Ankle sprains are one of the most common injuries in football (soccer), often occurring during sudden changes in direction, pivoting or awkward landings after a jump. Due to the sport’s high-impact nature and the physical contact involved, players are at a higher risk of twisting or rolling their ankles, particularly when contesting the ball or performing quick lateral movements. Typically, these injuries involve damage to the lateral ligaments of the ankle, resulting in pain, swelling, and limited mobility. Studies show that ankle sprains account for a substantial portion of lower-limb injuries in football, with the incidence especially high among amateur and youth players, who may lack proper training in techniques that could mitigate injury risks. Effective management, early diagnosis, and individualised rehabilitation are essential for players to regain full functionality and prevent recurring injuries, which could compromise long-term performance and health. The Ottawa Ankle Rules can help determine the need for x-rays in cases of an injured ankle.

For low grade ankle sprains, initial management usually involves a bit of a ‘wait and see’ or ‘walk it off’ approach. Some can continue playing soon after, other will require some rest and rehab before resuming play. For serious ankle sprains and those that are extremely painful at the time of incident, the result is usually a visit to the emergency department.

Understanding Ankle Sprains

Definition and Prevalence of Acute Ankle Injuries

Ankle sprains are a prevalent type of acute ankle injury, occurring when the ligaments that support the ankle joint are overstretched or torn. These injuries are incredibly common, accounting for approximately 68% of all ankle injuries and about 9% of all injuries in soccer. In fact, they are the single most common type of injury in the sport, with studies indicating that ankle sprains make up around 17-20% of all injuries. This high incidence underscores the importance of understanding and properly managing ankle sprains to prevent long-term complications and ensure a swift return to activity.

 

Anatomy of the Ankle

The ankle joint is a complex hinge joint that plays a crucial role in our mobility. It is formed by the articulation of the distal ends of the tibia and fibula with the talus, a bone in the foot. The medial malleolus, located on the inner side of the ankle, is the bony prominence of the distal tibia, while the lateral malleolus, on the outer side, is the bony prominence of the distal fibula. These structures work together to provide stability and allow for the up-and-down movement of the foot. Additionally, the subtalar joint, located below the ankle joint, enables the foot to move side-to-side, allowing for inversion and eversion. Understanding the anatomy of the ankle is essential for recognizing the mechanisms of injury and the importance of proper treatment and rehabilitation.

How ankle sprains are classified

Ankle sprains can lead to various outcomes depending on the severity of the injury, which is typically classified into three grades. Most ankle sprains are not properly managed initially, which contributes to their high reinjury rates.

A Grade 1 sprain involves mild stretching or slight tearing of the ligament fibers, causing minor pain and swelling, often allowing individuals to walk with minimal discomfort.

A Grade 2 sprain is a moderate injury with a partial tear of the ligament, leading to more significant pain, swelling, and bruising, usually limiting mobility and requiring a more extended period of recovery.

A Grade 3 sprain is a severe injury involving a complete ligament tear, resulting in marked instability, intense pain, and significant swelling; this may require immobilization or even surgical intervention.

In some cases, an ankle sprain can lead to an associated avulsion fracture, where a fragment of bone is pulled off by the ligament, or a stress fracture if the bone endures excessive force. Without appropriate diagnosis and treatment, even mild sprains can develop into chronic instability or recurring sprains, underscoring the importance of accurate assessment and targeted rehabilitation for long-term recovery.

 

Recognising the Severity of an Ankle Sprain

What are the signs I may have a fracture?

An ankle sprain that includes a fracture may present with more severe symptoms than a standard sprain, signaling a need for immediate medical attention. The Ottawa Ankle Rules are designed to assess the need for radiographs following acute ankle and foot injuries. Common signs include intense, sharp pain that persists despite resting and elevating the ankle, as well as significant swelling that appears rapidly after the injury. Bruising and discoloration often spread widely around the joint and foot, and a visible deformity may be present in more serious cases. An inability to bear weight on the affected foot, or severe tenderness when pressing on specific areas like the bones around the ankle, also indicate a potential fracture. Additionally, if there is a “crack” or “pop” sound at the time of injury, it may suggest bone involvement. Given these signs, further imaging, such as X-rays, is essential to confirm a fracture, as untreated fractures can lead to complications like misalignment, chronic pain, and instability in the ankle joint.

Symptoms and Signs of Ankle Sprains

Ankle sprains can vary significantly in severity, and recognizing the symptoms and signs is crucial for appropriate management.

• Grade 1 Ankle Sprains: These are mild injuries characterized by minimal pain and swelling. Individuals with a Grade 1 sprain may experience slight tenderness and can usually walk with little discomfort.
• Grade 2 Ankle Sprains: These are moderate injuries involving a partial tear of the ligament. Symptoms include moderate pain, swelling, and bruising, often accompanied by some difficulty in bearing weight and limited range of motion.
• Grade 3 Ankle Sprains: These are severe injuries with a complete tear of the ligament, leading to significant pain, swelling, and bruising. There is marked instability in the ankle joint, and walking is usually very difficult without assistance.

Common symptoms of ankle sprains include pain, swelling, bruising, and difficulty bearing weight on the affected ankle. Signs to look out for include tenderness to the touch, limited range of motion, and instability of the ankle joint.

It’s also important to consider the Ottawa Ankle Rules, a highly effective, evidence-based screening tool that helps determine if an X-ray is necessary after an ankle sprain. If you can take four steps and do not have tenderness in specific areas, it’s likely you do not have an ankle fracture and do not need an X-ray. However, if you cannot take four steps or have tenderness in specific areas, you should go to the emergency department and get an X-ray to rule out any fractures. This approach ensures that you receive the appropriate care and avoid unnecessary imaging.

Use these rules to work out whether your ankle sprain needs an x-ray

The Ottawa Ankle Rules are a set of clinical guidelines designed to help healthcare providers determine whether an X-ray is necessary for patients with ankle injuries, specifically to rule out fractures. These rules are particularly useful in assessing the need for radiographs following acute ankle and foot injuries. These rules are based on specific criteria that, when met, indicate a higher likelihood of a fracture. According to the Ottawa Ankle Rules, an X-ray should be ordered if any of the following criteria are met:

Ankle X-ray Criteria

• There is pain in the malleolar zone.
• Any one of the following conditions is present:
  • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or the tip of the medial malleolus.
  • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or the tip of the lateral malleolus.
  • An inability to bear weight both immediately after the injury and in the emergency department for four steps

 

Foot X-ray Criteria

• There is pain in the midfoot zone.
• Any one of the following conditions is present:
  • Bone tenderness at the base of the fifth metatarsal.
  • Bone tenderness at the navicular bone.
  • An inability to bear weight both immediately after the injury and in the emergency department for four steps

 

Exclusions

• Pregnant women.
• Patients with diminished ability to follow the test, such as those with head injuries or intoxication.
• Children under the age of 6, although the rules have been found to be highly sensitive (98.5%) in children over 6 years old

By applying these criteria, clinicians can efficiently identify patients who may require further imaging and avoid unnecessary imaging for those who are unlikely to have fractures, thus enhancing patient care and reducing healthcare costs.

A 2022 systematic review stated “Application of the OAR is highly sensitive and can correctly predict the likelihood of ankle fractures when present, however, lower specificity rates increase the likelihood of false positives. Overall, the use of the OAR tool is supported as a cost-effective method of reducing unnecessary radiographic referral, that should improve efficiency, lower medical costs and reduce waiting times.”.

(ref: https://pubmed.ncbi.nlm.nih.gov/36151550/)

Can you x-ray a swollen ankle?

Yes, you can perform an X-ray on a swollen ankle, and it is often a crucial step in diagnosing potential injuries. When an injured ankle is swollen, an X-ray can help identify fractures, dislocations, or other structural abnormalities that may not be immediately apparent during a physical examination. Swelling may result from various conditions, including ankle sprains, strains, fractures, or other injuries, and X-rays can assist in determining the underlying cause.

However, it is essential to consider the Ottawa Ankle Rules, which guide clinicians on whether an X-ray is necessary based on specific criteria. If a fracture is suspected or if the swelling is accompanied by significant pain and an inability to bear weight, an X-ray is warranted to ensure an accurate diagnosis and appropriate treatment plan.

Can I find out the grade of ankle sprain from an x-ray?

An ankle X-ray cannot directly determine the grade of a sprain, as the grading system for sprains primarily assesses the severity of ligamentous damage, which X-rays do not visualize. Most ankle sprains are not properly managed initially, which contributes to their high reinjury rates. Instead, X-rays are used to rule out associated bone injuries, such as fractures or avulsion fractures, that may occur with ankle sprains.

While X-rays are crucial for assessing bone integrity, an accurate determination of the sprain’s grade relies on a thorough physical examination and assessment by a healthcare professional. In some cases, advanced imaging techniques like MRI may be used to evaluate the soft tissue structures more comprehensively.

Where can I go to get an x-ray?

When it comes to obtaining an X-ray for an ankle injury, you have a couple of options. One common route is through a referral from your General Practitioner (GP). Your GP can assess the severity of your ankle injury and determine if an X-ray is necessary, providing you with a referral to a radiology clinic or hospital where the imaging can be conducted. This approach allows for a more controlled evaluation, often accompanied by a thorough physical examination and medical history review.

Alternatively, if the injury is severe and requires immediate attention, visiting the emergency department is another viable option. In the emergency department, healthcare professionals can quickly assess your condition, perform necessary diagnostic tests, and provide immediate care. This is particularly crucial if you experience intense pain, swelling, or an inability to bear weight on the injured ankle, as these symptoms may indicate a more serious injury.

Both pathways ensure that you receive the appropriate imaging and subsequent care needed to address your ankle injury effectively. Whether through a GP referral or a visit to the emergency department, obtaining an X-ray is an important step in diagnosing the extent of your injury and planning the best course of treatment.

What’s the next step in ankle rehab post sprain?

Ankle and foot fractures

If the fracture is unstable, or displaced, then surgical options may need to be investigated. Accurately identifying foot injuries is crucial to avoid unnecessary imaging and associated healthcare costs. This will involve a consult with an orthopaedic surgeon (usually via your GP) and then a rehab process post surgery involving your orthopaedic surgeon, GP and physiotherapist.

For fractures that are stable, management usually begins with a period of ankle immobilisation over 6-8 weeks. Some of that time period may also be spent non-weight bearing meaning the use of crutches.

Coming out of immobilisation, physiotherapy rehab is extremely important to help return ankle mobility, gait quality, muscle strength, endurance and then the more complex elements involved in a successful return to performance on the football pitch.

Ankle sprains that do not require x-ray or have been cleared of fracture

For an injured ankle that has been cleared of fracture, weight bearing can continue as tolerated, although some offloading of the ankle may be required to help higher grade sprains settle during the initial stage.

Focus can then be placed on a well balanced ankle rehab program to ensure that ankle function returns to a level that allows for high levels of performance on the field and reduces the risk of recurrent ankle sprains.

X-rays don’t tell the whole story….

It’s important to note that while x-rays are great to clear major fractures that can occur during ankle sprains, they can sometimes miss fine fractures or those deeper in the ankle, especially on a bone called the talus. X-rays can sometimes miss really fine fractures or those deeper in the ankle, especially in cases of foot injuries. Talar dome fractures occur when an ankle is rolled far enough for the talus to come into heavy contact with the tibia or fibula within the ankle joint. These can be missed by plain x-rays at times, so if your ankle sprain is particularly slow to respond to rehab, or you’re dealing with recurrent pain and swelling around your medial or lateral malleoli and achilles after activity, it may be worth considering an MRI.