Dr. Stephen Pinney, a foot and ankle specialist at the Cleveland Clinic and co-editor of Orthopaedia, answers our questions on ankle sprains, among other things. [Related information can be found in the Orthopaedia chapter on ankle sprains.]
Orthopaedia: The phrase “just a sprain” can understate the severity of an ankle sprain. Some people with sprains can be impaired for quite a while. On the other hand, some patients initially look much worse than they turn out to be. What’s your method for calibrating the severity of ankle sprain?
Stephen Pinney: Ankle sprains are among the most common musculoskeletal injuries. The spectrum of severity ranges from the tearing of a few fibers of the ligament with just mild discomfort, to a complete tearing and destabilization of the ankle joint. While it can often be difficult to definitively assess the severity of an ankle sprain right after the injury, there are some signs that can be helpful.
Like many orthopaedic surgeons, I use a 3-category classification: “mild, moderate, and severe.” (It may be more accurate to call this “good, bad, and ugly”.) This classification can guide prognosis. Patients suffering a mild ankle sprain will often recover in a week or less, moderate ankle sprains often take around 3 weeks or so to recover, and severe ankle sprains commonly take 8 weeks or longer to recover.
Accurate classification relies on information such as whether the patient can walk, a history of previous ankle sprains, and the extent of the swelling. For instance, patients with severe ankle sprains usually have difficulty bearing weight. Swelling is only a rough guide, but in general a more severe ankle sprain will be associated with more swelling (and discomfort). Taken together, an ability walk without much swelling suggests a moderate injury at most. On the other hand, great laxity of the ligaments when examined suggests a bad-to-ugly injury. There is one exception to that, though: a patient with previous ankle sprains usually has a lax joint from the prior damage to the ligaments. If this history is not considered, the examiner might incorrectly infer a new injury of great severity.
If I had a single pearl to offer in this area it would be this: try to be attentive to the area of the pain. In a classic ankle sprain, patients have pain in the outside-front part (anterolateral) of the ankle. Significant pain in other areas may be a sign that the injury is more severe or that more than the ligament alone has been injured.
Orthopaedia: Let’s say you meet a nice person at a cocktail party who tells you about an ankle sprain that just hasn’t gotten better in four months. You know not to give medical advice to strangers, and you remember reading in an etiquette book that people do not take their shoes off at a cocktail party. So, without the benefit of an exam, and sticking to generalities, can you offer some reasonable advice?
Stephen Pinney: First, remembering another lesson from the etiquette books (and from my best medical teachers), I would first express my sympathies. Having prolonged symptoms following an ankle sprain is an unpleasant surprise! Along those lines, I would also share that this is not particularly uncommon. About 5 to 10% of patients with ankle sprains can have persistent symptoms for months after their injury. Persistent symptoms are typically related to one of two causes. The first is a failure to fully rehabilitate the ankle: the biological healing phase may be over, but the functional restoration has not taken place. The second cause is a missed diagnosis—either an injury in addition to the ankle sprain, or a different diagnosis altogether, such as a cartilage, tendon or bone injury.
Inadequate rehabilitation is probably the more common explanation for persistent symptoms. The remedy for inadequate rehabilitation is– no surprise– adequate rehabilitation: that is, physical therapy. On the other hand, the possibility of a missed injury must be taken seriously. Therefore, I would not even say much about the techniques to treat an inadequately rehabilitated sprain, such as strengthening exercises, soft tissue mobilizations, flexibility-improving stretches. A patient with persistent symptoms needs a formal assessment.
Orthopaedia: What’s your take on high-top sneakers to control the ankle and prevent sprains? On the one hand, they seem to offer some stability, but on the other hand, they may also encourage passiveness and may not allow muscles to be optimally strong.
Stephen Pinney: Whether a patient uses high-top sneakers or ankle braces or nothing at all, there is no substitute for a comprehensive rehab program to regain strength and flexibility in the muscles about the ankle. However, in patients that have a history of ankle sprains or participate in high-risk activities, the use of high-top shoes, ankle bracing, or ankle taping, may minimize the risk of future sprains. There are two mechanisms of protection. First, high top shoes and ankle bracing can control the ankle a bit by simply holding on to it. Granted, this additional “static stability” (ie, passive restraint) is not enough to prevent a sprain if the forces are great enough, but it might be just enough to avoid an injury in some settings. Equally important, the use of high-top shoes or ankle bracing provides increased sensory feedback to the brain– that is, increase proprioception–and add to the “dynamic stability” (ie, muscle-provided restraint) as well. A person wearing high-top shoes or ankle braces will, by feeling the brace press against the body, have a better sense of their ankles’ location and motion. They will feel, for example, if the ankle is about to twist. With that sense in mind, they might be able to fire muscles to stabilize the joint. (Recall that when we examine patients’ ligaments in the office, we ask the patient to relax, precisely because muscle action alone can hold a joint in place, even if the ligament were deficient.)
So, at this risk of violating something from the etiquette books, I must question the premise of your question: the use of high-top shoes or ankle braces may not “encourage passiveness.” In fact, they may actually encourage an active response, at least not at the critical moments.