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Lateral Ligament Injury of the Ankle

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Introduction

Lateral ligament injuries are one of the most common sports-related injuries seen by physiotherapists. Lateral ankle sprains are thought to be sustained by men and women at approximately the same rates;[1] however, it is suggested that female interscholastic and intercollegiate basketball players have a 25% greater risk of incurring grade I ankle sprains than their male counterparts.[2] More than 23, 000 ankle sprains have been estimated to occur per day in the United States, which equates to one sprain per 10, 000 people daily.[1]

Lateral ankle sprains are referred to as inversion ankle sprains or as supination ankle sprains. Ankle sprains are usually a result of a forced plantar flexion/inversion movement, with the complex of ligaments on the lateral side of the ankle is torn by varying degrees. Although the ankle sprain is a relatively benign injury, inadequate rehabilitation can lead to residual symptoms; lateral ankle sprains have been reported to affect 55% to 72% of patients at six weeks to 18 months following injury.[3] The frequency of complications and breadth of longstanding symptoms after ankle sprain have led to the suggestion of a diagnosis of the sprained ankle syndrome.[4]

Individuals who suffer numerous repetitive ankle sprains have been reported as having functional and mechanical instability and increased likelihood of re-injury.[5][6][7] Care should also be taken to avoid missing the less common causes of ankle pain, namely; small fractures around the ankle and foot (e.g. Pott's fracture) and straining or rupture of the muscles around the ankle (e.g. calf, peroneal muscles, and tibialis anterior).

Functional Anatomy

Bones

The bones that make up the ankle joint include the distal tibia and fibula (the medial and lateral malleolus, respectively) and the talus.

Joints

  1. The Ankle Complex consists of 3 articulations[8] The talocrucal (ankle joint) ( Mortise joint) is a hinge joint between the inferior surface of the tibia and the superior surface of the talus. It allows the movements of plantarflexion and dorsiflexion (sagittal plane).The talocrural joint receives ligamentous support from a joint capsule and several ligaments, including the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), calcaneofibular ligament (CFL), and deltoid ligament. The ATFL, PTFL, and CFL support the lateral aspect of the ankle.[7]. Plantarflexion is the least stable position of the ankle joint, which explains why the majority of ankle injuries occur in this position.
  2. The inferior tibiofibular joint is the articulation between the distal parts of the tibia and fibula, where a small amount of rotation (transverse plane) is possible.Injury in this joints called (high ankle sprains[7]). The joint is stabilized by a thick interosseous membrane and the anterior and posterior inferior tibiofibular ligaments.
  3. The subtalar joint is an articulation between the talus and calcaneus and allows the movements of eversion and inversion (frontal plane). It also has an important role as a shock absorber.[7] The ligamentous support of the subtalar joint is extensive, it is divided into 3 groups: (1) deep ligaments, (2) peripheral ligaments, and (3) retinacula.[9]

Ligaments

The lateral ligaments of the ankle are composed of the anterior talo-fibular ligament (ATFL), the calcaneo-fibular ligament (CFL) and the posterior talo-fibular ligament.[10]

The ATFL lies on the dorsolateral aspect of the foot. It runs from the lateral malleolus anteriorly and medially toward the talus at an angle of approximately 45° from the frontal plane. It is an average of 7.2 mm wide and 24.8 mm long. It is the most frequently injured of the lateral ligaments.

The CFL is the second most often injured of the lateral talocrural ligaments. It extends from the lateral malleolus posteriorly and inferiorly to the lateral aspect of the calcaneus at a mean angle of 133° from the long axis of the fibula. It restricts excessive supination of both the talocrural and subtalar joints.

The PTFL courses from the lateral malleolus posteriorly to the posterolateral aspect of the talus. PTFL is broad and provides restraint to both inversion and internal rotation of the loaded talocrural joint. It is the least commonly injured of the lateral ankle ligaments.

Lateral Ankle Ligaments

Muscles

The following muscles are involved in moving the ankle joint:

  1. Calf group, made up of the gastrocnemius and soleus
  2. Peroneus longus and peroneus brevis
  3. Tibialis anterior

Innervation

The motor and sensory supplies to the ankle complex stem from the lumbar and sacral plexes. The motor supply to the muscles comes from the tibial, deep peroneal, and superficial peroneal nerves. The sensory supply comes from these 3 mixed nerves and 2 sensory nerves: the sural and saphenous nerves. [11]

Risk factors

Body mass index, slow eccentric inversion strength, fast concentric plantar flexion strength, passive inversion joint position sense, and the reaction time of the peroneus brevis were associated with significantly increased risk of lateral ankle sprain.[12]

Assessment of the ankle joint

The aims of the physical examination are to determine the:

  • Amount of instability present by assessing the grade of the sprain
  • Loss of Range of motion (ROM)
  • Loss of the muscle strength
  • Level of reduced Proprioception

Observation

Observation includes general observation of the foot and ankle, noting any signs of injury, inflammation, skin colour changes, or muscle atrophy/hypertrophy.[13] Observation of the foot and ankle can also be conducted in different positions, such as non-weight-bearing (NWB) and weight-bearing (WB) positions. Particular attention should be given to the gait pattern, degree of limp (if any), facial expression during weight bearing, and any other signs that may provide more information about the injury.

History

Taking an accurate history is an important step in determining the nature of the injury. A plantarflexion/inversion injury would indicate damage to the lateral ligament, whereas a dorsiflexion/eversion injury would indicate damage to the medial ligament. Previous history of injury on the same side will give clues as to whether the ankle was unstable to begin with, or that a previous injury wasn't properly rehabilitated. History of injury on the other side as well may indicate a biomechanical predisposition towards ankle injuries.

Instability and grade of sprain

Ligament sprains can be of the following grades:

  • Grade 1 - mild, painful, minimal tearing of the ligament fibres
  • Grade 2 - moderate, painful, significant tearing of the ligament fibres
  • Grade 3 - severe, sometimes not painful, complete rupture of the fibres

Range of motion (ROM)

ROM of the ankle needs to be assessed actively and passively. The movements to be assessed are:

  • Plantarflexion and dorsiflexion
  • Inversion and eversion.

Palpation

An important aspect of the initial examination is to determine the exact site of the lateral ligament sprain, whether it's the ATFL, CFL or PTFL (usually damaged in that order). Palpating the lateral aspect of the ankle over the course of the various aspects of the ligament complex will provide detailed information on the exact location of the tear. Palpation should begin gently given the potential for significant tenderness in the acute phase.

Special tests

  • An anterior drawer is done to test the integrity of the ATFL and CFL. With the ankle in plantarflexion, the heel is grasped with the tibia stabilised and drawn anteriorly.
  • Talar tilt is done to assess the integrity of the ATFL and CFL laterally and the deltoid ligament medially. Again, the heel is grasped, the tibia stabilised and the talus and calcaneus are moved laterally and medially.
  • Proprioception can be assessed in any number of increasingly difficult ways, beginning with a simple single-leg stance. The unaffected limb should be assessed first to establish a baseline for comparison and then attempt on the injured side.
  • Star Excursion Balance Test : This test is used for assessment and treatment purpose after ankle injury.

This test can be progressed by asking the patient to reach outside their base of support (BOS), rotating their neck or by closing their eyes. Moving onto a wobble board or any other unstable surface will allow the therapist to assess the patients ability to respond to a changing surface.

Functional movements

Functional movements such as lunges and hopping should be included in the assessment.

Differential diagnosis

A differential diagnosis must be carried out to exclude the possibility of the following, less common injuries:

  • Ankle fracture (medial/lateral malleolus, distal tibia/fibular)
  • Damage to the medial ligament
  • Dislocated ankle
  • Other soft tissue damage (peroneal tendons, muscle strain)

Ottawa Ankle Rules[14] provide useful guidance on determining the presence of a fracture. Bachmann et al in the systematic review found out that evidence supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot.[15] The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30-40%.

If a patient is unable to weight-bear immediately following the injury, an X-ray is indicated because of the risk of a clinically significant ankle fracture. Failure to use the Ottawa rules to assess for ankle fracture may be significant in any legal proceedings should they occur. Even though injuries to the lateral ligament are by far more common, be aware that there may be other injuries associated with the lateral ligament injury. Missing an associated injury may hamper a return to pre-injury level of functional activity and lead to the so-called “problem ankle”.

Treatment and rehabilitation

According to Green et, al, the overall quality of the existing Lateral Ankle Ligament Sprain Clinical Practice Guidelines is poor with the majority out of date. Also, several inconsistencies in the interpretation of the evidence between the CPG development group and an absence of consistent methodology of CPGs presents a barrier to implementation.[16]

Reduce pain and swelling

Initial management within the first 48-72 hours of an acute lateral ligament injury aims to reduce pain and swelling. Current evidence supports the use of the PEACE & LOVE framework[17], which provides a structured approach to both the acute and subacute phases of recovery:

PEACE (Acute Phase - First Few Days)
  • P (Protect): Restrict movement for 1-3 days to minimise bleeding, but avoid prolonged rest to prevent tissue weakness.
  • E (Elevate): Keep the injured limb above heart level to reduce swelling and promote fluid drainage.
  • A (Avoid anti-inflammatories): Avoid anti-inflammatory medications and ice, as they can disrupt the body's natural inflammatory response and impair long-term tissue healing.
  • C (Compress): Use taping or bandages to limit swelling and haemorrhage while still allowing a full range of motion.
  • E (Educate): Educate the patient on the benefits of an active recovery approach, avoiding over-treatment, and setting realistic recovery expectations.
LOVE (Subacute Phase - After the First Few Days)
  • L (Load): Resume normal activities and apply optimal mechanical loading as soon as symptoms allow to promote tissue repair and remodelling.
  • O (Optimism): Encourage a positive mindset, as psychological factors such as fear and catastrophising can act as significant barriers to physical recovery.
  • V (Vascularisation): Perform pain-free cardiovascular exercises to increase blood flow to the injured structures and support motivation.
  • E (Exercise): Use pain as a guide to gradually progress exercises aimed at restoring mobility, strength, and proprioception.

If weight bearing (WB) is too painful, the patient can be given elbow crutches and be non-weight bearing (NWB) for 24 hours. However, it's important that at least partial weight bearing (PWB) is initiated relatively soon, together with a normal heel-toe gait pattern, as this will help to reduce pain and swelling. Gentle soft tissue massage can be performed to assist with the removal of oedema and gentle stretches, as long as this is pain free.

Restore ROM

As soon as pain allows, the patient should begin pain free active range of movement (ROM) exercises. Various studies have reported that the ankle dorsiflexion range is affected after a lateral ankle sprain.[18][19][20] Ankle dorsiflexion plays a vital role in various movements like squatting, jumping or sprinting. Decreased ankle dorsiflexion ROM leads to compensatory movement strategies that increase risk of recurrent ankle sprain. [19] A systematic review by Terada et al. stresses the importance of restoring ankle dorsiflexion for ankle rehabilitation to restore functional movements and prevent reinjury.[20]

Restore strength

Strength is a crucial parameter in terms of decreasing the risk of osteoarthritis and improving functional level in the ankle joint. Regarding the literature, there is a reported lack of strength in the eversion, inversion, and plantar flexion of the ankle joint. Additionally, both ankle sprains and CAI (chronic ankle instability) include oedema leading to muscle inhibition. By resisting joint translation through antagonistic force, eccentric muscle actions effectively enhance overall joint stability. Overall, clinical evidence suggests that improving muscle strength, patients need both open and closed chain exercises.[21]

Restore proprioception

Ankle sprains often impair joint stability, causing deficits in proprioception, balance, and kinesthesia that can persist for over a year in athletes. This compromised dynamic defence system hinders recovery and predisposes individuals to chronic ankle instability (CAI) and recurrent sprains.[22]

Return to functional activity

Patients should be assessed for the ability to do the following activities pain free:[23]

  • Twisting
  • Jumping
  • Hopping on one leg
  • Running
  • Figure of 8 running

Before returning to full functional activity the patient should have full range of pain free movement in the ankle, normal strength and normal proprioception. If returning to sports, the athlete should be encouraged to wear an ankle brace or to tape the ankle for a further 6 months to provide external support. Types of taping include a heel lock and figure of 6.

External supports

  • Strong Level A evidence recommends functional supports, such as ankle braces, for 4 to 6 weeks rather than immobilisation or elastic bandages.[24]
  • High-quality evidence strongly supports using cryotherapy exclusively during the acute phase of an ankle sprain, as it reduces pain and swelling more effectively than analgesics. Ice is of limited effectiveness during the recovery phase and should therefore be restricted to the acute phase.[24]
  • Some clinical guidelines recommend NSAIDs as a safe option for short-term pain management during the acute phase of ankle sprain.[24] The PEACE & LOVE approach advises against routine anti-inflammatory use. [17] Although they reduce pain and swelling, inhibiting the initial inflammatory phase may impair tissue healing. Clinicians need to balance short-term pain relief with optimal recovery.[24][17]
  • The use of opioids has shown a low grade of recommendation; therefore, their use is not advised in the absence of higher-quality supporting evidence.[24]
  • There is insufficient evidence to support the use of ultrasound, diathermy, electrotherapy, or laser for ankle sprains. Ultrasound offers no benefits for pain, oedema, function, or return to sport (Level D evidence). Furthermore, despite its ability to mildly reduce swelling and gait deviations, diathermy is not highly recommended as it does not improve strength or range of motion.[24]

Understanding recurrent injury and implementing to the rehabilitation process

Athletes generally return to play 16 to 24 days after a lateral ankle sprain; however, long-term sequelae and re-injuries are exceedingly common. With recurrence rates ranging from 12% to 47%, most notably in junior basketball, volleyball, and American football, many athletes subsequently develop chronic ankle instability (CAI). CAI is clinically distinguished by a vicious cycle of repeated sprains, perceived instability, and episodes of the ankle “giving way”.[5]

While progressive balance training is traditionally used to improve functional outcomes in these individuals, patients with CAI frequently develop a compensatory over-reliance on visual feedback during postural control, which can limit rehabilitation efficacy. To counteract this visual overdependence, stroboscopic training can be employed to intermittently occlude vision and create visual perturbations . By reducing continuous visual input to the central nervous system, this technique forces an adaptive up-weighting of proprioceptive signals. Consequently, integrating stroboscopic eyewear into CAI rehabilitation holds significant potential to reverse visual overdependence, optimize cortical adaptations, and ultimately enhance the effectiveness of balance training.[25]

The following video illustrates how stroboscopic glasses can be applied in practice.[26]

Summary

Lateral ankle sprains (LAS) typically driven by excessive inversion and internal rotation with or without plantarflexion are among the most common sports-related musculoskeletal injuries. Despite an average return-to-play timeline of 16 to 24 days, reinjury and long-term sequelae remain widespread. To address this, contemporary clinical guidelines stress the importance of comprehensively quantifying both mechanical and sensorimotor impairments using validated clinician- and patient-reported outcome measures. [5]

Resources

Practical applications of acute taping stabilization and therapeutic exercises for lateral ankle sprains can be accessed via supplementary video demonstrations.[27][28]



References

  1. ↑ 1.0 1.1 Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med. 2014;44(1):123–140.
  2. ↑ Hosea TM, Carey CC, Harrer MF. The gender issue: epidemiology of ankle injuries in athletes who participate in basketball. Clin Orthop Relat Res. 2000;(372):45–49.
  3. ↑ Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg. 1998;37(4):280-285.
  4. ↑ Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19(10):653-660.
  5. ↑ 5.0 5.1 5.2 Wagemans J, Bleakley C, Taeymans J, Schurz AP, Kuppens K, et al. Exercise-based rehabilitation reduces reinjury following acute lateral ankle sprain: a systematic review update with meta-analysis. PLoS One. 2022;17(2):e0262023.
  6. ↑ Freeman MA. Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint Surg Br. 1965;47(4):669-677.
  7. ↑ 7.0 7.1 7.2 7.3 Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002;37(4):364.
  8. ↑ Huson A. Joints and movements of the foot: terminology and concepts. Acta Morphol Neerl Scand. 1987;25(3):117-30.
  9. ↑ Viladot A, Lorenzo JC, Salazar J, Rodríguez A. The subtalar joint: embryology and morphology. Foot Ankle. 1984;5(2):54-66.
  10. ↑ Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of athletic training. 2002 Oct;37(4):364.
  11. ↑ Viladot A, Lorenzo JC, Salazar J, Rodríguez A. The subtalar joint: embryology and morphology. Foot Ankle. 1984;5(2):54-66.
  12. ↑ Kobayashi T, Tanaka M, Shida M. Intrinsic Risk Factors of Lateral Ankle Sprain: A Systematic Review and Meta-analysis. Sports Health. 2016 Mar-Apr;8(2):190-3.
  13. ↑ Hengeveld E, Banks K, editors. Maitland's Peripheral Manipulation: Volume 2 - The Management of Neuromusculoskeletal Disorders. 5th ed. Edinburgh: Churchill Livingstone; 2014.
  14. ↑ Kyriacou H, Mostafa AM, Davies BM, Khan WS. Principles and guidelines in the management of ankle fractures in adults. Journal of Perioperative Practice. 2021 Nov;31(11):427-34.
  15. ↑ Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417.
  16. ↑ Green T, Willson G, Martin D, Fallon K. What is the quality of clinical practice guidelines for the treatment of acute lateral ankle ligament sprains in adults? A systematic review. BMC musculoskeletal disorders. 2019 Dec 1;20(1):394.
  17. ↑ 17.0 17.1 17.2 Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020;54(2):72–73.
  18. ↑ Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. Journal of Orthopaedic & Sports Physical Therapy. 2002 Apr;32(4):166-73.
  19. ↑ 19.0 19.1 Almansoof HS, Nuhmani S, Muaidi Q. Role of ankle dorsiflexion in sports performance and injury risk: A narrative review. Electronic Journal of General Medicine. 2023 Oct 1;20(5).
  20. ↑ 20.0 20.1 Terada M, Pietrosimone BG, Gribble PA. Therapeutic interventions for increasing ankle dorsiflexion after ankle sprain: a systematic review. Journal of athletic training. 2013 Oct 1;48(5):696-709.
  21. ↑ Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, et al.National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes.J Athl Train.2013;48(4):528-545.doi: 10.4085/1062-6050-48.4.02
  22. ↑ Alshahrani A. Assessment of ankle proprioception, balance, and kinesthesia for ankle sprain: a narrative literature review. Niger J Clin Pract. 2026;29(6):600-607.
  23. ↑ Vuurberg G, Hoorntje A, Wink LM, Van Der Doelen BF, Van Den Bekerom MP, Dekker R, Van Dijk CN, Krips R, Loogman MC, Ridderikhof ML, Smithuis FF. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine. 2018 Aug 1;52(15):956-.
  24. ↑ 24.0 24.1 24.2 24.3 24.4 24.5 Ruiz-Sánchez FJ, Ruiz-Muñoz M, Martín-Martín J, Coheña-Jimenez M, Perez-Belloso AJ, Romero-Galisteo RP, et al. Management and treatment of ankle sprain according to clinical practice guidelines: a PRISMA systematic review. Medicine. 2022;101(42):e31087.
  25. ↑ Uzlaşır S, Özdıraz KY, Dağ O, Tunay VB. The effects of stroboscopic balance training on cortical activities in athletes with chronic ankle instability. Phys Ther Sport. 2021;50:50-58.
  26. ↑ Evolve Physical Therapy. 3D ankle matrix | challenge proprioception after ACL-R and ankle fracture | Senaptec strobe eyewear [Video]. YouTube; 2018 Jun 3 [cited 2026 Oct 9]. Available from: https://www.youtube.com/watch?v=xrLXRAmrvxg
  27. ↑ ePainAssist. Exercises for ankle joint ligament injury & it's recovery period [Video]. YouTube; 2017 Mar 30 [cited 2026 Oct 9]. Available from: https://www.youtube.com/watch?v=eVSC8eIP72M
  28. ↑ Gibbons J. How to treat an ankle inversion sprain - kinesiology taping to stabilise ligaments [Video]. YouTube; 2012 Mar 6 [cited 2026 Oct 9]. Available from: https://www.youtube.com/watch?v=ELsu25Gow0I
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