Ankle Sprain

What is Ankle Sprain?

An ankle sprain is a stretch, partial tear or complete tear of the ligaments that support the ankle joint.^[1] It is one of the most common musculoskeletal injuries, and most sprains involve the lateral (outer) ligaments, especially the anterior talofibular ligament.^{[1, 2]}

Common symptoms

An acute sprain triggers an inflammatory response that causes pain, swelling and a sense that the joint is unstable.^[1] Bruising and tenderness over the injured ligament are common, and walking may hurt.

Symptoms that last beyond the first weeks are not unusual. Up to 40% of sprains lead to chronic symptoms such as pain, swelling, instability or repeat sprains lasting at least 12 months, and about 20% develop into chronic ankle instability.^[3]

Causes and risk factors

A sprain happens when the ankle is forced past what its ligaments can handle, most often by rolling the foot inward.^[1] Poor balance and position sense, a previous sprain, loose ligaments and leg alignment are intrinsic risk factors, while warm-up, footwear, uneven ground and sports with jumping or sudden direction changes are external ones.^[1]

A review of prospective studies found a higher rate in females than males and in indoor and court sports.^[2]

How it is diagnosed and treated conventionally

A sprain is diagnosed from the history of the injury and a physical examination of the bones and ligaments, and imaging is used when a fracture or more severe injury is suspected.^{[1, 4]}

Current treatment follows the POLICE approach: protection, optimal loading, ice, compression and elevation. Early supervised movement is preferred over long immobilization, and bracing, taping and balance training are used for recovery and to prevent repeat sprains.^[1] An overview of systematic reviews found strong evidence for anti-inflammatory drugs and early mobilization, moderate evidence for exercise and manual therapy, and strong evidence for bracing in preventing recurrence.^[5] Exercise-based rehabilitation reduced the chance of a repeat sprain over 12 months.^[6] Surgery is kept for chronic instability or treatment that has failed.^[1]

Why Ankle Sprain calls for a whole-person approach

A sprain is a local injury, but how well it recovers depends on more than the ligament. Balance and position sense, the first days of swelling, and whether the ankle is retrained afterward all matter.^{[1, 3]}

Care that looks at these factors alongside rehabilitation is a reasonable addition. It does not replace the exercises and bracing that conventional treatment relies on.

Inflammation and swelling

A sprain triggers inflammation, which brings pain and swelling in the first days.^[1] This is one reason people look for ways to ease pain and swelling while they stay active.

Balance and position sense

Poor position sense (proprioception) before an injury raises the risk of a sprain, and the impairment after one is thought to make repeat sprains more likely.^{[1, 3]} This is why balance and neuromuscular training is part of standard care.^[5]

Repeat sprains and chronic symptoms

Ankle problems that last often combine mechanical looseness with changes in how the nervous system controls the joint, so a thorough early assessment looks for both.^[4]

Return to activity

Rehabilitation, bracing and a gradual return to sport lower the risk of another sprain.^{[5, 6]} Pain relief that lets you do your exercises is useful, but it should not tempt you to go back to full activity too soon.

Acupuncture for Ankle Sprain

What the research shows

The evidence for acupuncture in acute ankle sprain is limited, and the reviews that have looked at it rate most trials as low quality. A Cochrane review of 20 trials with 2012 participants, 17 of them in China, found that all had a high risk of bias and rated the evidence for the main reported outcome, the rate of symptom resolution, as very low certainty. It concluded that the evidence did not provide reliable support for the effectiveness or the safety of acupuncture.^[7]

A meta-analysis of 17 trials with 1,820 participants found more people reported improvement with acupuncture than without, but called this probably an overestimate. Trial quality was generally poor, and the authors judged the evidence insufficient to recommend acupuncture as an evidence-based option.^[8] An overview of systematic reviews described the evidence on acupuncture for acute sprain as conflicting.^[5]

One later trial of 80 patients with acute sprains compared a micro-needle-knife technique with conventional acupuncture. Pain and function improved in both groups. The micro-needle-knife group did better right after treatment, and the groups did not differ at one month.^[9] The trial had no untreated or sham group, so it says little about whether acupuncture itself helps.

How acupuncture may work

How acupuncture might help a sprained ankle is not established, and none of the studies above tested a mechanism. In traditional Chinese medicine, an acute sprain is described as injury with local stagnation of qi and blood, which causes pain and swelling, and needles are placed to move this stagnation. This is a traditional framework, not a proven explanation.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points around the ankle, lower leg and sometimes the hand or other regions, usually left in place for about 20 to 40 minutes. We plan a short course of visits and reassess whether it is helping. The trials in the reviews varied widely in how many sessions they gave.^[7]

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, pain or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[10] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture). An injury that has not been assessed by a physician should be seen by one first.

Ayurvedic medicine for Ankle Sprain

The Ayurvedic view

Ayurveda has no classical diagnosis that equals a sprain. Injury-related pain and swelling are traditionally described as arising from trauma (abhighata), with Vata and sometimes Pitta and Kapha involved, depending on whether the area is stiff, hot or swollen. These are traditional categories used to plan care, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Protection of the injured ankle and a gradual return to movement, in line with your physician's advice and standard sprain care^[1]
• Gentle, warm oil massage around, not over, an acutely swollen joint once the first days of swelling have passed
• Herbs traditionally used for pain and swelling, such as turmeric and ginger, which need review if you take blood thinners, since ginger has been reported with bleeding in people taking warfarin^[11]
• Diet and daily routine intended to calm the aggravated dosha

Panchakarma, the traditional cleansing program, is not appropriate for a sprain, and is also unsuitable during pregnancy, acute illness or frailty.

What the research shows

There is no clinical research on Ayurveda for ankle sprain. A PubMed search found no clinical trials of Ayurvedic treatment, Ayurvedic herbs or oil therapies for ankle sprain or similar soft tissue injuries. The treatments above are traditional practice, and we cannot point to evidence that they speed recovery.

Herbal medicine for Ankle Sprain

Herbs and formulas that have been studied

Herbal treatment of acute sprains has been studied mostly in East Asia. Chinese herbal medicine taken by mouth and herbal patches applied to the skin were among the comparison treatments in acupuncture trials.^[7] A Korean herbal extract called Dangguixu-san, used for pain and swelling after sprains, has been tested in a placebo-controlled trial.^[12] A herbal preparation applied to the skin falls under the clinic's transdermal medication therapy, but we found no trial of it for sprains.

What the research shows

The evidence is limited. In a double-blind trial of 48 people with acute lateral ankle sprains, everyone received acupuncture once a day for 5 days, and half also took Dangguixu-san while half took placebo. The herbal group had a larger reduction in pain and better symptom scores between week 1 and week 5, with no adverse events reported. The trial was small and tested the herb on top of acupuncture, and it was done in Korea.^[12]

We found no other placebo-controlled herbal trials in ankle sprain. Evidence for anti-inflammatory herbs such as turmeric, ginger or Boswellia in sprains was not found.

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Case reports describe serious problems such as bleeding and hematomas when warfarin was combined with herbs including dan shen (Salvia miltiorrhiza), dang gui (Angelica sinensis), ginger and Boswellia.^[11] A broader review found that herb-drug interactions can have serious clinical consequences.^[13] People who take blood thinners or anti-inflammatory drugs, or who have a bleeding problem, need a practitioner's review before using herbs.

In the Cochrane review, only one trial reported adverse events: three participants in a comparison group had skin problems from over-the-counter Chinese herbal patches.^[7] Skin preparations should not be applied to broken skin. In another study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[14] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, or have surgery planned.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine describes an acute sprain as stagnation of qi and blood at the injury. Biomedicine describes a stretched or torn ligament with local inflammation, swelling and pain.^[1] Whether acupuncture or herbs influence any of these processes in people with sprains has not been shown.

Ayurveda's description of trauma with aggravated Vata, pain and swelling covers a similar picture in different words. No study has shown that a dosha or a qi pattern corresponds to a specific biological process in the ankle.

How this care fits with your medical care

Integrative care for ankle sprain is complementary. Keep your physician, physical therapist or sports medicine doctor, and continue the bracing, loading and balance exercises they prescribe, because these are the best-supported parts of recovery.^{[5, 6]} Do not stop or change prescribed medicines without your prescriber.

We do not diagnose the extent of an ankle injury, so a new sprain should be assessed by a clinician, especially when you cannot walk on it. Please bring your diagnosis, any x-ray or MRI reports, a full list of medicines and supplements, and your rehabilitation plan.

When to seek urgent medical care

Some ankle injuries are fractures or severe ligament injuries and need an examination and often imaging.^[4]

• Being unable to bear weight on the foot, or to take four steps, right after the injury
• Severe pain or tenderness over the bone at the ankle or the base of the foot
• Obvious deformity of the ankle or foot
• Numbness, a cold or pale foot, or a blue color in the toes
• Redness, warmth and fever, or a calf that is swollen and painful without a clear cause
• No improvement after the first week or two, or a repeatedly giving-way ankle

If any severe symptom occurs after a serious fall or accident, call 911 or go to the nearest emergency department.