Management of Lateral Ankle Sprains

Original Editor - Ewa Jaraczewska based on the course by Helene Simpson
Top Contributors - Ewa Jaraczewska and Jess Bell

Introduction[edit | edit source]

There is no such thing as a simple ankle sprain.[1] This is not an injury where patients will be ready to go after couple of days.[1] Instead, lateral ankle sprains require careful assessment and management. The following are key considerations when managing lateral ankle sprains: delay the detailed assessment for a few days; understand of the mechanism of the injury; conduct a thorough assessment when the patient can participate; the patient's compliance with treatment is essential; and re-assessment is necessary when there is a lack of progress.

General Guidelines[edit | edit source]

Lateral Ankle Sprain

Before choosing a treatment intervention, clinicians should understand the basic guidelines for the management of lateral ankle sprains, which include the following:


  • Provide hands-on treatment
  • Discuss expectations and timelines
  • Expect compliance
  • Respect pain
  • Reassess when there is a lack of progress


  • Order unnecessary imaging
  • Keep the patient non-weight-bearing when unwarranted
  • Order immobilisation when unnecessary
  • Delay functional movements
  • Provide insufficient rehabilitation

Grading System[edit | edit source]

Lacerda and colleagues[2] found significant heterogeneity in the literature on classification systems for lateral ankle sprains.[2] Most systems use three levels to describe the severity of lateral ankle sprains:[1]

  1. Mild: the patient can walk with minimal swelling and pain. No ligament involvement.
  2. Moderate: the patient complains of pain when walking, limps while walking and demonstrates a moderate amount of swelling, haematoma, and pain on palpation of ligaments. Single ligament involvement.
  3. Severe: the patient cannot walk, pain is present with daily activities, there is a large amount of swelling, and pain on palpation. Two or more ligaments are involved.

Another grading system for lateral ankle sprains uses grades 1 through 3:

  • Grade 1: little or no haemorrhage, no point tenderness, no loss of function, decreased total ankle motion by ≤ 5 degrees, presence of swelling ≥ 0.5 cm.
  • Grade 2: the presence of haemorrhage, point tenderness, some loss of function, decreased total ankle motion by more than 5 degrees, but less than 10 degrees, and less than 2 cm of swelling.
  • Grade 3: the presence of haemorrhage, extreme point tenderness, near total loss of function, decreased total ankle motion by ≥ 10 degrees, and ≥ 2 cm of swelling.

Management/Interventions[edit | edit source]

Despite the availability of evidence-based research studies, there are differences in how lateral ankle sprains are managed worldwide. There is, therefore, a need to develop international evidence-based clinical guidelines accepted by all medical professionals treating lateral ankle sprains.[3] According to Green et al.,[4] the majority of lateral ankle sprain protocols developed for various professions (athletic trainers, nurses and physicians, and physiotherapists) are out of date and of poor quality.[4]

Acute Phase[edit | edit source]

General Guidelines:[edit | edit source]

  • Delay full assessment for up to 14 days (4-14 days); a complete assessment earlier on is impossible to perform because the patient's participation is usually restricted by pain.[1]
  • The subjective interview should cover how many sprains the patient has had (first vs consecutive sprain(s)), pain location and severity, and the mechanism of injury. The mechanism of injury helps to identify injured anatomical structures and prioritise the clinical assessment.[1]
  • Observation should include skin appearance, the shape of the ankle, the patient's ability to stand up and accept weight on the injured leg, and the presence of swelling.[1]

In general, sprains occur due to inversion and internal rotation regardless of sagittal plane position: plantar flexion or dorsiflexion.[1]

Examples of mechanisms of injury and types of sprains:

  • Forefoot adduction, hindfoot inversion, and tibial external rotation with the ankle in plantar flexion: one or more of the lateral ligaments can be involved. Usually affects the anterior talofibular ligament first, followed by the calcaneofibular ligament and posterior talofibular ligament.[5]
  • External rotation of the foot and/or extreme ankle dorsiflexion: injury to the distal tibiofibular syndesmosis (high-ankle sprain).[5]
  • Pronation–abduction, pronation–external rotation, or supination–external rotation of the foot: medial-ankle sprain.[5]
  • Extreme eversion injury: impingement of the talus and lateral malleolus.[5]
  • Plantar flexion and excessive inversion: injury to the lateral forefoot region known as cuboid syndrome when the cuboid bone moves out of alignment.[5]
  • Foot planted on the ground with ankle in dorsiflexion and inversion: closed packed position can cause compressive forces on the mortise joint, and shear forces. Results in injury to the lateral collateral ligaments, and the base of fifth metatarsal. The peroneal muscles can also be involved.[1]
Grades of Ankle Sprains

The grade / level of injury to the ankle may be established based on the initial assessment, following known guidelines (grade 1 through 3).[6]

Treatment Principles[edit | edit source]

  • PRICE (1-10 days):
    • Protect: do not weight bear with walking when limping.
    • Rest (prevent further injury).
    • Ice: start within 36 hours with intermittent application three times per day (10 minutes on/10 minutes off/10 minutes on). However, with cryotherapy, Vuurberg et al.[3] found no improvement in pain at rest, function, or swelling.
    • Compression: current evidence on the effectiveness of compression is questionable.[3] However, clinicians are using bandages, taping, Tubigrip, and DVT stockings despite a lack of evidence on their effectiveness in recovery.
    • Elevation: there are no controlled trials on the efficacy of rest or elevation in managing acute ankle sprains.[5] One protocol suggests a 15-25 cm elevation above the level of the heart to enhance venous and lymphatic drainage and minimise swelling.[7]
  • Early Mobilisation: offers good outcomes when pain is respected, and the patient can walk without limping and without pain. Kerkhoffs and colleagues[8] found that early mobilisation has the following benefits: shorter time to return to sport; greater reduction in swelling; and decreased radiographic evidence of instability.[8]
CAM Walker Moon Boot
  • CAM Boot / Moon Boot or below-knee cast to protect until further assessment can be completed:[1]
    • There is good evidence for semi-rigid and lace-up braces.
    • Improve psychological confidence.
    • Cost-effective.
    • Do not affect performance.
    • Effective in reducing swelling.
    • There is no evidence that long-term use of external support causes “weakness” of lower limb musculature.

Detailed Assessment and Comprehensive Treatment Phase[edit | edit source]

The time frame for conservative management depends on the severity of the injury, and it usually lasts:[1]

  • 10 days in mild sprains
  • 2-3 weeks in moderate sprains
  • 6 weeks in severe sprains

Assessment[edit | edit source]

The assessment must include:

Lace-up Brace

General Guidelines[edit | edit source]

  • Set expectations and timelines to ensure patient compliance.[1]
  • Blend with other training if possible.[1]
  • Protect the ankle with a lace-up brace to preserve joint motion and limit extreme joint positions such as maximum inversion.[3] The brace is to be worn during sports and daily activities, and can be taken off at night or when not active. The use of an ankle brace has better positive effects compared with non-elastic sports tape or elastic kinesiotape.[11]
  • Monitor the patient.[1]
  • Provide hands-on treatment to stimulate plantar receptors[1][12] in order to:
    • Reduce faulty movement.
    • Offer quality vs quantity.
  • Use a pain-free approach.[1]

In summary: exercises should not make the patient feel worse.[1]

Therapeutic Management[edit | edit source]

  • Functional rehabilitation[13] is a type of treatment "during which the function of the joint is retained."[3] It includes:
    • Closed chain functional exercises. Examples: body movement over a stable base,[14] squats, tandem stance, lunges, hop to stabilisation.[15]
Tandem gait
  • Postural control and proprioception.[16][17] Strategies include coordination exercises from simple to complex and predictable to unpredictable environmental constraints.[1]
  • The Star Excursion Balance Test (SEBT) assesses dynamic postural control in patients with lateral ankle sprains.[10]
  • Motor learning strategies[12][18]
  • Cardiovascular fitness
  • Foot core strength training: foot strength influences somatosensory control of standing, posture and balance.[1] Short foot exercises (SFE) should be included early in proprioceptive re-training following an ankle injury.[1] Typically, SFE training is performed three times a week with three sets of 12 repetitions. Each movement is held for 5 seconds and is performed:[1]
    • Weeks 1-4 in a sitting position
    • Weeks 5-8 in a standing position
    • Weeks 5-9 in single-leg stance
Short Foot Exercises
  • Increase range of movement through stretches and manual mobilisation.[19] According to Izaola-Azkona et al.[20] "distal fibular mobilisation with movement may be the most appropriate choice of treatment for an acute lateral ankle sprain to achieve long-term activities of daily living and sport function".[20]
  • Prevent faulty control mechanisms, including drop landing, [21] excessive hip strategy, and faulty forefoot position.[22]
  • Assessment for return to sports readiness.[23][24]

Re-Assessment Phase[edit | edit source]

If there is no improvement at six weeks, the re-assessment must be completed, including:[1]

  • Review of the initial assessment.
  • Review of the mechanism of injury.
  • Re-evaluation of the intrinsic and extrinsic factors influencing recovery.

Based on the results of this re-assessment, the following actions must be considered:[1]

  • Further investigation.
  • Referral to a specialist (i.e. medical doctor with a speciality in sports or an orthopaedic surgeon).

Resources[edit | edit source]

References[edit | edit source]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 Simpson H. Lateral Ankle Sprains. Plus Course 2022.
  2. 2.0 2.1 Lacerda D, Pacheco D, Rocha AT, Diniz P, Pedro I, Pinto FG. CURRENT CONCEPT REVIEW: STATE OF ACUTE LATERAL ANKLE INJURY CLASSIFICATION SYSTEMS. The Journal of Foot and Ankle Surgery. 2022 Aug 18.
  3. 3.0 3.1 3.2 3.3 3.4 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-.
  4. 4.0 4.1 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;20(1):1-3.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 Chen ET, Borg-Stein J, McInnis KC. Ankle Sprains: Evaluation, Rehabilitation, and Prevention. Curr Sports Med Rep. 2019 Jun;18(6):217-223.
  6. McGovern RP, Martin RL. Managing ankle ligament sprains and tears: current opinion. Open Access J Sports Med. 2016 Mar 2;7:33-42.
  7. Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy W, Richie D; National Athletic Trainers' Association. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013 Jul-Aug;48(4):528-45.
  8. 8.0 8.1 Kerkhoffs GM, van den Bekerom M, Elders LA, van Beek PA, Hullegie WA, Bloemers GM, de Heus EM, Loogman MC, Rosenbrand KC, Kuipers T, Hoogstraten JW, Dekker R, Ten Duis HJ, van Dijk CN, van Tulder MW, van der Wees PJ, de Bie RA. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012 Sep;46(12):854-60.
  9. 9.0 9.1 Goulart Neto AM, Maffulli N, Migliorini F, de Menezes FS, Okubo R. Validation of Foot and Ankle Ability Measure (FAAM) and the Foot and Ankle Outcome Score (FAOS) in individuals with chronic ankle instability: a cross-sectional observational study. Journal of orthopaedic surgery and research. 2022 Dec;17(1):1-7.
  10. 10.0 10.1 Pierobon A, Raguzzi I, Soliño S, Salzberg S, Vuoto T, Gilgado D, Perez Calvo E. Minimal detectable change and reliability of the star excursion balance test in patients with a lateral ankle sprain. Physiotherapy Research International. 2020 Oct;25(4):e1850.
  11. Kemler E, van de Port I, Backx F, van Dijk CN. A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med. 2011 Mar 1;41(3):185-97.
  12. 12.0 12.1 Helly KL, Bain KA, Hoch MC, Heebner NR, Gribble PA, Terada M, Kosik KB. The effect of attending physical rehabilitation after the first acute lateral ankle sprain on static postural control in patients with chronic ankle instability. Journal of Sport Rehabilitation. 2021 Mar 22;30(7):1000-7.
  13. Delahunt E, Bleakley CM, Bossard DS, Caulfield BM, Docherty CL, Doherty C, Fourchet F, Fong DT, Hertel J, Hiller CE, Kaminski TW, McKeon PO, Refshauge KM, Remus A, Verhagen E, Vicenzino BT, Wikstrom EA, Gribble PA. Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. Br J Sports Med. 2018 Oct;52(20):1304-1310.
  14. Han K, Ricard MD, Fellingham GW. Effects of a 4-week exercise program on balance using elastic tubing as a perturbation force for individuals with a history of ankle sprains. J Orthop Sports Phys Ther. 2009 Apr;39(4):246-55.
  15. Hall EA, Chomistek AK, Kingma JJ, Docherty CL. Balance- and Strength-Training Protocols to Improve Chronic Ankle Instability Deficits, Part I: Assessing Clinical Outcome Measures. J Athl Train. 2018 Jun;53(6):568-577.
  16. Guzmán-Muoz E, Rodríguez SS, Concha-Cisternas Y, Badilla PA, Méndez-Rebolledo G. The effects of neuromuscular training on the postural control of university volleyball players with functional ankle instability: a pilot study. Archivos de medicina del deporte. 2020;36(5):283-7.
  17. Barnes RY, Raubenheimer J, Wilson M. Effect of core stability, M. gluteus medius and proprioceptive exercise programme on dynamic postural control in netball players. South African Journal for Research in Sport, Physical Education and Recreation. 2020 May 27;42(1):1-1.
  18. Khalaj N, Vicenzino B, Smith MD. Hip and knee muscle torque is not impaired in the first three months of a first-time lateral ankle sprain. Physical Therapy in Sport. 2022 Jan 1;53:1-6.
  19. de Ruvo R, Russo G, Lena F, Giovannico G, Neville C, Turolla A, Torre M, Pellicciari L. The Effect of Manual Therapy Plus Exercise in Patients with Lateral Ankle Sprains: A Critically Appraised Topic with a Meta-Analysis. Journal of Clinical Medicine. 2022 Jan;11(16):4925.
  20. 20.0 20.1 Izaola-Azkona L, Vicenzino B, Olabarrieta-Eguia I, Saez M, Lascurain-Aguirrebeña I. Effectiveness of Mobilization of the Talus and Distal Fibula in the Management of Acute Lateral Ankle Sprain. Physical therapy. 2021 Aug;101(8):pzab111.
  21. Herb CC, Grossman K, Feger MA, Donovan L, Hertel J. Lower Extremity Biomechanics During a Drop-Vertical Jump in Participants With or Without Chronic Ankle Instability. J Athl Train. 2018 Apr;53(4):364-371.
  22. McGrath D, Patterson M, Persson UM, Caulfield B. Frontal-Plane Variability in Foot Orientation During Fatiguing Running Exercise in Individuals With Chronic Ankle Instability. J Athl Train. 2017 Nov;52(11):1019-1027.
  23. Smith MD, Vicenzino B, Bahr R, Bandholm T, Cooke R, Mendonça LD, Fourchet F, Glasgow P, Gribble PA, Herrington L, Hiller CE. Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework—an international multidisciplinary consensus. British journal of sports medicine. 2021 Nov 1;55(22):1270-6.
  24. D’Hooghe P, Cruz F, Alkhelaifi K. Return to play after a lateral ligament ankle sprain. Current Reviews in Musculoskeletal Medicine. 2020 Jun;13(3):281-8.