Sprained ankle or inversion trauma

Almost everyone has fallen through their ankle at one time or another. In most cases, the ankle then folds inward. This movement of the ankle is called inversion. Hence the name inversion trauma. The symptoms are mainly on the outside of the ankle where the ankle ligaments are. These can be stretched or even torn. The ankle is then also often swollen and walking is often difficult. In this article we will take you through what a sprained ankle is and how best to treat it.

How does injury to the (outside of the) ankle occur?

An ankle sprain is relatively common in the Netherlands. Every year there are an average of 680,000 cases of a similar ankle injury. Most injuries happen when the foot lands incorrectly during a jump or fall. In this case, the ankle cannot absorb the entire body weight properly and folds inward. Sports where you have to change direction quickly are by far the most prone to this type of injury. Examples include:


  • Soccer
  • Basketball
  • Volleyball
  • Field hockey


The ankle consists of 3 bone pieces that make up the ankle joint. These are the tibia, fibula and talus. Furthermore, the joint is formed by muscles, ligaments, tendons a connective tissue membrane the syndesmosis(more on this later). Muscles such as the calf muscles, tibialis anterior, tibialis posterior and the peroneal group are responsible for the active stability of the ankle. Passive stability is formed by ankle ligaments (ligaments). These are located mainly on the outside but also on the inside of the ankle. On the outside are the following ligaments:


  • anterior talofibulare ligament
  • posterior talofibulare ligament
  • calcaneofibulare ligament


Sounds very complicated but actually it is not. In anatomy we work with Latin names. Latin is no longer a spoken language and is used primarily in writing. Latin is mainly used by scientists to clarify terms and concepts. For example, a physical therapist in the Netherlands knows what a doctor in India means by a particular injury or body region. While the English language has broadly adopted this, it was originally done through the Latin language. Hence, anatomical terms are still represented in the Latin name.


Example: anterior = anterior, talofibulare = between talus and fibula and ligament = band.


So, literally translated, anterior talofibular ligament is the band at the front located between the ankle bone and the fibula. Easy as that!


These ankle ligaments are originally quite sturdy yet they show some degree of stretching. For example, when you stumble with sports where the ankle flips inward, these ligaments come on stretch. With a severe sprain, these ligaments can be stretched considerably or even rupture. Within physiotherapy we work with 3 degrees:


  • Grade 1 = mild strain, some tearing of certain fibers but this is minimal. This causes pain but usually no instability of the ankle.
  • Grade 2 = a rupture of the ligament(s). So possibly several ligaments on the outside of the ankle that are affected. This causes pain but also some form of instability (feeling of sinking through the ankle). This grade is by far the most common.
  • Grade 3 = severe strain of the ankle ligament(s) possibly also a complete tear of the ankle ligament. This causes a lot of pain but also a lot of instability of the ankle. In this case, a fracture of ankle should also be ruled out.

What symptoms are associated with a sprained ankle?

When you have just fallen through your ankle, swelling can occur relatively quickly. Especially on the outside of the ankle but when the injury is large enough, all of the ankle will appear thick. Over time, you may even see discoloration. This is because the ankle ligaments also have blood vessels. Moving can be painful especially toward inversion(ankle inward). Sometimes it is difficult to take full support on the affected ankle. Crutches are then an option to get through the first few days. After that, it is helpful to just start loading again and return to a normal walking pattern as soon as possible. If the injury is so severe that you cannot take any support at all or can walk less than 4 steps, you may have a bone fracture. In order to make a statement about this, we use a decision tree within physical therapy. We call this decision tree the Ottawa ankle rules. If you meet one or more criteria within 7 days after the accident, the chance of a bone fracture is present. Does not mean it is actually a fracture but an x-ray is appropriate. The Ottawa ankle rules consists of the following criteria:


  • Inability to load the ankle (walking four steps either immediately after the accident or during the examination)
  • Pain on the outside of the ankle(malleolus lateral) up to 6 to the top
  • Pain on the inside of the ankle(malleolus medial) up to 6 cm upward
  • Pain on the metatarsal bone(metatarsal 5)
  • Pain at foot root bone(os naviculare)


Rare case, the syndesmosis rupture

Between the tibia and fibula runs the syndesmosis. This is a rigid structure that connects these two bone parts. About 11-18% of inversion traumas involve a syndesmosis injury.

  • A syndesmosis rupture occurs almost exclusively in combination with other injuries
  • Severe instability due to syndesmotic rupture determines whether surgery is necessary or a normal course can be started
  • Recovery time with a syndesmosis rupture is significantly longer than with regular inversion trauma.

The injury is often present in combination with other damage to structures. Bone fractures are also included. We often see syndesmosis injury in combination with a high fracture of the fibula. We call this a Mainsonneuve fracture. The recovery time from a syndesmosis rupture takes 2x as long as for ankle ligament injury alone. It is often difficult to pick out syndesmosis injury in physical examination. Indeed, 40% of people who have suffered a significant ankle rupture complain of recognizable pain at the level of the syndesmosis(interosseous ligament). Often there is irritation or damage to the anterior portion of the capsule of the ankle that resembles these complaints. Again in a very small group(11-18%) there is real damage of the syndesmosis.

With injury to the syndesmosis, we often see the following symptoms:

  • Average high degree of pain front ankle
  • Walking and pushing off on uneven surfaces is painful
  • Mobility is severely limited, dorsal flexion is painful
  • The higher the pressure pain at the front ankle, the more severe the injury

If you really want to know if there is a syndesmosis injury, an MRI often gives the answer. However, this is not done lightly. But when there is a high degree of instability along with recognizable pain during the physical examination, an MRI may be considered.


Rupture and luxation of the peroneal tendon

Pain on the outside of the ankle can also be caused by a tear of one of the peroneal tendons. The peroneal nerve is a small calf muscle that runs on the outside of your calf bone. Plural of peroneus is peroneii. The sheath through which this tendon runs is then severely irritated and painful. Stretching the muscle is painful along with pressure pain. Sometimes people hear a distinct snap at the point of origin.

What can we do for you and how long will recovery take?

During the intake we first gather all information about, for example, the moment of origin of the symptoms, nature of the pain and limitations you may experience during the day. Then the process will focus on ruling out a fracture. This can be done through the Ottawa Ankle Rules (OAR). These are guidelines to determine if there may be an indication for an x-ray. If the OAR are positive in combination with the moment of origin, it is first recommended to have X-rays taken. This is always done through the general practitioner. Further treatment depends on the diagnosis made. Tests such as the anterior drawer/ exorotation stress and squeeze test are performed. Through these tests a distinction can be made between the different types of ankle injuries.

Fracture: If there is a fracture, you will first be treated by plaster. After the bone has healed sufficiently you can visit Fysio Fitaal. The therapy will focus on improving the strength, movement and active stability of the ankle.

Tires: Ankle ligament damage can be classified from grade 1 - 3.

  1. Stretching ATFL
  2. Full rupture ATFL, overstretching/partial rupture CFL
  3. Full rupture ATFL + CFL, overstretching/partial rupture PTFL

For a grade 1 injury, treatment will consist of conservative therapy. Buildup will be guided by pain. The ankle often fully recovers within 0-3 weeks.

With a grade 2 injury, the ankle must be spared for a longer period of time. Conservative therapy will also be chosen initially in this case. Recovery usually occurs between weeks 6 and 12 after the injury occurs.

At grade 3, ligamentous reconstruction(surgical repair) is considered. This is usually the case in young/professional athletes. Chronic instability, very frequent ankle twisting can also be a reason for surgical intervention. Then we will help you further through physical therapy. The treatment consists of restoring mobility, strength and, in time, explosiveness.

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