These injuries are often considered minor, but given the overall importance of the ankle joint for any activity on your feet, they can keep athletes out of their sports for months, and can interfere with daily activities for the Regular Joe.
This article will discuss some specific information about low ankle sprains, how they differ from other types of sprained ankles, and some general perspective on treatment.
What is a low ankle sprain?
A low ankle sprain refers to damage of the ligaments that help provide passive stability to the ankle joints, namely the talocrural joint and the subtalar joint.
Medial ankle sprains and lateral ankle sprains are both subsets of low ankle sprains, given they both occur lower down in the ankle joint.
The anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) are the most common ligaments injured in a lateral ankle sprain, whereas a medial ankle sprain typically involves to injury to the deltoid ligament complex.
High Ankle Sprain vs. Low Ankle Sprain
A high ankle sprain refers to damage of the ligaments that hold the distal ends of the tibia and fibula together, which are the two shin bones.
We won’t go into too much detail about high ankle sprains in this article, but it’s worth mentioning the difference between high ankle sprains vs. low ankle sprains.
The anterior inferior tibiotalar ligament (AITFL) is the most commonly injured ligament in a high ankle sprain, but the posterior inferior tibiofibular ligament (PITFL) can sometimes be injured as well.
Furthermore, it’s possible that the thin membrane that connects the tibia and fibula together along their length can also be injured with a high ankle sprain.
Overall, given high ankle sprains typically involve the connection between the two shin bones, we can differentiate this from low ankle sprains that span the ankle joint itself with specific testing in a physical therapy assessment.
High ankle sprains are typically treated much more conservatively at the start of the recovery process, sometimes requiring protection and immobilization in a walking boot for up to 6 weeks, whereas this usually isn’t the case for low ankle sprains.
How do you know if you have a low ankle sprain?
Assessment of a musculoskeletal injury is best done by a physical therapist or sports medicine physician. They will be able to properly assess you injury, let you know if you need an x-ray or other diagnostic imaging, and can get you started on a rehab program.
Therefore, we always recommend seeking guidance from a healthcare professional in person if you suspect you injured something.
Aside from that, you can often tell if you have a low ankle sprain based on the mechanism of injury, location of pain, location of other symptoms like swelling and bruising, things that aggravate the ankle, and associated functional limitations.
What is the mechanism of injury for a low ankle sprain?
The mechanism of injury for a low ankle sprain typically involves rolling the ankle into excessive inversion (lateral ankle sprain) or rolling the ankle joint into excessive eversion (medial ankle sprain).
This can happen without any contact from someone else. For example, slipping off a curb can be enough to roll the ankle. It can also happen from contact with an opponent while playing a sport, or even somewhere in between, like landing on someone else foot in the conflict zone in volleyball.
These aren’t the only ways you can sustain a low ankle sprain, but usually there is some component of stretching out the outside or inside of the ankle beyond the limits that the ankle ligaments can withstand.
Where do you feel pain with a low ankle sprain?
Depending on the severity of injury and possibly other structures that may also be injured, pain can be very localized to one small area of the foot and ankle, or it can be very widespread in more severe cases. Most of the pain should be concentrated within the area where the damaged ligaments.
For a lateral ankle sprain, this can be on the outside of the foot or ankle joint, and may include the bony part of the end of the fibula where the ligaments attach.
For medial ankle sprains, this may be on the inside of the foot and ankle, including the end of the tibia where there are attachments for the medial ankle ligaments.
These areas may also be bruised, which can also help identify where much of the damage occurred. Additionally, while swelling may be widespread throughout the ankle at first, it can often stick around in the area with the most damage as you go through the recovery process.
What can make a low ankle sprain worse?
Stretching the ligaments that are injured in a low ankle sprain can reproduce familiar pain, which can help assess which specific ligaments are injured.
For example, stretching the outside of the ankle joint will often be painful in a lateral ankle sprain, whereas stretching the inside of the ankle will often be painful for a medial ankle sprain.
Additionally, in the early stages of injury, or for more severe ankle sprains, general activity on your feet may bother the ankle, especially if there is lots of motion or impact involved, like walking, jogging, running, or jumping.
Should you get an x-ray for a low ankle sprain?
If there is any suspicion of a fracture that may affect how the ankle injury is managed, then it could be worth seeking an x-ray to rule in or out the presence of a fracture. This should be guided by your physical therapist or physician.
The physical therapist will use the information provided in your account of the ankle injury, whether or not you were able to weight bear after the injury, where your pain is in the foot and ankle, as well as other findings in the history or physical exam.
The most common guide that physical therapists and physicians use to determine the suitability of an x-ray for an injured ankle is called the Ottawa Ankle Rules.
Feel free to check out our article discussing when an x-ray may be needed for more comprehensive information on this subject.
Treatment for a Low Ankle Sprain
Exercise-Based Treatment for a Low Ankle Sprain
The treatment for a low ankle sprain typically involves initial protection and swelling management, restoration of ankle range of motion, and improvement in foot and ankle strength, stability, and proprioception.
For any sprained ankle, the initial phase of protection and swelling management is crucial to allow the body to progress through the necessary inflammatory phase of healing, but without making this process excessive or prolonged. It is often advised to follow the R.I.C.E. guidelines during this phase.
Subsequently, once the acuity of the low ankle sprain has settled, then it becomes safer and more tolerable to work on ankle range of motion, which is important for normal function and comfort of the ankle.
Once cleared to do so, the most important part of completing recovery for a low ankle sprain, and especially for reducing the risk of future low ankle sprains, is to focus on improving strength, stability, and proprioception.
Good muscle strength will allow for the ankle to safely withstand the forces placed upon it and keep up with task demands from daily activities to high level sport, and this is crucial to help prevent any other ankle injury as well.
Stability can be considered functional strength where many muscle groups work together to keep the ankle in an optimal position while you’re on your feet. This will mean there is less reliance on passive stabilizing structures like the medial and lateral ankle ligaments, thus reducing pain and risk of injury.
Proprioception refers to joint position awareness and is a type of sensation that is extremely quick to travel through the body. It can almost be thought of as a high-speed internet connection for the ankle, whereby it’s constantly sending information to the brain and receiving subsequent signals as to how it needs to correct its position.
Proprioception is necessary to maintain balance and provide enough reactive control to correct any slips and catch yourself from falling. It’s also very important for sport performance, so it’s important to focus on when rehabbing an injured ankle, especially if you are an active individual.
To be the most efficient, this system requires reduced swelling, good range of motion, and appropriate strength, which is why these precursors are very important to build up. In an injured ankle, all of these important pieces of function will be limited, this limiting ankle proprioception.
Once all of these goals regarding range of motion, strength, stability, and proprioception have been achieved, then return to sport training with exercises that involve a high rate of loading, for example, jumping, may be introduced.
Lastly, as we indicated in the pictures above, there may be differences in what types of exercises to focus on, and what types of exercises to avoid, for treating a low ankle sprain.
For example, a medial ankle sprain may require longer duration of protection for the deltoid ligament complex and other medial ankle ligaments, whereas a lateral ankle sprain may need protection of the anterior talofibular ligament (ATFL) and other lateral ligaments while they heal.
Other Helpful Tools for Treatment of a Low Ankle Sprain
Given that exercise-based rehab is by far the most effective way to treat a sprained ankle (Ortega-Avila et al, 2020), any other form of therapy for low ankle sprains should be considered an adjunct to treatment, meaning it may help, but should not be done completely in isolation.
Ankle braces can be quite effective at preventing the incidence of ankle injuries, particularly low ankle sprains, especially in sport settings. Ankle braces should not be relied upon completely, but they can certainly be a very helpful tool in preventing the incidence of ankle sprains or secondary injuries.
Transcutaneous Electrical Nerve Stimulation (TENS) and Interferential Current (IFC) are modalities that can help provide temporary pain relief for an injured ankle, so they can often be used throughout the rehab process, especially in the early phase of recovery when the ankle is quite painful.
Ultrasound is another common tool in clinics that is believed to have some ability to promote healing of damaged ligaments, but the evidence behind this is controversial at best (van den Bekerom et al, 2011), so again it’s best not to solely rely on this modality for effective rehab.
Dry needling is another tool that can be used, but is usually brought in near the later phases of rehab for lingering pain or neuropathic changes that may have occurred over time, such as increased tone or stiffness in muscles.
Low ankle sprains are high up on the list of most common injuries seen in a physical therapy setting. There will always be unique components to these injuries, and as such, we highly suggest consulting with a physical therapist in-person to help guide your comprehensive rehab low ankle sprain rehab program.
Exercise-based therapy is the best method fro treating low ankle sprains, but other tools can help too, and when combined together, and optimal approach for full recovery can be employed.
Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 603-610.
Ortega-Avila, A. B., Cervera-Garvi, P., Marchena-Rodriguez, A., Chicharro-Luna, E., Nester, C. J., Starbuck, C., & Gijon-Nogueron, G. (2020). Conservative treatment for acute ankle sprain: A systematic review. Journal of Clinical Medicine, 9(10), 3128.
van den Bekerom, M. P., van der Windt, D. A., Ter Riet, G., van der Heijden, G. J., & Bouter, L. M. (2011). Therapeutic ultrasound for acute ankle sprains. Cochrane Database of Systematic Reviews, (6).
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