Is It an Ankle Sprain or Break? Symptoms & Treatment of a Common Ankle Injury

We’ve all had a similar moment of panic as we feel our ankle roll or wrench to one side. Whether you fell on the court, ran through a pothole, or tripped on uneven surfaces, there is nothing quite like the sudden pain of a badly injured ankle. We immediately wonder, “is it an ankle sprain or break, and what do I do now?” Let’s look at what sprains and breaks are, how to tell the difference, and how to treat the injury so we can get back on our feet again.

Ankle Anatomy

To determine whether you have an ankle sprain or break, it is essential to understand the structure of the ankle. The ankle is made up of two large joints called the true ankle joint and the subtalar joint. The true ankle joint, which moves the ankle up and down, is comprised of three bones:

  1. The tibia (shin bone) is the lower leg bone that runs the length of the inside of the ankle. The bottom of the tibia bone forms the bony protrusion on the inside of the ankle (medial malleolus).
  2. The fibula is the lower leg bone next to the tibia that forms the outside of the ankle. The bottom of the fibula creates bony protrusions on the outside of the ankle (lateral malleolus).
  3. The talus: a small bone underneath the tibia and fibula bones and the top of the foot.

Beneath the true ankle joint lies the subtalar joint, which allows the ankle to move from side to side. The subtalar joint consists of the talus bone of the true joint and the calcaneus (heel) bone beneath it.

These joints are surrounded and supported by muscles, tendons, and ligaments. Muscles help move the ankle, and tendons attach the bones to the muscle. Ligaments connect the ankle bones to the foot bones and the bones of the legs, providing stability to the ankle joint.

Three main groups of ligaments connect the ankle to the foot and leg bones. These are:

  1. Deltoid ligaments (Medial ligaments): The deltoid ligament starts at the base of the tibia and spreads out into four ligaments connecting the tibia to the calcaneus, talus, and navicular bones. With the tibia, it forms the inside bump of the ankle.
  2. Lateral ligaments: The lateral ligaments start at the end of the fibula bone and spread into three ligaments that connect to the calcaneus and talus bones. With the fibula, it forms the bump on the outside of the ankle.
  3. Syndesmotic ligaments: Four syndesmotic ligaments connect the tibia and fibula bones.

What is an Ankle Sprain?

Ankle sprains are everyday occurrences and account for 16%-40% of all sports-related injuries – especially in football, basketball, and soccer. In fact, sprained ankles are the number one top sports injury. A sprain means there has been damage to ligaments, including tearing and overstretching.

What is an Ankle Break?

Ankle breaks, also known as ankle fractures, are common ankle injuries that usually involve breaking of the tibia, fibula and sometimes the talus bone. About 187 per 100,000 adults break their ankle per year in the United States.

How to Tell the Difference Between an Ankle Fracture and Sprain

The most common symptoms for both sprained ankles or fractured ankles are swelling, bruising, pain and joint instability or weakness. While the signs of broken or sprained ankle may be similar, there are some clues and questions you can use to determine the type of ankle injury sustained.

What Do You See?

If your ankle is swelling or bruising, you may have a sprain or a break. Seek immediate medical attention at an emergency room or urgent care center for a possible severe ankle fracture if:

  • You see blood or a wound, or if there is bone protruding through the skin.
  • You see a deformity, or the ankle looks different.
  • There is massive swelling.
  • The ankle or foot is blue or changing color.

What Did You Hear?

If you heard a ‘pop’ sound at the time of the injury, you likely sprained your ankle. If you heard a ‘crack’ sound, you may have a break. Stress fractures usually don’t make a sound; however, and not all sprains make a noise either.

What Do You Feel?

Take an assessment of the sensations you are feeling at the moment of the ankle injury and later on.

  • Is the pain severe?
  • Is the pain staying the same or getting worse?
  • Is there tenderness and weakness in the ankle?
  • Does your ankle or foot feel hot?
  • Is there any numbness or tingling?

An ankle fracture has immediate, sharp, severe pain, while a sprained ankle can see an increase in pain if not treated. However, both a sprain and a fracture can experience varying levels of pain that change or get worse. Determine where the pain is coming from; pain, tenderness and weakness in the soft tissue can indicate a sprain and pain above a bone may be a fracture. Numbness, tingling, or loss of feeling in your leg or foot can indicate a bone break is interfering with your nerves or circulation, and you need to see a physician right away.

How Did the Injury Occur?

  • Did your ankle experience an acute trauma?
  • Was there a hard impact or severe force placed on the ankle, leg or foot?
  • Did the ankle bend to the outside or inside while walking, or stepping off a curb?

Ankle breaks tend to occur because of pre-existing medical conditions that weaken the ankle’s structure, direct impact trauma (like car accidents), or a sudden, violent twisting of the ankle as seen in some sports and high-impact activities.

Sprains are usually caused by falling or stepping awkwardly, rolling or twisting your ankle, landing unevenly after a jump, or when someone else step on the ankle. The outside ligaments (lateral collateral ligaments) are the most common sprain area.

Can You Move Your Ankle and Foot?

  • Can you walk and can your ankle bear weight?
  • Does your ankle have full range of motion?
  • Can you move your foot and toes?
  • Is it pain or swelling preventing movement?

In general, sprains tend to allow for movement of the ankle and foot despite the pain, where fractures can prevent movement. Sprains can support some weight, and fractures usually won’t support much weight at all. Remember, you can have both a sprain and an ankle break simultaneously.

General Treatment and Recovery for an Ankle Sprain or Break

In the absence of visual evidence, the only way to truly know whether you have an ankle sprain or break is to see a doctor. Doctors and orthopedic specialists will take a history, learn about the accident, and perform a physical exam of your ankle. They will use diagnostic imaging equipment like an X-Ray, CT Scan, or possibly an MRI to determine the type of injury and extent of the damage. Knowing whether it is an ankle sprain or break will dictate the proper treatment plan and your recovery time.

At Home Treatment

The basic home care for both ankle sprains and breaks is the five-step P.R.I.C.E. method:

  1. Protect: Limit the use of the injured ankle by using a crutch or splint.
  2. Rest: Limit activity of the injured ankle, especially movements that may increase damage.
  3. Ice: Ice the affected area (not directly) in 20-minute cycles.
  4. Compression: Wrap your ankle in an elastic bandage (like an Ace bandage) to reduce swelling and help prevent further injury.
  5. Elevate: Raise your ankle above your heart using pillows or blankets under the injured area to reduce swelling and pain.

Ankle pain can be reduced using over-the-counter medications (like anti-inflammatory medications) but it is a good idea to contact your healthcare provider for medical advice.

Contact your doctor for an in-person consultation or get emergency care if you see any deformities, or bleeding, the pain remains severe, or if swelling is not reduced after 24 hours.

During recovery, physical therapy is recommended to help strengthen the joints and muscles. Improper healing of ligaments and bones can lead to loss of mobility, stability, and chronic pain.

Ankle Sprain Types and Recovery

Sprains are generally mild injuries, but they can escalate in severity. Sprains have three severity levels based on the damage to the ligaments:

  • Grade 1: Mild Sprain – The ankle is sore and slightly swollen. Likely the ligaments are stretched but not torn. Recovery may take 2 weeks.
  • Grade 2: Moderate Sprain – There is likely a partially torn ligament, and a doctor may feel instability in your ankle. The pain is usually worse than a mild sprain, and recovery may take 6-8 weeks. There may be bruising under the injury, and the ankle is not weight-bearing.
  • Grade 3: Severe Sprain – A severe ankle sprain means some of the ankle ligaments are completely torn. There are high levels of pain, along with bruising and swelling. The ankle has limited mobility and is not weight-bearing. The ankle will likely feel unstable, and the injury can take 3-6 months to heal completely.

Note that sprained ankles can become weaker even after the injury has healed, creating a higher likelihood of re-spraining the ankle.

Fracture Types and Recovery Time

The type of fracture determines the ankle break treatments. Treating broken bones of the ankle have the same basic goals as any other bone fracture:

  • Reduce swelling
  • Immobilize the break and surrounding areas
  • Reduce pain
  • Avoid infection
  • Align the bones, so they heal properly and without further damage (if needed)

These goals are met by closing open wounds, icing the swelling, and using splints and short leg casts to immobilize the joint. If the break is unstable or severe, or if the injury also includes damage to the ligaments or tendons, surgical intervention may be required.

Although there are many different types of breaks, doctors usually refer to the general fracture types: stress, displaced and non-displaced, closed, and open.

Ankle Stress Fracture

Stress fractures (also known as hairline fractures) are tiny cracks in a bone and are most common in the lower legs and feet. Runners and soccer players are the most susceptible to ankle stress fractures caused by repetitive motion and overuse. Stress fractures can also happen as the result of trauma to the area or a medical condition that affects the bones, like osteoporosis. The symptoms of a stress fracture may not occur at the time of injury. However, tenderness and increasing pain at the break site are common. Stress fractures are closed, non-displaced fractures. They are usually treated with a walking boot and take 6-8 weeks to heal completely.

Displaced and Non-Displaced Ankle Fractures

A displaced fracture occurs when the bones snap and move out of alignment. The orthopedic physician will attempt to realign the bones manually. More severe displaced fractures may require surgery to align the broken bones, and rod, pins, or metal plates are commonly used to help the bones heal together correctly. A nondisplaced fracture means the bones have broken but remain together correctly. These fractures are usually closed, stable, and don’t require surgery.

Open and Closed Fractures

A closed fracture means the broken bones have not pierced the skin. The bone or bone fragments are not visible. An open fracture (or compound fracture) is a bone break in which the bones have pierced the skin or there is a wound so deep you can see the broken bone. These are particularly dangerous because there can be blood loss and an increased risk of infection.

Most Common Ankle Breaks

Most ankle breaks occur on the bottom (at the ankle) of the tibia and fibula bones. Physicians will determine whether the break is stable (it doesn’t affect the talus bone and the bones are not displaced) or unstable (the talus is unable to move in the standard way or the break has displaced the bones).

The most common ankle breaks are:

  1. Lateral Malleolus Fractures – Fibula Break. Since these breaks are often closed and non-displaced (stable) surgery is not usually required. Breaks of the fibula bone at the ankle are very common. This break occurs in the fibula on the outside bump of the ankle.
  2. Medial Malleolus Fractures – Tibia Break. This is a break on the inner side of the ankle on the bony protrusion. Usually this displaced break can be treated without surgery.
  3. Bimalleolar Ankle Fractures – Tibia and Fibula Breaks. This fracture involves the inside and outside of the ankle joint and are usually unstable (displaced). Surgery is recommended because proper bone alignment is essential for the ankle structure to work.
  4. Bimalleolar Equivalent Fracture – Fibula Break and Torn Ligaments. This type of ankle fracture means you have a break in only your fibula but you also have tears in one or more of the inside ankle ligaments (you have an ankle sprain and break). This usually requires surgery as it creates ankle instability (displaced fracture.)
  5. Trimalleolar Fracture – Tibia and Fibula Breaks. Similar to a bimalleolar ankle fracture, except this break is in the back of the tibia (the posterior malleolus).
  6. Maisonneuve Fracture – Tibia and Fibula Break with Torn Ligaments. This is a less common injury but it is worth noting because it can be easily misdiagnosed and missed in an examination. A Maisonneuve fracture involves a fibula fracture far up the bone near the knee, but the inner side of the ankle (the medial malleolus) is also injured. The lateral malleolus is intact but the large ligament that connects the tibia and fibula (the syndesmosis) is injured. Because the break is near the knee, the damaged ankle is often missed. Surgery is usually necessary to fix the instability in the ankle joint.

This general information on the difference between ankle sprains and breaks can be used to help you understand your ankle injury. However, the best way to determine whether an injury is serious or in need of treatment is best left to doctors and orthopedic surgeons. A proper diagnosis from an ankle specialist will come with the correct treatment options, follow-ups to make sure the ankle is healing properly, pain medication recommendations, and specific instructions tailored to your injury to speed up healing and prevent further damage.

No matter what type of ankle sprain or break you have, you can be sure the orthopedic specialists at MOSH and our Joint Replacement Institute are ready to help you heal and get you back to your active lifestyle.

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