Welcome back to Mangled Mondays, where every Monday we talk about another facet of maiming, mangling, mauling, and mistreating your main characters — and all of their friends.
Today we’ll be talking about Sprained Ankles. While this injury seems fairly superficial, it can actually affect your character’s mobility for years and has a very high risk of reocurrance!
For the rest of the Mangled Mondays series, [click here].
QUICK HEADS UP: Due to the way the holidays are falling this year, this will be the last Mangled Monday of 2017. I’m taking 12/25 through 1/1 off of the blog completely. Mangled Mondays will resume on January 8th 2017. Thanks and happy holidays to those who celebrate!
What Is It?
An ankle sprain is a tear in the ligaments that hold the ankle together. There are many variations of the injury, but this entry will only deal with the most common: the lateral ankle sprain.
Ankle sprains range from extremely mild (Grade I) through completely debilitating (Grade III). The grade of the sprain is based upon the amount of damage done to the tendons.
A Grade I ankle sprain doesn’t typically require medical attention. These injuries involve some pain and swelling, but can bear weight very well and don’t really affect a character’s quality of life. Grade I sprains won’t be discussed further in this entry, as their impact and care are minor.
A Grade II sprain has moderate pain, swelling, and bruising. The stability of the joint has begun to be affected, and it’s painful and difficult to bear weight on the affected ankle. Walking will be poor if it’s possible at all.
A Grade III sprain is one in which the ligament involved has torn completely and is severed. The pain and swelling are immense, and the character can’t bear weight on the ankle or walk.
- Tenderness, swelling, and bruising on the lateral side of the affected ankle.
- When examined, Grade II and III sprains will show some instability of the joint.
- Pain upon motion of the ankle during examination which mimics the mechanics of how the foot was injured.
- Inability to bear weight (Grade II – partial; Grade III – total).
How Does It Happen?
Ankle sprains happen when the calf is going one way and the foot goes another. Almost exclusively, this happens when…
…the foot is angled down (plantar-flexed) and rolls inward (inverted). This causes hyperextension of the ligaments on the lateral side, or outside, of the leg.
This can happen in any number of circumstances. Running through woods, sand, or really on any surface is an excellent cause; the character’s ankle might also be caught in some kind of netting or by some other means. Parkour, skateboarding, football of all kinds, or tripping in high heels can also cause this.
The first thing for a character with an ankle sprain to do is to find a way to stabilize the ankle. Splints are easy to make in the field, and crutches can be improvised if need be.
Characters will ideally see a doctor, but of course, characters rarely do what is ideal. An ankle sprain can be managed without physician contact if the character has limited resources or cannot seek medical aid for other reasons.
Emergency Department: Imaging
The emergency department staff will use a “decision tree” called the Ottawa Ankle Rules to determine whether the character needs X-rays of the ankle. This involves seeing about weight-bearing and looking for pain in specific parts of the foot. High-grade sprains are more likely to need X-rays than low-grade sprains.
Surgery / Hospitalization
Grade I and Grade II ankle sprains do not require surgery, though Grade II sprains may require significant time to heal. Grade III ankle sprains may benefit from surgery, but they also may not; the data are unclear about the benefit. If surgery is performed, it will likely be at least two weeks after the initial injury, in order for the swelling to go down.
In the Austere Environment
Outside the auspices of a hospital, the best thing a character can do is splint the ankle, make a makeshift crutch, and wait for the pain and swelling to go down.
RICE is the meal of the day: Rest, Ice, Compression, and Elevation, just as it is for a character who has hospital access.
Immobilizing the ankle is debated among physicians. (Yes, even in the 21st century we’re still not entirely sure how to treat sprained ankles, fevers, or the common cold. Medicine is weird.)
A soft or air-filled splint might be used, especially for more severe ankle sprains, to keep the ankle immobile and prevent further damage. However, beginning rehabilitation early is clearly beneficial; splints might be removed to allow for exercises, or may simply not be used.
The Rocky Road to Recovery
Characters with Grade II sprains can bear weight on the ankle occasionally, with significant pain and difficulty; those with Grade III sprains cannot bear weight at all. Characters with significant upper body strength might still be able to use ladders and possibly climb ropes. Neurocognitive function and the strength and function of other limbs are preserved.
Characters may not be able to move quickly over rough terrain even with a weight-bearing sprain; climbing will likely be impossible. With a high-grade ankle sprain, the character may not be able to walk for an extended period and will likely rely on crutches or, if both legs are injured, a wheelchair.
Characters who drive manual-transmission (stick-shift) cars cannot drive with either ankle sprained; characters who drive automatic-transmission vehicles may drive with left ankle sprains but may not be able to drive with right ankle sprains.
Characters cannot ride a bicycle or a skateboard with a Grade II or Grade III sprain.
Characters with severe ankle sprains may recover fairly poorly. Up to 1 in 3 characters with a Grade II or Grade III ankle sprain will have some amount of longer-term ankle instability, which makes the character prone to reinjury. The affected ankle can also “give way” in surprising moments (without necessarily respraining the ankle), or have some level of chronic inflammation and pain.
Features of Recovery: Hospital Stay
Characters will not be admitted for overnight care unless the ankle sprain is concurrent with another, more serious injury. They’ll be seen in the ER, have their ankle immobilized with a splint or with ACE wrap, and will then be discharged home.
Features of Recovery: PT/OT
Engaging in range-of-motion therapy early will help the character get back to walking and maintain as much strength in the ankle as possible. Flexing the foot away from the body (plantar flexion) and toward the body (dorsiflexion), along with moving the toes in circles, will be performed at least twice a day starting as soon as the worst of the initial pain goes down.
A typical mobility exercise would be to remove the splint twice a day and draw each letter of the alphabet with the big toe.
Later, characters will be encouraged to spend more time balancing on the injured ankle and may use an ankle balance board, which is designed to keep the affected ankle off-balance and will help the character strengthen the ligaments, tendons, and muscles.
The New Normal
Ankle sprains can be slow to heal and can cause instability even months after the injury, but characters who recover well and fully participate in their physical therapy can return to active lifestyles. They may develop a penchant for wearing higher-shaft boots or high-tops rather than sneakers in order to support the ankle.
Your character will be at risk for repeating the ankle sprain, either in the same ankle or in the opposite one due to overcompensation.
Characters are also at significant risk of developing arthritis after a high-grade ankle sprain; in fact, it’s more likely to occur than not.
Total Recovery Time (Typical)
- Grade I: already walking
- Grade II: 2–4 weeks
- Grade III: 1–3 months
- Grade I: 2–4 weeks
- Grade II: 4–8 weeks
- Grade III: 3–6 months
Full Recovery: up to 3 years
In the first few minutes, an ankle sprain may not show any visible sign of injury. However, swelling will come on rapidly, and inside 30 minutes to 4 hours, the ankle will be swollen and may be red. After 24 hours, the ankle will likely be obviously bruised.
Ankle sprains are not usually associated with sounds.
Characters may be able to feel a tearing sensation in the ankle, though it’s much more likely that they’ll simply feel pain. The swollen ankle will also be hot to the touch.
The great majority of ankle sprains are caused by what is colloquially known as “rolling” the ankle. This is when the sole increasingly faces the opposite foot, and is technically known as plantar inversion.
A “high ankle sprain” is tearing of the muscle that holds the tibia and fibula together.
Several forms of splint are available to providers: gel cast, ankle stirrup, lace-up ankle brace, or air cast. These are all devices that are designed to stabilize the ankle. Which one is used will depend on institutional and provider preference.
Awalking boot or ortho boot is a rigid boot that’s used for high-grade sprains to stabilize the ankle in all directions of motion.
- Ankle sprains exist on a continuum, but are graded in Grades I, II, or III, depending on the extent of tearing of the ligament and functionality of the ankle.
- The injury may look like “nothing” at first, but will soon develop swelling and bruising (Grade II, III). This can take weeks to go away.
- Characters may need surgery for severe sprains (Grade III).
- Characters might develop arthritis years later, and will likely lose stability (“roll” the ankle) with or without sprain in the future.
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.