Ankle sprains are one of the most common athletic injuries. Each day it is estimated that between 23,000 and 27,000 ankle sprains happen each day in the United States. Ankle injuries are occur most often in athletes participating in
sports with side to side movement than that with straight ahead
motion.Court sports such as Basketball, Tennis and Raquetball
all create a fair share of ankle sprains. Running on level
ground does not often result in an ankle sprain but cross country
running, trail running and stepping in a pot hole all could
potentially lead to an ankle sprain. Unfortunately the reinjury rate may be high and can approach 70% in sports such as basketball.
sprains are more common in athletes participating in
sports with side to side movement”
The most frequent ankle sprain is an inversion ankle sprain.
This can injure the outer structures of the ankle. More rarely
the medial (inner) ankle ligaments are sprained.
Anatomy: The ankle includes the Talus or
ankle bone and the ankle mortise created by the lower Tibia
(inner ankle bone, leg bone) and fibula (outer ankle, leg bone).
There are three main outer ankle ligaments. The anterior talo-fibular
ligament, the calcaneo-fibular ligament and the posterior talo-fibular
ligament. Other structures in this area which your doctor will
want to examine which can also be injured in an inversion injury
include the peroneal tendons (which can sublux or move out
of place), the calcaneo-cuboid ligament, and the base of the
5th metatarsal (which can break).
On the medial side of the ankle you'll find the broad, fan
shaped deltoid ligament. This is less often sprained, but is
more difficult to treat than lateral ankle sprains. One of
the probable reasons that this ligament is harder to treat
is that when the foot pronates either normally or abnormally
in gait, the deltoid ligament is under tension and stretched.
The continued stretching motion in this area would retard the
Most Common Injury:
The most common injury resulting from an inversion ankle injury
is a partial tear of the anterior talo-fibular ligament (ATFL).
This ligament may also tear completely. The next most frequently
injured ligament is the calcaneo-fibular ligament and least
injured is the posterior talo-fibular ligament. On occasion
the fibula itself may be fractured or the talar dome is injured
which may include an osteochondral fracture.
More serious ankle sprains can involve the anterior
As already mentioned, all of the other structures on the lateral
side of the ankle should always be carefully examined to make
sure they are not injured.
The grading of ankle sprains is officially done on an inadequate
3 point scale. Grade 1 is a mild "stretch" of the
ligaments, Grade 3 is a complete tear of the ligament and Grade
2 is everything in between. In my office I use a subjective
10 point scale to finer grade the ligament injury for the benefit
of the patient.
Palpate all key lateral ankle structures including: Lateral Malleolus, Anterior Talo-fibular Ligament, Calcaneo-fibular ligament, posterior talo-fibular ligament, Anterior Inferior Tibio-fibular Ligament, Talus, Calcaneo-cuboid ligament, Peroneal tendons, Base of 5th metatarsal (styloid process), shaft of 5th and 4th metatarsals.
Anterior Drawer Test - Stabilize lower leg. Grasp Calcaneus and pull forward. Look for a dimple anterio-laterally which might be easier to visualize than the movement itself. A positive Anterior Drawer sign indicates that at the least the Anterior Talo-fibular ligament is torn.
Xray studies are not routinely done, but are done if the "Ottawa Criteria" are met:
Pain in the ankle and any one of the following:
1. Tenderness on palpation of the lateral malleolus or medial or medial.
2. Inability to bear weight both immediately and in the emergency facility (for 4 steps).
Foot Xray is indicated if there is pain in the midfoot and any one of the following:
3. Tenderness around the navicular bone.
4. Tenderness around the 5th styloid process.
These criteria are not for use in patients under age 18.
Ottawa Rules: Stiell, I. et al. BMJ 1995;311:594-597
High Ankle Sprain:
Tibiofibular Syndesmosis Injury
- Anterior Inferior tibiofibular ligament
- Interosseous membrane
- Ankle squeeze test positive
- Ankle external rotation test positive
- Tender at anterior ankle
- Pain at Tibiofibular joint - distal
Additional Injuries To Consider: Differential Diagnosis:
- Anterior Talo-Fibular Ligament sprain
- Calcaneo-fibular Ligament sprain
- Posterior talo-fibular ligament sprain
- Calcaneo-cuboid ligament sprain
- Lateral malleolus fracture
- Anterior inferior tibio-fibular ligament sprain
- Posterior inferior tibio-fibular ligament sprain
- Syndesmosis tear
- Osteochondral injury to talus
- Posterior-lateral talar process fracture
- Anterior process of calcaneus (beak) fracture
- Achilles tendon injury
- Fifth metatarsal fracture (styloid process or base)
- Subtalar joint injury
Instability: Mechanical And Functional
Physical instability occurs when disrupted ligaments cause true instability of the ankle joint. Chronic complaints include: swelling, pain during activbity, a feeling of giving out and repeted injury.
Functional instability includes impairment of joint position sense (proprioception), decreased strength, impaired postural control and impairment of neuromuscular control in the absence of ligamentions laxity.
Treatment For Minor Sprain:
It is impossible to guess via the Internet how badly injured
you are. If you have doubts or your ankle swells very rapidly
you should head for the emergency room. Immediate treatment
should consist of R.I.C.E. or even better P.R.I.C.E.:
The ice should be applied for about 20 minutes at a time and
then off for about 40 minutes. Avoid damaging your skin with
the chemical bags you can place in your freezer. Frozen corn
or peas works just fine.
If the ankle does not respond quickly to this treatment, it
is probably best to visit your sports physician for an evaluation
and treatment. This way you'll avoid having your sprain be
worse than a break.
Frequently for Grade 2 sprains, I'll recommend a plastic splint
such as that made by Air Cast - Air Splint. This holds the
ankle quiet as it heals and prevents most inversion and eversion.
On occasion crutch walking for a few days (or longer) is needed.
The first exercise I recommend after the ankle
is starting to feel better is dorsiflexion - plantarflexion
or just plain moving the ankle up and down. After more improvement
small circles, painting the alphabet with your toes and other
exercises can be done. Later still a theraband or other elastic
band can be used to strengthen the muscles that help hold the
ankle stable. Beam balance exercises and figure 8 running are
also possible exercises later in recovery.
I recommend avoiding forcing your ankle to move in pain too
soon. I also recommend avoiding weight bearing or walking in
pain early in the course of an ankle sprain. There is no reason
to start testing your ankle until it has had time to heal.
Slow and easy gets more gain than rushing into painful exercises.
Rehab Regimen Mild to Moderate Ankle Sprains:
- Dorsiflexion-Plantar Flexion Range Of Motion Exercises
- Night Splint To Keep Foot Dorsiflexed
- Encourage guarded weight bearing with protection (brace or pneumatic walker)
Immediate Care through First Week:
- Plantar Flesion Exercises
- Eversion Exercises
|Rocker (square or circular 20"):
|Same as week 2 +
|Rocker (square or circular 20"):
Side - Side
|Same as week 3 +
|Rocker (square or circular 20"):
|Same as week 4 +
|Rocker (square or circular 20"):
One Foot. Front-Back
- Continue Dorsiflexion-Plantar Flexion ROM Exercises
- Night Splint
- Inversion-Eversion Exercises
- Square Rocker or 20" Circular Rocker: Anterior Posterior
Exercises for proprioception
- Theraband Strengthening Exercises
Continue: DF-PF Exercises and Inversion-Eversion
Circular Rocker: Anterior-Posterior and Side To Side Rocking
Theraband Strenghtening Exercises for peroneal muscles
For optimal proprioceptive and strenght training, continue
using the theraband for 6 weeks and the rocker 8 - 12 weeks.
The rocker should be used for circular balance exercises in
addition to front-back and side to side. It may also be used
for unilateral balancing and motion such as front back.These
exercises are additive. Add one more exercise to the rocker
to those you have been doing:
- Front - Back
- Side to Side
- Circular Clockwise
- Circular Counterclockwise
- Balance 1 Foot
- Front - Back 1 Foot
Return To Activity:
When you can walk down the steps without any pain or hop on
your foot as high as you can 4 times without pain, you are
likely ready to resume your sports activity. A recent study
correlated a test within the first few days of injury of hopping
down 18 steps with an early return to running. If you can do
that without pain ( or tripping and breaking your skull) you
probably are not hurt badly and will return to running soon.
I do NOT recommend trying that test. It is mentioned as what
some researchers may attempt to study in looking for a statistically
Delayed Return To Activity:
In the event of prolonged pain and swelling and the inability
to perform the "jump test" comfortably or a rapid stair descent, it will be
important to futher evaluate the ankle for problems not initially
detected. This includes osteochondral fracture of the dome
of the talus (bone and cartilage chip). X-rays are often negative
(nothing abnormal is seen) and further evaluation with an MRI
or other diagnostic modality is indicated. Other diagnostic
tests that may be used include CT scan and bone scan.
Pribut, SM. Quick and Easy Look at Ankle Injuries 2012 Slideshare Presentation
Bachmann, L et. al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review BMJ 2003;326:417
Leddy JJ, Smolinski RJ, Lawrence J, et al. Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center: with a modification to increase specificity for identifying malleolar fractures. Am J Sports Med 1998;26(2):158-65
Stiell, I. et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. BMJ 1995;311:594-597
Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries: refinement and prospective validation. JAMA 1993;269(9):1127-32