracture. The goals of surgery are to encourage bony and soft tissue healing by providing more stability and alignment to the damaged area. Commonly, surgeons use various plate and screw constructs tailored to the individual fracture pattern.

Studies show the most optimistic prognosis for recovery comes by restoring the anatomy to as close to “normal” as possible. Contrary to my old coach’s opinion, it isn’t better to break an ankle than to sprain it. Many fractures are severe and cause lasting problems despite appropriate treatment. The good news, however, is patients can manage most ankle fractures successfully and typically return to doing many, if not all, of their prior activities. 

Treating Ankle Injuries at OHOW

The orthopedic surgical techniques for treating ankle injuries are too many to list. Experts are always developing new concepts, surgical approaches, specialty plate, and screw systems and wound management adjuncts.

Arthroscopic techniques and less invasive approaches to reconstructing ankles are also evolving. Injuries that were incredibly challenging to treat just a few years ago now have several treatment options, and the future looks brighter than ever. The Orthopaedic Hospital of Wisconsin stays at the cutting edge of these advancements, and patients can rest assured we’re continually improving our options for these sometimes-serious conditions.

The take-home message is simple. You don’t need to suffer in silence if you’re experiencing problems after an ankle sprain. Proper treatments exist and you should explore them because patients can manage chronic pain and dysfunction after an ankle sprain, strain, or fracture quite successfully.

More significant pain, swelling, severe bruising, and an inability to put weight down may indicate a more serious situation. If you are unsure about the severity of your ankle injury, seek care from your doctor or orthopedist. They will help you find a course of treatment to get you back on your feet in no time!