Original Editor - Dale Boren, Michael Kauffmann, Pieter Jacobs as part of the Vrije Universiteit Brussel Evidence-Based Practice Project
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Definition/Description[edit | edit source]
An ankle sprain is where one or more of the ligaments of the ankle are partially or completely torn.
Epidemiology[edit | edit source]
An ankle sprain is a common injury. Inversion-type, lateral ligament injuries represent approximately 85% of all ankle sprains. The incidence of ankle sprain is highest in sports populations. Poor rehabilitation after an initial sprain increases the chances of this injury recurrence.
The ankle joint is the body part that is second most likely to be injured in sport.  In the United States of America the total cost of ankle sprains is approximately $2billion . A meta-analysis by Doherty et al, found that indoor sports carry the greatest risk of ankle sprain with an incidence of 7 per 1,000 cumulative exposures. Severe ankle sprains occur commonly in basketball players. From a study of elite Australian basketball players, McKay et al (2001), reported that the rate of ankle injury was 3.85 per 1000 participations . Recurrence rates amongst basketball players is reported to be greater than 70%. Athletes with chronic ankle instability miss practices and competition, require ongoing care in order to remain physically active, and display sub-optimal performance.
Clinically Relevant Anatomy[edit | edit source]
Of the lateral ankle ligament complex the most frequently damaged one is the anterior talofibular ligament (ATFL). Their anatomical location and the mechanism of sprain injury mean that the calcaneo-fibular (CFL) and posterior talofibular ligaments (PTFL) are less likely to sustain damaging loads.
On the medial side the strong, deltoid ligament complex [posterior tibiotalar (PTTL), tibiocalcaneal (TCL), tibionavicular (TNL) and anterior tibiotalar ligaments (ATTL)] is injured with forceful "pronation and rotation movements of the hindfoot".
The stabilising ligaments of the distal tibio-fibular syndesmosis are the anterior-inferior, posterior-inferior, and transverse tibio-fibular ligaments, the interosseous membrane and ligament, and the inferior transverse ligament. A syndesmotic (high ankle) sprain occurs with combined external rotation of the leg and dorsiflexion of the ankle.
Risk Factors[edit | edit source]
Several intrinsic and extrinsic risk factors predispose an athlete to chronic ankle instability. The most common risk factor is previous history of sprain. A previous sprain may compromise the strength and integrity of the stabilisers and interrupt sensory nerve fibres. Sex, height, weight, limb dominance, postural sway and foot anatomy are intrinsic. Extrinsic risk factors may include taping, bracing, shoe type, competition duration and intensity of activity.
Mechanism of Injury/Pathological Process[edit | edit source]
Lateral ankle sprains usually occur during a rapid shift of body center of mass over the landing or weight-bearing foot. The ankle rolls outward, whilst the foot turns inward causing the lateral ligament to stretch and tear. When a ligament tears or is overstretched its previous elasticity and resilience rarely returns. Some researchers have described situations where return to play is allowed too early, compromising sufficient ligamentous repair. Reports have proposed that the greater the level of plantar flexion the higher the likelihood of sprain Yeung et al, 1994, in an epidemiological study of unilateral ankle sprains, reported that the dominant leg is 2.4 times more vulnerable to sprain than the non-dominant one.  . A less common mechanism of injury involves forceful eversion movement at the ankle injuring the strong deltoid ligament.
|Aspect||Mechanism of injury||Ligaments|
|Lateral||Inversion and plantarflexion||anterior talofibular ligament|
posterior talofibular ligament
|Medial||Eversion||posterior tibiotalar ligament|
anterior tibiotalar ligament
|High||External rotation and dorsiflextion||anterior-inferior tibiofibular ligament|
posterior-inferior tibiofibular ligamen
transverse tibiofibular ligament
inferior transverse ligament
Clinical Presentation[edit | edit source]
- 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[edit | edit source]
Additional differential diagnosis to look out for:
- Tarsal Tunnel Syndrome
- Sinus Tarsi Syndrome
- Cartilage or osteochondral injuries
- Peroneal Tendinopathy or subluxation
- Posterior Tibial Tendon Dysfunction
Classification Grading Systems[edit | edit source]
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[edit | edit source]
- Lower Extremity Functional Scale (LEFS)
- Foot and Ankle Ability Measure (FAAM)
- Foot and Ankle Disability Index (FADI)
Clinical Examination[edit | edit source]
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[edit | edit source]
- 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[edit | edit source]
Mild Ankle Sprain[edit | edit source]
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[edit | edit source]
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 
- Inflammatory phase,
- Proliferative phase,
- Early Remodelling,
- Late Maturation and Remodelling. 
Inflammatory Phase (0-3 days)[edit | edit source]
Goals:[edit | edit source]
Reduction of pain and swelling and improve circulation and partial foot support
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
Despite its widespread clinical use, the precise physiologic responses to ice application have not been fully elucidated. Moreover, the rationales for its use at different stages of recovery are quite distinct. There is insufficient evidence available from RCTs to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults. But no evidence exist to reject the RICE protocol. 
Foot and Ankle ROM:
- Patient performs active movements with the toes and ankle within pain free limits to improve local circulation. 
- Manual therapy in the acute phase could also effectively increase ankle dorsiflexion. 
- Anteroposterior manipulation and RICE results in greater improvement in range of movement than the application of RICE alone. 
Proliferative Phase (4-10 days)[edit | edit source]
Goals:[edit | edit source]
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
It is important to begin early with the rehabilitation of the ankle. First week exercises produce significant improvements to short term ankle function.
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.(level of evidence 2b)
- 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)[edit | edit source]
Goals: [edit | edit source]
Improve muscle strength, active (functional) stability, foot/ankle motion, mobility (walking, walking stairs, running).
- 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.
- 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[edit | edit source]
Goals:[edit | edit source]
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
Return to Activities after Ankle Sprain[edit | edit source]
It is often thought that ankle sprain is a harmless injury, but we have previously seen that it can be the cause of subsequent pathologies such as osteoarthritis or chronic ankle instability.
Some protocols and standardizations for Return To Sport have been used for situations such as post- LCA operation or hamstring injury, but still remains unknown to many subjects. Evidence-based medicine is missing, particularly related to foot injuries and ankle, to assist in the decision to allow an athlete to RTS. Thanks to a recent systematic review by Tessigol et al. we know that there are currently no published evidence-based criteria to inform RTS decisions for patients with an LAS injury. 
Even if the literature doesn't help us have the usual bases on a return to sport after ankle sprain, it doesn't mean that athletes are not to be tested.
Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence
Richard Seah 1, Sivanadian Mani-Babu
PMID: 20710025 DOI: 10.1093/bmb/ldq028
To summarize the best available evidence in the last decade for managing ankle sprains in the community, data were collected using MEDLINE database from January 2000 to December 2009. Terms utilized: 'ankle injury primary care' (102 articles were found), 'ankle sprain primary care' (34 articles), 'ankle guidelines primary care' (25 articles), 'ankle pathways primary care' (2 articles), 'ankle sprain community' (18 articles), 'ankle sprain general practice' (22 articles), 'Cochrane review ankle' (58 articles). Of these, only 33 satisfied the inclusion criteria. The search terms identified many of the same studies. Two independent reviewers reviewed the articles. The study results and generated conclusions were extracted, discussed and finally agreed on. Ankle sprains occur commonly but their management is not always readily agreed. The Ottawa Ankle Rules are ubiquitous in the clinical pathway and can be reliably applied by emergency care physicians, primary care physicians and triage nurses. For mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. For severe ankle sprains, a short period of immobilization in a below-knee cast or pneumatic brace results in a quicker recovery than tubular compression bandage alone. Lace-up supports are a more effective functional treatment than elastic bandaging and result in less persistent swelling in the short term when compared with semi-rigid ankle supports, elastic bandaging and tape. Semi-rigid orthoses and pneumatic braces provide beneficial ankle support and may prevent subsequent sprains during high-risk sporting activity. Supervised rehabilitation training in combination with conventional treatment for acute lateral ankle sprains can be beneficial, although some of the studies reviewed gave conflicting outcomes. Therapeutic hyaluronic acid injections in the ankle are a relatively novel non-surgical treatment but may have a role in expediting return to sport after ankle sprain. There is a role for surgical intervention in severe acute and chronic ankle injuries, but the evidence is limited.
References:Gribble PA, Bleakley CM, Caulfield BM, et al. . Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med. 2016;50:1496–505. - PubMed[edit | edit source]
Fong DT, Hong Y, Chan L-K, et al. . A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007;37:73–94. - PubMed[edit | edit source]
Golditz T, Steib S, Pfeifer K, et al. . Functional ankle instability as a risk factor for osteoarthritis: using T2-mapping to analyze early cartilage degeneration in the ankle joint of young athletes. Osteoarthritis Cartilage. 2014;22:1377–85. - PubMed[edit | edit source]
Waterman BR, Owens BD, Davey S, et al. . The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92:2279–84. - PubMed[edit | edit source]
Richie DH. Functional instability of the ankle and the role of neuromuscular control: a comprehensive review. J Foot Ankle Surg. 2001;40:240–51. - PubMed[edit | edit source]
Tests and Criteria[edit | edit source]
- Ankle Mobility: knee to wall test
- Lower Limb Strength: A typical load level during a single leg vertical jump landing is approximately 1.5 your own weight corporeal ; in fact, in order to perform certain dynamic activities, it would be advisable to have capacity to generate force (and absorption) equal to 1.5 times its own body weight. Lee Herrington et al. following the data previously exposed, they introduced the ability to perform 10 reps of single leg press (1.5 times of body weight) as a criterion for return to run after a cruciate ligament injury. While it is not proven for ankle sprain, it can be of great help in returning an athlete to running.
- Static Balance Test: Y balance test
- Dynamic Balance Test: LESS or HOP Test
- Agility Test: Illinois Test, T-test or some sport specific agility test.
Chronic Ankle Instability[edit | edit source]
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.
Chronic ankle instability has been describes as a combination of mechanical (pathological laxity, arthrokinematic restrictions, and degenerative and synovial changes) and functional (Impaired proprioception and neuromuscular control, and strength deficits) insufficiencies. A sound treatment program must adhere to both mechanical and functional insufficiencies.
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.
Ankle Bracing and Taping[edit | edit source]
Ankle Bracing and taping is often used as a preventative measure which has gained increasing research. Ankle taping may be used to help stabilise the joint by limiting motion and proprioception. Ankle taping is said to have a greater effect in preventing recurrent strains rather than an initial sprain. A study on basketball players detailed the effectiveness of ankle taping on reducing the risk of re-injury in athletes who have a history of ankle-ligament sprains. The large sample size of the study (n=10,393) and identification of 40 ankle injuries adds reliability to the results expressed. Tropp et al, 1985, undertook a study in soccer players who wore an ankle brace. The subjects in the brace group experienced a significant decrease in the incidence of ankle sprains when compared to no intervention. Surve et al, 1994, described similar effects in their prospective study with bracing but noted there was no difference in the ankle sprain severity in the braced and unbraced groups.
Reports are inconclusive on the effective of ankle taping. Several reports have suggested the ineffectiveness of taping. It’s effectiveness is also affected by the experience of the taper. Some of the advantages of bracing over taping are; cost, reusability, no expertise is required for application and minimal effect of an allergic reaction.
Resources[edit | edit source]
- 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
References[edit | edit source]
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