Ankle Sprain

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Definition/Description

An ankle sprain is where one or more of the ligaments of the ankle are partially or completely torn.

Epideimiology

An ankle sprain is a common injury. Inversion ankle sprains are the most common, making up 85% of all ankle sprains. It is know that the incidence of lateral ligament injuries is the most common amongst the sporting population and the consequence of not rehabilitating after an initial injury increases the chances of recurrence. 

Clinically Relevant Anatomy

The most commonly torn ankle ligament is the anterior talofibular ligament (ATFL) which is on the lateral aspect of the ankle. Additional ligaments on the lateral aspect of the ankle include the calcaneo-fibular ligament (CFL) and the posterior talofibular ligament (PTFL).

Ankle Complex

On the medial side of the ankle the strong deltoid ligament complex which consists of the posterior tibiotalar ligament, tibiocalcaneal ligament, tibionavicular ligament and anterior tibiotalar ligament may be injured with forceful eversion.

A syndesmotic (high ankle) sprain may occur with external rotation with dorsiflexion. It involves the Distal Tibiofibular Syndesmosis and may injure the anterior-inferior tibiofibular ligament, posterior-inferior tibiofibular ligament, transverse tibiofibular ligament, interosseous membrane, interosseous ligament, inferior transverse ligament.

Mechanism of Injury / Pathological Process

The most common mechanism of injury for an ankle sprain is an inversion injury commonly called a lateral or inversion ankle sprain.  This is when the foot is forced into a combined movement of plantarflexion and inversion, which applies too much force to the lateral structures of the ankle; causing them to fail. A less common mechanism of injury involves a forceful eversion movement at the ankle, resulting in injury to the strong deltoid ligament.  

Aspect	Mechanism of injury	Ligaments
Lateral	Inversion and plantarflexion	anterior talofibular ligament calcaneo-fibular ligament posterior talofibular ligament
Medial	Eversion	posterior tibiotalar ligament tibiocalcaneal ligament tibionavicular ligament anterior tibiotalar ligament
High	External rotation and dorsiflextion	anterior-inferior tibiofibular ligament posterior-inferior tibiofibular ligamen transverse tibiofibular ligament interosseous membrane interosseous ligament inferior transverse ligament

Clinical Presentation

• Presents with history of inversion injury or forceful eversion injury to the ankle. May have previous history of ankle injuries or instability.
  
• Able to weight-bear through the limb.
  
• If patient presents with description of cold foot or paraesthesia, suspect neurovascular compromise of peroneal nerve.
  
• Tenderness, swelling and bruising can occur on either side of the ankle.
  
• No bony tenderness, deformity or crepitus present.
  
• Passive inversion or plantar flexion + inversion should replicate symptoms for a lateral ligamnet sprain, passive eversion should replicate symproms for a medial ligamnet sprain.
  
• Special Tests: +ve Anterior Draw, Talar Tilt or Squeeze Test (depending structures involved).
  

Differential Diagnosis

The Ottawa Ankle Clinical Prediction Rules constitute an accurate tool to exclude fractures within the first week after an ankle injury.

Additional differential diagnosis to look out for:

• Impingement
  
• Tarsal Tunnel Syndrome
• Sinus Tarsi Syndrome
• Cartilage or Osteochondral Injuries
  
• Peroneal Tendinopathy or subluxation
  
• Posterior Tibial Tendon Dysfunction

Classification Grading Systems

There are a number of different grading systems used for the classification of ligament sprains each have strengths and weaknesses. One important consideration is that each therapists will employ different systems so it is important to be aware of a wide variety for continuity of care. This is evident when reading research regarding sprains and authors not disclosing which system they used, reducing rigour and quality of the write up of research. 

The traditional grading system for ligament injuries focuses on a single ligament

1. Grade I injury represents a microscopic injury without stretching of the ligament on a macroscopic level.
2. Grade II injury has macroscopic stretching, but the ligament remains intact.
3. Grade III injury is a complete rupture of the ligament.

As all ready discussed in ligaments of the ankle the ankle has several complexes of multiple ligaments so it may be difficult and inappropriate to use a system that is suited for the description of the state of a single ligament unless it can be sure only one ligament it torn.

Some authors have thus resorted to grading lateral ankle-ligament sprains by the number of ligaments injured. Again it is hard to be certain on the number of ligaments torn unless there is clear, high quality radiographic or surgical evidence.

A third system which can be adopted is a 3 graded classification based on the severity of sprain injury. 

1. Grade I - Mild - Little swelling & tenderness with little impact on function 
2. Grade II - Moderate - Moderate swelling, pain and impact on function. Reduced proprioception, ROM and instability
3. Grade III - Severe - Complete rupture, large swelling, tenderness⁺⁺⁺, Loss of function and marked instability

This scale is largely subjective due to individual therapist interpretation. However the same can be said for the other classifications unless clear radiographic evidence is available or assessment and treatment by surgical intervention. In this case the assessment will be post-treatment.

Outcome Measures

Lower Extremity Functional Scale (LEFS)

For other outcome measures see: Outcome Measures Database

Clinical Examination

In the case of an ankle sprain  multiple structures may be involved therefore a full foot and ankle assessment is recommended.

The therapist should begin by taking a thorough subjective history to gain an understanding of the mechanism of injury. The therapist should observe gait pattern, standing posture and the position of wear on the individuals shoes. The assessor should observe for any gross deformity, malalignment or atrophy of the musculature. Any oedema and ecchymosis should be noted.

The foot, ankle and lower leg should be palpated to feel the structures that may be involved in the injury (including bone, muscle and ligamentous structures). Following which, active and passive range of movement should be assessed.

Special Tests

• Anterior Draw - tests the ATFL
• Talar Tilt - tests the CFL
  
• Posterior Draw - tests the PTFL
• Squeeze test - for syndesmotic sprain  
• External rotation stress test (Kleiger’s test) - syndesmotic sprain

It has been suggested that these tests be performed at 4-7 days post acute injury to allow the initial swelling and pain to settle, this enable the clinician to gain a more accurate diagnosis. 

Physical Therapy Management

Mild Ankle Sprain

• Natural full recovery within 14 days
• Taping and making an appointment for a check-up to evaluate the healing of the ankle sprain

First time lateral ligament sprains can be innocuous injuries that resolve quickly with minimal intervention and some approaches suggest that minimal intervention can be given to this population. The NICE guidelines 2016 recommend advice and analgesia, but not routine physiotherapy referrals. However it has has also been highlighted that recurrence rate of first time lateral ankle sprains is 70%. With the recurrence rate so high and the guidelines not recommending any rehabilitation others have questioned this approach.

Severe Ankle Sprain

Physiotherapy is required. Functional therapy of the ankle is shown to be more efficient than immobilisation. Functional therapy treatment will be divided in four steps, related to the four steps in the tissue recovery after an acute ankle sprain, Inflammatory phase, Proliferative phase,  Early Remodelling, Late Maturation and Remodelling.

Step 1: Inflammatory Phase (0-3 days)

Goals:

Reduction of pain and swelling and improve circulation and partial foot support

Actions:

The most common approach to manage ankle sprain consists of Protection, Rest, Ice, Compression, and Elevation (PRICE)

1. Recommendations for the Patient:

• PROTECTION: Protect the ankle from further injury by resting and avoiding activities that may cause further injury and/or pain

• REST: Advise rest for the first 24 hours after injury, possibly with crutches to offload the injured ankle and altering work and sport and exercise requirements as needed

• ICE: Apply a cold application (15 to 20 minutes, one to three times per day)

• COMPRESSION: Apply compression bandage to control swelling caused by the ankle sprain

• ELEVATION: Ideally elevate ankle above the level of the heart but minimally avoid positions where the ankle is in a dependent position relative to the body

2. Practice Foot and Ankle Functions:

• Ask your patient to move toes and ankle within pain-free limits to improve local circulation.

Step 2: Proliferative Phase (4-10 days)

Goals:

Recovery of foot and ankle function and improved load-carrying capacity.

Actions:

1. Patient education regarding gradual increase in activity level, guided by symptoms.

2. Practise Foot and Ankle Functions

• Range of Motion
• Active Stability 
• Motor Coordination

3. Tape/Brace :

• Apply tape as soon as the swelling is decreased.
• Whether you use a tape or a brace depends on the preferences of the patient.
• Boyce et al (2005) found that the use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function compared with standard management with an elastic support bandage.
• Still it remains uncertain which treatment (brace, bandage or tape) is most beneficial.
  

Here are two examples of ankle sprain taping techniques but please note that many different techniques exist.

Step 3: Early Remodelling (11 -21 days)

Goals: 

Improve muscle strength, active (functional) stability, foot/ankle motion, mobility (walking, walking stairs, running).

Actions:

1. Education:

• Provide information about possible preventive measures (tape or brace)
• Advise regarding appropriate shoes to wear during sport activities - judge the quality of the shoes in relation to the type of sport and surface

2. Practise Foot and Ankle Functions (See Resource Videos below)

• Practice balance, muscle strength, ankle/foot motion and mobility (walking, stairs, running).
• Look for a symmetric walk pattern.
• Work on dynamic stability as soon as load-bearing capacity allows, focusing on balance and coordination exercises. Gradually progress the loading, from static to dynamic exercises, from partially loaded to fully loaded exercises and from simple to functional multi-tasking exercises. Alternate cycled with non-cycled exercises (abrupt, irregular exercises). Use different types of surfaces to increase the level of difficulty.
  
• Encourage the patient to continue practicing the functional activities at home with precise instructions regarding the expectations for each exercise.

3. Bandage

• Advise to wear tape or brace during physical activities. These procedures are needed until the patient is able to execute correctly the static and dynamic exercises of balance and motor coordination.

Step 4: Late Remodelling and Maturation

Goals:

Improve the regional load-carrying capacity, walking skills and improve the skills needed during activities of daily living as well as work and sports.

Actions:

1. Practise and Adjust Foot Abilities (Functions and Activities)

• Practise motor coordination skills while practising mobility exercises
• Continue to progress the load-bearing capacity as described above until the pre-injury load-carrying capacity is reached
• Increase the complexity of motor coordination exercises in varied situations until the pre-injury level is reached
• Encourage the patient to continue practicing at home
  

Chronic Ankle Instability

On going issues following a lateral ligament injury within the ankle are reported in 19-72% of patients.  An ability to complete certain movement tasks, evidence of deficits during the Star Excursion Balance Test and poorer self-reported function as quantified using the Foot and Ankle Ability Measure can be utilized as predictive measures of a Chronic Ankle Instability (CAI) outcome in the clinical setting for patients with a first-time lateral ankle sprain injury. Around 20% of people develop CAI and this has been attributed to a delayed muscle reflex of stabilizing lower leg muscles, deficits in lower leg muscle strength, deficits in kinaesthesia, or an impaired postural control.

It is recommended that all patients undergo conservative treatment to improve stability and improve the muscle reflex and strength of those stabilising lower limb muscles. Although this may help some people cannot compensate for defecit of the lateral ligament complex, and therefore surgery is required.

Read more about Chronic Ankle Instability here

Resources

• The Sprained Ankle from Connecticut Centre for Orthopedic Surgery contains a range of resources on Ankle Sprains including patient resources and surgical techniques.

Coordinated Health TV Ankle Sprain Video Series

Denver-Vail Orthopedics, P.C Ankle Sprain Video Series

Recent Related Research (from Pubmed)

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Presentations

Physical Therapy Management of Acute Ankle Sprain This presentation was created by Rich Westrick and Cody McAndrew as part of the Regis University OMPT Fellowship. Physical Therapy Management of Acute Ankle Sprain/ View the presentation

PT in Injury Prevention: Ankle Sprains This presentation was created by Sumesh Thomas as part of the Regis University OMPT Fellowship. PT in Injury Prevention: Ankle Sprains/ View the presentation

Current Best Evidence: Management of Chronic Ankle Sprain This presentation was created by Cheryl Sparks as part of the Regis University OMPT Fellowship. Current Best Evidence: Management of Chronic Ankle Sprain/ View the presentation

Current Best Evidence: Management of Chronic Ankle Sprain This presentation was created by Chris Kramer as part of the Regis University OMPT Fellowship. Current Best Evidence: Management of Chronic Ankle Sprain/ View the presentation