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 with inversion ankle sprains being the most common, making up 85% of all injuries. Incidence of lateral ligament injuries is 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) on the lateral aspect of the ankle. Additional ligaments on the lateral aspect 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 combined external rotation and dorsiflexion. It involves the Distal Tibiofibular Syndesmosis and may injure numerous structures, such as the anterior-inferior tibiofibular ligament, posterior-inferior tibiofibular ligament, transverse tibiofibular ligament, interosseous membrane, interosseous ligament and inferior transverse ligament.

Mechanism of injury/pathological process

A lateral or inversion ankle sprain 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 injuring 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

• Patient presents with inversion injury or forceful eversion injury to the ankle. May have previous history of ankle injuries or instability.
• Able to partial weight-bear only on the affected side.
• 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 with inversion should replicate symptoms for a lateral ligament sprain. Passive eversion should replicate symptoms for a medial ligament sprain.
• Special Tests: +ve Anterior Draw, Talar Tilt or Squeeze Test (depending on the structures involved)

Differential Diagnosis

The Ottawa Ankle Clinical Prediction Rules are 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 psteochondral injuries
• Peroneal Tendinopathy or subluxation
• Posterior Tibial Tendon Dysfunction

Classification grading systems

There are numerous grading systems used for the classification of ligament sprains, each having their strengths and weaknesses. Different therapists may employ different systems so effective continuity of care, the patient should see the same therapist each time. Authors do not always disclose which system they used, reducing rigour and quality of some research. 

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

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

As there are ankle multiple ligaments across the joint it may not be always straight forward to use a grading system that is designed for describing the state of a single ligament unless it is certain that only a single ligament is injured.

Some authors have therefore resorted to grading lateral ankle ligament sprains by the number of ligaments injured. It is, however, 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.

• Grade I Mild - Little swelling and tenderness with little impact on function
• Grade II Moderate - Moderate swelling, pain and impact on function. Reduced proprioception, ROM and instability
• Grade III Severe - Complete rupture, large swelling, high 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 assessed and treated by surgical intervention.

Outcome Measures

Lower Extremity Functional Scale (LEFS)

Clinical Examination

With an ankle sprain multiple structures may be involved, therefore a full foot and ankle assessment is recommended, including the mechanism of injury, observation of the patient's gait pattern, standing posture and wear on the individual's shoes. Any gross deformity, mal-alignment or atrophy of the musculature should also be observed and noted as well as any oedema and/or ecchymosis.

Palpation is used to feel for the structures that may be involved in the injury, including bone, muscle and ligamentous structures, followed by an active and passive range of movement assessment.

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 is recommended that these tests be performed at 4-7 days post acute injury to allow the initial swelling and pain to settle, enabling the therapist to gain a more accurate diagnosis. 

Physical Therapy Management

Mild ankle sprain

• Natural full recovery within 14 days
• Taping and follow up to evaluate healing progression

First time lateral ligament sprains can be innocuous injuries that resolve quickly with minimal intervention and some approaches suggest that only minimal intervention is necessary. 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, this approach has been questioned.

Severe Ankle Sprain

Physiotherapy is required with functional therapy of the ankle shown to be more efficient than immobilisation. Functional therapy treatment can be divided in 4 stages, moving onto to the next stage as tissue healing allows

1. Inflammatory phase,
2. Proliferative phase, 
3. Early Remodelling,
4. Late Maturation and Remodelling.

Inflammatory Phase (0-3 days)

Goals:

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

The most common approach to manage ankle sprain is the PRICE protocol: Protection, Rest, Ice, Compression, and Elevation

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 as a minimum, avoid positions where the ankle is in a dependent position relative to the body

Foot and Ankle ROM:

• Patient performs active movements with the toes and ankle within pain free limits to improve local circulation.

Proliferative Phase (4-10 days)

Goals:

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

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 has decreased.
• Tape or a brace use depends on patient preference
• Boyce et al 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.
• It remains uncertain, however, which treatment (brace, bandage or tape) is most beneficial.
  

Two examples of ankle sprain taping techniques, but there are many other different techniques.

Early Remodelling (11 -21 days)

Goals: 

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

Education:

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

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 loa -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.

Taping/bracing

• Advise wearing tape or a brace during physical activities until the patient is able to confidently perform static and dynamic balance and motor coordination exercises.

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.

Practise and adjust foot abilities (functions and activities)

• Practise motor coordination skills while performing 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 self-reported function as quantified using the Foot and Ankle Ability Measure can be utilised 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 stabilising lower leg muscles, deficits in lower leg muscle strength, deficits in kinaesthesia or impaired postural control.

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

Resources

• The Sprained Ankle from the 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

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