Running and Ankle Sprains:

What about the common "ankle sprain"? Ankle sprains typically occur following a rollover type injury, such as when the runner steps into a rut or pothole, which causes the foot to roll with the sole inwards, called "inversion". Depending upon the degree of inversion, and the reflexive and protective pull of the outside muscles and tendons (peroneals), the resultant damage to the outside ligaments of the ankle can be highly variable.

As usual, first we need some background anatomy (figure 1). Three ligaments connect the bones and stabilize the outside of the ankle: the anterior talofibular (ATF), the calcaneal fibular (CF), and the posterior talofibular (PTF). These can be thought of as passive leashes or restraints to inversion type motions of the ankle joint. The typical inversion sprain most commonly produces damage to the ATF +/- CF ligaments, and more rarely the PTF. The peroneal tendons pass over this area. Muscles and tendons are active restraints. As muscles contract, they provide forces countering inversion proportional to the intensity of contraction. It is important to recognize that these tendons are very important stabilizers as well. It is only when these muscles and tendons are overpowered or caught off guard that they fail in their mission, and the underlying ligaments are tested. Stronger muscles can mean milder sprains!

When a sprain occurs, the ligaments may be injured, but not stretched (grade 1), stretched, but not torn (grade 2), or completely torn or ruptured (grade 3). In the ankle, the actual grade of the sprain is almost never of consequence, as virtually all initial first-time sprains are treated the same. Acutely, during the first 2-7 days, it is recommended that one use "R.I.C.E.", a mnemonic that means rest, ice, compression and elevation. The intent is to prevent further injury, control inflammation (swelling), and reduce pain. Ice is useful for as long as 72 hours (20 minutes on, 20 minutes off, etc.), and elevation (as often as possible) should continue until swelling has peaked and is decreasing. Compression with an elastic wrap or sleeve should continue until swelling is gone.

Rest does depend upon the degree of injury. Some mild sprains may necessitate only a few seconds of rest, such as during a run. Obviously, if one can keep running after a rollover during training or a race, the sprain is quite mild. However, it would be wise to elevate, ice, and wrap immediately afterwards. On the other hand, a severe "blowout", that causes intense pain with difficulty with even standing characterizes a grade 3 injury, and needs a longer period of rest for healing to occur. These "bad sprains" typically produce bruising, marked swelling, and a prominent limp.

A good rule of thumb is that when one can stand without pain, try walking. When one can walk without pain, try jogging. When one can jog pain-free, advance to running, etc. Let pain be the guide.

What is the role of medical evaluation and physiotherapy in the sprained ankle? Many studies have tried to define the need for x-rays following a sprain: based upon the location of pain and tenderness, presence of instability, etc. It is my opinion that it is reasonable to get x-rays of the ankle after a sprain, especially if there is pain with weight-bearing. It is very difficult to determine by physical exam alone whether a fractured fibula exists or not without an x-ray. Furthermore, when the ankle bone (talus) rolls over during inversion, small pieces of the dome of the talus can be sheared off. The treatment for fractures is markedly different from the treatment of a sprain.

There is no doubt that physiotherapy or physical therapy (P.T.) can make a big difference in recovery. Although ligaments require a given time to recover from injury, P.T. offers distinct advantages over benign neglect: reduction in pain and swelling, faster restoration of motion, and better strength preservation during healing. Most importantly, it facilitates retraining, reeducation, and strengthening of the injured ankle to allow earlier and safer return to activity, with a lower risk of reinjury.

Dan Wnorowski, M.D.

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