Ankle Sprain | PM&R KnowledgeNow (2024)

Disease/Disorder

Definition

Ankle sprain is the stretching or tearing of ankle ligaments. In grade 1 (mild) sprains, a few fibers are torn but there is no laxity or residual instability. Grade 2 (moderate) sprains involve an incomplete tear of the ligament with mild laxity and instability. Grade 3 (severe) sprains are characterized by complete disruption of the ligament with gross instability and laxity.¹

Etiology

Lateral ligament sprains are most common (85% of sprains) and occur from subtalar supination/inversion, talocrural plantarflexion, and tibial external rotation.^2-4 As the foot rotates, the anterior talofibular ligament (ATFL) is injured first, then the calcaneofibular ligament (CFL) and posterior talofibular ligaments (PTFL) tend to tear in that sequence, depending on severity of the injury. Eversion sprains are caused by extreme external foot rotation, injuring the deltoid ligament that helps to stabilize the medial ankle. High ankle sprains occur via more severe eversion injuries affecting the tibiofibular syndesmosis and/or the anterior tibiofibular ligament.⁵

Epidemiology including risk factors and primary prevention

Lateral ankle sprains are the most common athletic injury, comprising 2%-25% of all sports injuries. Up to 25,000 occur in the United States daily, and up to 40% of ankle sprains become chronic. Female athletes are at higher risk than male athletes.Children are also shown to be at higher risk compared to adolescents and adults.⁵ The highest prevalence of lateral ankle sprains is seen in basketball, volleyball, and field sports.Among field athletes, associated risk factors for increased incidence of ankle sprain include high body mass index (BMI), decreased hip strength, single leg standing performance, and decreased ankle plantar and dorsiflexion strength and range of motion.^6,7 Collegiate men’s and women’s soccer, men’s football, and women’s gymnastics have the highest incidence of medial ankle sprain.High ankle sprains are most commonly seen in football, wrestling, and ice hockey.³

Recent studies have shown grade 1 and 2 sprains take about 7-15 days before full recovery while grade 3 can range from 4.5 to 26 weeks. Complete ligament rupture occurs in 10% of cases.⁴ Risk factors and primary prevention strategies address poor ankle proprioception, weak ankle dorsiflexors and invertors, and poor flexibility. Additionally, body mass index, slow eccentric inversion strength, fast concentric plantar flexion strength, passive inversion joint position sense, and peroneus brevis reaction time correlated with lateral ankle sprains.^9,10 Thirty to forty percent of ankle sprains, especially high ankle and lateral ankle sprains, can result in chronic ankle instability and may ultimately require surgery.¹¹

Patho-anatomy/physiology

Lateral Ankle Sprains

As the ankle moves from dorsiflexion to plantar flexion, bony stability decreases and forces on the ankle ligaments increase.⁸ The ATFL generally consists of two bands that are separated by branches of the perforating peroneal artery.¹² The ATFL is intracapsular, has the lowest failure resistance, and is the most important ligament in talofibular stability. It is under maximal stress with the ankle in plantarflexion. The CFL is extracapsular, thicker, and stronger than the ATFL, and the next to tear in a plantarflexion/inversion injury. The PTFL is the strongest of the three ligaments and least likely to fail because it is only taut in extremes of dorsiflexion.^7,8

High Ankle Sprains

An injury to the distal tibiofibular syndesmosis is known as a high ankle sprain.⁷The syndesmosis encompasses several structures in the distal ankle, including the anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament, interosseous ligament, and the transverse tibiofibular ligament. Together, these ligaments significantly contribute to the stability of the ankle and stabilize the distal tibiofibular architecture and prevent separation. The most common mechanism of injury is a high energy forced external rotation with the foot in dorsiflexion.⁷This injury may coexist with either medial or lateral ankle sprains, with medial ankle sprains being more common.¹³

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

New onset/acute
There is swelling and hemorrhage at the site of ligament disruption. The typical inflammatory cascade ensues with the release of painful inflammatory mediators, such as prostaglandins and interleukins. Capillary endothelial permeability increases, and monocytes migrate to the area. There is pain, often an antalgic gait, and decreased range of motion (ROM).^14,15

Subacute
Ecchymosis, swelling, and ROM may worsen before starting to improve. There is fibrous exudation and scar tissue formation as early as 3 weeks post-injury if the ligament ends are well-approximated. The scar has roughly 75% of the strength of native tissue but retains the ability to support weight bearing.^14,15

Chronic/stable
Chronic ankle instability (CAI) is characterized by persistent pain, swelling, feelings of “giving way,” and recurrent ankle sprains that continue at least 12 months after initial injury. Ankle instability is a strong prognostic factor for recurrence of sprain resulting in CAI.¹⁶ Swelling may take several months to completely resolve. ROM deficits and muscular and ligamentous weakness may persist to varying degrees. Functional instability, proprioceptive deficits, and loss of normal ankle kinematics increase the risk of persistent symptoms, recurrent injury, and early degenerative changes.^7,14,15,17

Specific secondary or associated conditions and complications

Ankle dislocation, bony contusion, osteochondral defects (especially in the talar dome), distal lateral malleolar avulsion or spiral fracture, medial malleolar fracture, avulsion of the 5th metatarsal base, talar neck or medial compression fractures, extensor digitorum brevis injuries, peroneal tendon injuries, and calcaneal-cuboid ligament injuries may occur. Sural or peroneal nerve neurapraxia or neuritis may develop, particularly notable with Maisonneuve fractures (proximal fibular fracture and syndesmotic injury) that are sometimes seen concomitantly with high ankle sprains. Knee, hip, low back, or contralateral lower limb pain may develop from altered gait kinematics. Patients who use axillary crutches to offload the affected ankle are at risk for radial nerve injury.^18-20

Essentials of Assessment

History

A detailed history of the mechanism of injury is critical. Patients typically report a history of walking on an uneven surface such as a pothole and suffering an inversion injury.Inversion injuries of the ankle are more common than eversion injuries of the ankle. Athletes may also relate a history of jumping and landing with the foot plantarflexed and inverted, which often occurs when landing on another player’s foot and may cause a lateral ankle sprain. Patients may report feeling an immediate pop, develop swelling, or notice limited range of motion, ankle weakness, or ankle instability. Pain is typically worse with weight bearing. It is important to note the patient’s ability to bear weight both immediately after the injury and at the time of the examination, as it may influence the decision to obtain radiographs.^1,8

Physical examination

Physical examination for lateral ankle sprains should include the fundamental components of a peripheral joint examination, including inspection, palpation, range of motion, strength testing, sensory testing, reflexes, gait analysis, and special tests.¹ Inspection may reveal soft tissue swelling or ecchymosis.

Palpation may reveal tenderness along the course of the ligaments involved. It is crucial to palpate bony structures as point tenderness can indicate the need for imaging, as indicated by the Ottawa Ankle Rules.Per the Ottawa Ankle rules, radiographic imaging of the ankle is indicated if any of the following are present: inability to bear weight for four steps either immediately after imaging or during the initial clinical examination, or tenderness at the posterior distal tibia, posterior distal fibula, tip of the medial malleolus or tip of the lateral malleolus.²¹ According to the literature, the Ottawa Ankle rules have a relatively high sensitivity and may be useful in determining if further imaging is warranted.²¹

It is important to assess bilateral ankle ROM in all planes, keeping in mind that normal ankle dorsiflexion is 10 degrees with the knee extended and approximately 20 degrees with the knee flexed.²³ Manual muscle testing of dorsiflexion, plantarflexion, inversion, and eversion should be performed and compared to the contralateral side, especially given that inversion and eversion are particularly variable between different individuals.²³ Injury to the lateral or medial ankle ligaments may cause notable laxity of the ankle that may be appreciated during range of motion testing.

Perhaps most importantly, stability of the involved ligaments should be assessed. The anterior drawer test, when performed in plantarflexion, assesses the integrity of the ATFL by applying a force anteriorly in an attempt to displace the talus from the tibia. The anterior drawer test has a sensitivity of 80% to 95% and a specificity of 74% to 84% for ligament rupture.²³Note that the optimal timing to perform the anterior drawer test in order to maximize sensitivity and specificity is 4 to 5 days post-injury.²⁴ The calcaneofibular ligament can be assessed by performing the anterior drawer test in dorsiflexion, or with the talar tilt test, which also assesses for subtalar instability. To perform the talar tilt test, the distal leg is stabilized as the hindfoot is inverted to evaluate for degree of talar tilting. Up to 25 degrees of tilt between the articular surfaces of the tibia and talus may be considered normal, though comparison to the unaffected side is critical.²³

Sensory testing, reflexes, and palpation of distal pulses can assess for concomitant neurovascular injury. This should include assessment of the peroneal nerve (superficial and deep branches), sural nerve, dorsalis pedis pulse, and posterior tibial pulse.Acute compartment syndrome has been very rarely reported in the literature and may occur with disruption of the peroneal artery following a lateral ankle sprain.²²

Functional assessment

A full gait and kinetic chain assessment should be performed, as ankle pain and instability can place undue stress on more proximal joints as well. The unaffected ankle should also be assessed, as inherent laxity, decreased strength, or limited flexibility are underlying risk factors for ankle injury.Static and dynamic hip abduction strength, single-leg stance assessment, single-leg squat, and stepdown tests can be useful in formulating an appropriate treatment protocol to minimize risk factors. A referral to physical therapy to correct these gait mechanics may be warranted.

Laboratory studies

Laboratory studies are not typically indicated in routine workup of an ankle sprain.

Imaging

Decisions to obtain X-rays should follow the Ottawa Ankle Rules, as described above. To reiterate, X-ray imaging of the ankle is indicated if any of the following are present: inability to bear weight for four steps either immediately after injury or on initial clinical examination, or tenderness at the posterior distal tibia, posterior distal fibula, tip of the medial malleolus or tip of the lateral malleolus. Anteroposterior, mortise, and lateral ankle radiographic views should be obtained. When weight-bearing is tolerated, weight-bearing radiographic evaluation may be helpful. Radiographs provide information on ankle spacing and, in the case of ankle sprains, may show decreased tibiofibular overlap, increased medial clear space and increased tibiofibular clear space.²⁴ These values may change when the ankle is placed into external rotation stress view indicating high ankle sprain or instability. External rotation stress views are useful in evaluating the structural integrity of the syndesmosis and deltoid ligaments which may be injured in a high ankle sprain. Increased medial space widening on external rotation stress views may be indicative of disruption of the deltoid ligament. Talar stress views may also be useful in assessing lateral ankle instability by placing the ankle in an inverted and plantarflexed position, though this is unnecessary in confirming the diagnosis of a lateral ankle sprain.²⁶

Ultrasonography may be used to assess the integrity of the ATFL, CFL and PTFL, to assess for tibiotalar effusion, and to potentially identify loose bodies or defects of the talar dome. Advantages of ultrasound include low cost, relatively quick to obtain and ability to obtain real-time dynamic stress views.²⁷ Dynamic ultrasound may demonstrate reduced tendon movement in complete tears while partial tears are characterized by hypoechoic thickening.²⁷ It has been demonstrated that ultrasound is as accurate as MRI in the diagnosis of major ankle ligament injury in the emergency department setting, though the accuracy is operator-dependent.^26,28

Magnetic resonance imaging (MRI) is typically the study of choice and gold standard to assess both intra-articular and extra-articular manifestations of lateral ankle sprains.The literature suggests that MRI may have a sensitivity of over 75% in diagnosing lateral ligamentous rupture.²⁶ However, MRI may take longer to obtain, is less cost-effective and may have inferior resolution for partial tears compared to ultrasound. Overall, MRI is rarely indicated for acute ankle sprains, but is useful in cases of persistent symptoms or chronic ankle instability or to assess for osteochondral defects, occult fractures, anterior or posterior syndesmosis injuries, and other bony pathology not identified on radiographs.²⁶

Environmental

Risk factors for ankle sprain should be assessed including the types of surfaces on which the patient works or on which the athlete competes. Footwear should be assessed for proper fit, wear, stability, and appropriate arch support. If necessary, high-top sneakers or high work boots can be utilized to provide increased medial-lateral support and reduce risk of re-injury. Patient education on the mechanism of ankle ligamentous injury may be beneficial in increasing compliance with wearing specialized footwear.

Social role and social support system

Patient and family education on appropriate management of the acute ankle sprain as well as counseling on best practices to decrease the risk of recurrent ankle sprains may be helpful. Highly competitive athletes or performers may require psychological support to cope with the stress of not being able to perform. Injured workers may have better outcomes if they return to work sooner with restrictions or modified/limited duty rather than remaining out of work completely.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Generally accepted guidelines regarding the treatment of lateral ankle sprains include the following^30-32

• Use of Ottawa ankle rules to determine need for radiography
• Early mobilization and weight bearing as tolerated
• Use of bracing and/or taping for functional support and to facilitate the above
• Individualized, comprehensive rehabilitation program to promote range of motion and function

Additional aspects of treatment at different disease stages

New-onset/Acute

• Potential curative interventions:
  In the acute phase, clinicians should assess for clinical signs of instability that may require surgical intervention. This includes using the Ottawa rules to assess the need for radiographs to evaluate for fractures.
  • Rarely, high-energy trauma can lead to ankle dislocation or neurovascular compromise that could require urgent surgical intervention.
  • High-grade syndesmosis injuries with significant tibiofibular diastasis or concurrent disruption of the deltoid ligament may benefit from surgical stabilization.
• Syndesmosis injury associated with malleolar fracture requires surgical stabilization of the bony fracture. However, concurrent repair of the syndesmosis injury is controversial.³⁶
• Symptom Management:
  Although no longer considered the gold standard of care of acute injuries, most ankle sprains receive RICE therapy as the mainstay of acute care, which consists of relative rest, ice, compression, and elevation.³⁰The goal is to reduce swelling, minimize pain, and minimize loss of ROM. There is relatively strong evidence for both NSAIDs and early mobilization, and moderate evidence supporting exercise and manual therapy techniques, in reducing pain and swelling and promoting function.^25,31NSAIDs should be used judiciously given the risk of cardiovascular, renal, and gastrointestinal side effects.Note that acetaminophen is equally effective as NSAIDs in reducing pain in the first two weeks after an ankle sprain.²⁵
• Immobilization:
  For mild to moderate (Grade 1 and 2) sprains, evidence favors use of flexible external support with taping or a semi-rigid ankle brace, to facilitate early mobilization. In cases of a severe (Grade 3) sprain, providers should consider a short period (10 days) of rigid immobilization (such as a cast or boot) followed by semi-rigid bracing as the patient engages in rehabilitation.^25,33 Crutches may be needed for protected weight bearing, but long-term use should be discouraged in the absence of fracture or other bony injury.
• Rehabilitation:
  Strategies are intended to stabilize or optimize function and prepare for potential interventions at later disease stages.Functional rehabilitation should be stressed. Patients are typically instructed in “alphabet exercises” to maintain ROM and resistance band exercises for strengthening. Dorsiflexion and eversion strengthening should be stressed for lateral ankle sprains. Static stretching as a standard component of a rehabilitation program was shown to yield the greatest effects on restoring dorsiflexion after ankle sprains.Implementation of neuromuscular training within the first week of injury results in higher overall activity levels without increasing pain, swelling, or the rate of reinjury when compared with traditional RICE therapy.²⁹ In addition, proprioceptive exercises improve ankle outcome measures, such as the Functional Ankle Disability Index and Excursion Balance Test.³⁴
• Return-to-Play:
  An athlete may return to play when full, painless range of motion and full strength is attained. A gradual return to sport-specific activities should occur without recurrence of symptoms.Though full ligament healing takes place over a period of 6 to 12 weeks, 15 observational studies show that 90% of high school athletes return to play within 1 week of initial or recurrent ankle sprain.³⁵

Subacute to Chronic/Stable

• Secondary prevention and disease management strategies:
  Continuation of proprioceptive and neuromuscular training exercises, as well as balance training and ROM is critical, as chronic pain may result from incomplete rehabilitation. Surgical intervention for uncomplicated lateral ankle sprains without associated fracture or syndesmotic injury is reserved for cases with persistent symptoms or instability despite conservative care.The modified Broström procedure can directly repair injured lateral ligaments and reinforce the extensor retinaculum.This can be done along with ankle arthroscopy to assess for concomitant intra-articular pathology.³⁷
• Symptom Management:
  Control of pain and edema can continue with oral or topical anti-inflammatories as well as cryotherapy. This includes the rehabilitation strategies previously discussed that intend to optimize function and reduce risk of symptom recurrence.
• Immobilization:
  Functional bracing can help to reduce pain and swelling in subacute and chronic phases.This can include elastic bandages, tape, lace-up ankle supports, or semi-rigid ankle supports. Semi-rigid ankle supports (e.g., stirrup braces) are often used to permit flexion and extension while minimizing inversion and eversion stress on injured ligaments. Studies have shown a semi-rigid brace is preferred over an elastic bandage or kinesiotape (k-tape), as these have not been shown to provide enough structural support.^25,32

Pre-terminal or end of life care

• Symptom relief:
  For patients with limited mobility or cognitive deficits and a history of chronic ankle instability, a removable cast or walking boot may be necessary to maintain functional mobility.

Coordination of care

Professional athletes have contractual obligations to fulfill their team roles. Physicians may feel pressure from coaches, athletic trainers, the public, or the athlete to return to play prematurely, often resulting in re-injury. It is the physician’s role to design and ensure completion of a proper ankle rehabilitation program. For injured workers, there may be pressure from the employer to return to work. It is the physician’s job to ensure safe accommodations at work, possibly coordinating work-specific rehabilitation.Patients may also have less incentive to improve if there is pending litigation. Care should be coordinated, multidisciplinary and interdisciplinary.

• Parallel practice: Patients can continue rehabilitation while working, competing, or performing.
• Coordinated: Employers, coaches, and family may need to be involved to promote a successful outcome.
• Multidisciplinary: Athletic trainers, physical therapists, and orthotists may be utilized.
• Interdisciplinary: Orthopedic surgeons or podiatrists can be consulted in refractory cases.

Patient & family education

It is important to educate patients about their injury, encourage early mobility, review the home exercise program, and discuss balance training. The patient should be well-versed in proprioceptive and sports-specific programs. The role of the family is often pivotal in encouraging adherence to home exercises.

Impairment-based measurement

Time off from work or performance in athletics can be used to estimate severity of symptoms or to chart treatment outcomes.

Measurement of patient outcomes

Outcome measures for research purposes include the Foot and Ankle Outcome Score (FAOS), Functional Ankle Disability Index, Excursion Balance Test, Karlsson’s scale, return to work or sport, or the more generalized SF-36 or PROMIS scales. The visual analogue scores (VAS) are often used to track pain.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Often, disagreements exist among clinicians about how aggressively to treat ankle sprains, or when to transition the patient from ice and rest to the mobilization and rehabilitation phases of treatment. After injury, use of the Ottawa Ankle Rules delineates the need for radiographs to assess for possible ankle fracture.RICE therapy, electrical stimulation, and pain control with NSAIDs or acetaminophen, do not accelerate recovery but can improve pain control in the short term. Regarding rehabilitation, early mobilization including neuromuscular and proprioceptive training, as well as a focus on strength, coordination, and function, is preferred to accelerate return to play and reduce risk of recurrence in athletes with ankle sprains. For chronic instability, functional, non-rigid bracing can reduce the risk of recurrent injury.

Cutting Edge/Emerging and Unique Concepts and Practice

Emerging/unique interventions

There may be a role for regenerative therapy for torn ligaments, such as prolotherapy, platelet-rich plasma (PRP), bone marrow aspirates, or lipoaspirates. However, the effectiveness of these treatments is not yet fully proven as the current literature includes small size and low powered studies.

A 2020 journal article in Foot and Ankle surgery compared PRP to the ATFL to standard care for 21 patients with grade 2 lateral ankle sprains after a 10 day period of immobilization. There was initial improvement in the PRP group at 8 weeks, but no statistically significant difference between the groups at 24 weeks, suggesting possible benefit in the short term.³⁸

A randomized controlled trial by Laver et al. compared standard rehabilitation to rehabilitation plus a one-time ultrasound-guided PRP injection to the AITFL and tibiofibular joint in 16 athletes with high ankle sprain and found faster return-to-play and lower pain scores in their intervention group.³⁹

A 2021 paper by Paget et al showed that intra-articular PRP injections for 100 patients with ankle osteoarthritis, compared with placebo, did not significantly improve ankle symptoms and function over 26 weeks.⁴¹

A cohort study of 10 rugby players with syndesmosis injuries were given one PRP injection into the AITFL followed by a standardized rehab protocol. These patients were compared to 11 historical athletes with similar injuries treated with the same rehab protocol. Time to return to play and fear avoidance was lower in the interventional group. Additionally, the intervention group saw higher agility and vertical jump than the control.⁴²

There is a double-blind, randomized, placebo-controlled study evaluating the use of ultrasound guided PRP for 33 patients with acute ankle sprains in the emergency department. Results showed no difference in VAS or lower extremity functional scale (LEFS) after 8 days and again after 30 days.⁴⁰

Dextrose prolotherapy may also offer some benefit in the treatment of chronic ankle ligamentous injuries. One small study demonstrated a significant decrease in VAS at 6 months follow-up in patients with chronic ankle ligament injury who were treated with two injections of dextrose 12.5% in one month. Further research is needed to evaluate the efficacy of prolotherapy for chronic ankle sprains and to identify patients who would be most likely to benefit from this treatment.⁴³

Gaps in the Evidence-Based Knowledge

Evidence on the role of surgery for chronic ankle instability is conflicting. Kerkhoffs et al. found similar functional and subjective symptom outcomes when comparing surgical intervention versus conservative management of lateral ligament complex ankle injuries.¹⁷ Evidence on regenerative therapies to improve ligament healing is still incomplete and currently not standard of care. Additionally, there is no strong evidence supporting or discouraging the use of alternative treatment modalities, such as acupuncture, therapeutic ultrasound, electric stimulation, laser therapy, and shortwave therapy. More studies are needed to evaluate the indications and efficacies of these therapies.²⁵

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Original Version of the Topic

Jonathan Kirschner, MD. Ankle Sprain. 11/4/2012.

Previous Revision(s) of the Topic

Jonathan Kirschner, MD. Ankle Sprain. 8/23/2016.

Jonathan Kirschner, MD, Roderick Geer, MD. Ankle Sprain. 4/15/2021

Author Disclosure

Sara Flores, MD
Nothing to Disclose

Ayana Taylor, MD
Nothing to Disclose

Merideth Byl, DO MBA
Nothing to Disclose

Jennifer Tram, MD
Nothing to Disclose