AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

Section 2 of 11  

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Background

A large percentage of musculoskeletal injuries observed in the outpatient setting involve the ankle. Sprains constitute 85% of all ankle injuries. Of these, 85% are inversion sprains. Up to one sixth of participation time lost from sports results from ankle sprains. Proper rehabilitation begins with accurate diagnosis, because up to 40% of patients with untreated or misdiagnosed ankle injuries develop chronic symptoms. Most injuries respond to treatment. Pain reduction is essential, but improvement of any loss of motion, strength, and/or proprioception is equally important.^{1, 2, 3}

Related eMedicine topics:
Acute Ankle Sprains
Ankle Sprain [Sports Medicine]
Recurrent Ankle Sprains

Pathophysiology

The lateral ankle complex, which is composed of the anterior talofibular, calcaneofibular, and posterior talofibular ligaments, is the most commonly injured site.^{4, 5, 6} Approximately 85% of such sprains are inversion sprains of the lateral ligaments, 5% are eversion sprains of the deltoid or medial ligament, and 10% are syndesmotic injuries. The anterior talofibular ligament is the most likely component of the lateral ankle complex to be injured in a lateral ankle sprain. Osteochondral or chondral injuries of the talar dome should be considered when diagnosing an ankle injury.

Frequency

United States

Sprains of the lateral ankle complex make up 38-45% of all injuries in sports. In one study, 50% of patients with ankle sprains had recurrence.

Mortality/Morbidity

Each day approximately 25,000 people suffer an ankle sprain. Up to 40% of these individuals have residual symptoms due to chronic instability.⁷ Because instability is a potential problem following an ankle sprain, it is important that this injury be treated aggressively to prevent further disability.

Sex

No good data suggest a significant sex predilection for ankle sprains.

Age

Because older individuals tend to be less active than younger persons, and therefore often lack conditioning and proprioceptive conditioning, they are at risk for ankle sprain. For similar reasons, weekend warriors and overweight individuals are at risk for ankle injuries.

CLINICAL

Section 3 of 11  

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History

Determining the mechanism of injury is essential. Sudden, intense pain and rapid onset of swelling and bruising suggest a ruptured ligament. Suspect neurovascular compromise if the patient complains of a cold foot or describes paresthesias.⁴ Determine the presence of any complicating conditions, such as arthritis, connective tissue disease, diabetes, neuropathy, previous ankle sprain, or trauma.

Physical

Because most ankle sprains are tender during examination, observation can help the clinician to determine the severity of the injury.

• Observe for obvious deformity and note the location of ecchymosis and edema.
• The patient's ability to bear weight on the affected ankle and to ambulate also determines severity. In most cases, patients who are able to ambulate without severe pain are unlikely to have a fracture or instability.
• Ankle sprains commonly are classified into the following 3 grades:
• • Grade I - These sprains produce a mild degree of swelling, and stretch has occurred to the ligamentous structures. Weight bearing is possible.
  • Grade II sprains - These injuries are characterized by a moderate degree of swelling and an incomplete tearing of ligamentous structures. Mild instability may be present, but a definite endpoint is found on ligamentous testing. Pain may be noted with weight bearing.
  • Grade III - These sprains produce severe swelling and are defined by the complete rupture of at least 1 ligamentous structure. Evidence of instability may be noted.
• This grading system fails to characterize ankle injuries involving 2 or more ligamentous structures and excludes consideration of nonligamentous injuries.
• Drawer and talar tilt examination techniques are used to assess ankle instability; however, the use of these techniques in acute injuries is in question because of pain, edema, and muscle spasm. The fibular compression, or squeeze test, is used if a syndesmotic or fibular injury is suspected.
• • Perform the anterior drawer test with the ankle at 90° to the leg. Grasp the heel and pull forward while, with the other hand, placing posterior force on the tibia. If the test is positive, the so-called suction sign occurs. Dimpling is observed at the anterolateral aspect of the ankle, indicating compromise of the anterior talofibular ligament. A firm endpoint will be absent.
  • The talar tilt test also is performed with the ankle at 90° to the leg. Abduct and invert the heel. If a firm endpoint cannot be felt when compared with the opposite ankle, suspect damage to the calcaneal fibular ligament. Note that the degree of tilt ranges from 0-23°.
  • To perform the squeeze test, place the thumb on the tibia and the fingers on the fibula at the midpoint of the lower leg; then squeeze the tibia and fibula together. Consider pain along the length of the fibula, which indicates a positive test result.

Related eMedicine topic:
Ankle Fracture

Causes

Typically, plantarflexion and inversion of the foot occur, perhaps as a result of moving on uneven terrain or of landing on the foot of another athlete.⁴ Overloading the peroneal muscles also may play a role. Invariably, ankle sprains involve trauma.

• Forced, external rotation of the ankle results in a syndesmotic, or high, ankle sprain. These injuries occur less frequently than do inversion injuries, but they are more disabling and require a prolonged recovery period.
• Recurrent ankle sprains or chronic, lateral instability are consequences of Grade III ankle sprains.⁷

DIFFERENTIALS

Section 4 of 11  

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Other Problems to Be Considered

Distal fibula fracture
Fifth metatarsal fracture
Peroneal tendon dislocation
Acute gout exacerbation

Related eMedicine topics:
Peroneal Tendon Pathology
Peroneal Tendon Syndromes

WORKUP

Section 5 of 11  

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Lab Studies

• Lab tests typically are not necessary for acute ankle sprains related to trauma or sports injury. Obtain appropriate studies if a rheumatologic condition is suggested.

Imaging Studies

• Plain films of the ankle are not always necessary.⁸ Stress radiographic films may provide further assessment for ankle stability; however, patient cooperation may be limited, depending on the severity of the injury. Obtain radiographs in the following situations:
• • Bone tenderness is evidenced on palpation of the navicular, the base of the fifth metatarsal bones, or the posterior edge or tip of the medial or lateral malleolus.
  • The patient shows an inability to bear weight, which should alert the clinician to a possible fracture.
• Computed tomography (CT) scanning may be indicated if imaging of soft tissues is warranted or if bone imaging beyond radiography is indicated. In complex injuries, 3-dimensional CT scanning may be useful.
• Magnetic resonance imaging (MRI) may be useful when osteochondrosis or meniscoid injury is suspected in patients with a history of recurrent ankle sprains and chronic pain.⁹
• A bone scan can detect subtle bone abnormalities (eg, stress fracture, osteochondral defects). A bone scan can also detect syndesmotic disruption.

Other Tests

• Arthroscopy of the ankle may be used diagnostically and therapeutically in subacute or chronic ankle problems. Arthroscopy is indicated if osteophytes, meniscoid lesions, foreign bodies, or osteochondral defects are present.

TREATMENT

Section 6 of 11  

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Rehabilitation Program

Physical Therapy

Physicians frequently recommend physical therapy for patients who have suffered moderate to severe ankle sprains, especially persons who have chronic instability and recurring symptoms.⁷ Following the acute injury, the physical therapist may provide therapeutic modalities (eg, cryotherapy,¹⁰ electric muscle stimulation) to speed the reduction of pain and swelling. As the patient progresses and is able to tolerate further therapy, the goals should be aimed at regaining the full range of motion (ROM), strength, and stability of the ankle joint. (See Further Outpatient Care.)^{11, 12}

The physical therapist also completes patient education throughout the rehabilitation process and establishes an appropriate home exercise program for each patient. The goal of the program should be to enable the patient to return to his/her previous level of activity. For less severe injuries, immediate, protected ambulation should be encouraged, and physical therapy should emphasize the return of ROM, strength, endurance, and proprioception.

Medical Issues/Complications

Treatment during the acute phase of injury is meant to minimize swelling and allow the patient to begin walking.¹³ The acute phase of treatment should last for 1-3 days after the injury. A combination of protection, relative rest, ice, compression, elevation, and support is used. This approach can be remembered by using the mnemonic PRICES.⁴

• Protection - Protective devices include air splints or plastic and Velcro braces. Most sprains can be treated without casting. Depending on the severity of the sprain, protective devices are used for 4-21 days. Criteria to discontinue use of the device include minimal swelling and pain at the site of injury. The ROM should be smooth, particularly with dorsiflexion and plantarflexion.
• Relative rest - Relative rest is advocated, because it promotes tissue healing. Advise the patient to avoid activities that cause increased pain or swelling. Advocate early, pain-free movements during this time. The patient may perform alphabet exercises or towel stretches, if tolerated, to maintain his/her ROM.
• Ice - Use ice to control swelling, pain, and muscle spasm. As a rule, do not apply ice or cold pack directly to the skin; wrap the pack in a towel before use. Recommend that the patient apply ice for 15-20 minutes, 3 times daily. Contrast baths can be used 24-48 hours after injury.
• Compression - Recommend the use of compression with an ACE wrap, an elastic ankle sleeve, or a lace-up ankle support. Advise the patient that further support of the ankle can be facilitated by wearing high-top, lace-up shoes. This can help to minimize edema.⁶
• Elevation - Encourage elevation of the injured ankle to facilitate the reduction of swelling. Advise the patient to keep the ankle above the level of the heart.
• Support - This can include taping or the use of lace-up ankle supports with combination hook-eye (ie, Velcro) straps.⁶

Related eMedicine topic:
Ankle Taping and Bracing

Surgical Intervention

Surgery may be indicated when the fibulocalcaneal ligament is torn or a displaced or unstable fracture is identified. Most ankle sprains do not require surgical intervention.

Consultations

Consultations seldom are indicated unless the physician suspects that the ankle or a fracture is unstable. Most ligamentous injuries and fractures heal well after 4-6 weeks of guarded weight bearing and guarded motion, along with a progressive rehabilitation program (as previously outlined). Surgical intervention by an orthopedic or podiatric surgeon may be warranted in these situations. The clinician simply has to determine a comfort level in treating a particular condition. Once that level has been exceeded, consultation with the appropriate specialist is indicated.

MEDICATION

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Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) frequently are used to control pain and inflammation. Ultimately, the clinician has the prerogative to determine the most appropriate medication.

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.

Drug Category: Nonsteroidal anti-inflammatory drugs

If significant ecchymoses is observed at presentation of acute injury, consider not prescribing for 24-48 h, which may prevent further hemorrhage into the site of injury. Several other NSAIDs are available. The ones listed here are considered first-line drugs on most formularies.⁴

FOLLOW-UP

Section 8 of 11  

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Further Outpatient Care

• The recovery phase of rehabilitation begins after the third day following injury and may last up to 2 weeks. The goal during this period is to have the patient walk without a limp. Continue ice and elevation if swelling persists. Some pain is acceptable during this time; however, reevaluate the patient if pain persists.
• Initiate therapeutic exercises, including flexibility/ROM, strengthening, and proprioceptive/balance exercises.¹²
• • Encourage active ankle motion in inversion and eversion. Add standing lower leg stretches (gastroc-soleus complex and Achilles tendon) or non–weight-bearing towel stretches to the regimen.
  • Begin strengthening exercises with isometrics. Then, recommend progressing to closed-chain loading (eg, toe raises). Add elastic bands or rubber tubing for open-chain loading.
  • Recommend beginning proprioceptive or balance training on the injured leg. As an added challenge, have the patient stand on a pillow 2-3 times per day. A wobble board may be helpful during this time, depending on the patient's progress.
  • Recovery phase return-to-play criteria include the following:
  • • Full, pain-free, active and passive ROM
    • No pain or tenderness
    • Strength of ankle muscles 70-80% of the uninvolved side
    • Able to balance on 1 leg for 30 seconds with eyes closed
• The functional phase of rehabilitation lasts 2-6 weeks. The goal is to return the patient to his/her previous level of activity. Once this has been achieved, rehabilitation is complete.
• • The 3 components addressed in the recovery phase reflect an advanced stage of rehabilitation. The ankle should move in full ROM. Strengthening continues with advanced, open-chain and closed-chain exercises. Add exercises that promote agility and power, including line jumping, 5-point drill, jump rope, and plyometrics.
  • Supportive devices still can be used if the patient is participating in strenuous or competitive play. See Images 1-5 for examples of these devices.
  • Functional phase return-to-play criteria include the following:
    • Normal ROM of the ankle joint
    • No pain or tenderness
    • Satisfactory clinical examination
    • Strength of ankle muscles 90% of the uninvolved side
    • Ability to complete functional examination

Deterrence

• The prevention of future ankle sprains depends on the type of activity in which the patient is engaged. Certain sports (eg, soccer, basketball, volleyball) have a high incidence of ankle sprains.^{4, 6, 14, 15, 16}
• The athlete must understand the importance of adequate training and conditioning to prevent future injury or to minimize injury severity. An adequate warm-up period and a gradual transition into activity are general principles that also can be applied to prevent future injury. The athlete should wear shoes with good stability and, if possible, should exercise on even surfaces.¹⁵ High-top shoes, lace-up ankle braces, Velcro ankle braces, and/or ankle taping may add stability during activities and prevent further injury.

Complications

• Complications following ankle sprain are limited. If pain persists despite rehabilitation, further workup is indicated. Diagnoses to consider include the following:
• • Chronic lateral ankle instability typically is accompanied by a feeling of instability by the patient. Swelling is noted with activity, and recovery is prolonged.
  • Intra-articular meniscoid lesions represent localized fibrotic synovitis in the lateral ankle following inversion sprains. The condition also is known as impingement syndrome.
  • Peroneal tendon subluxation is due to detachment of the peroneal retinaculum from its normal insertion on the posterior border of the fibula to the lateral surface of the fibula.
  • Talar dome fracture occurs with inversion and eversion injuries, but it may not be readily seen on radiographs.
  • Anterior process fracture of the calcaneus occurs with inversion injuries. Patients commonly display bony tenderness rather than ligamentous point tenderness.
  • Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy, can develop after ankle sprains. The reason for this is unknown; however, the condition may arise from an abnormal response to disuse and/or splinting of the foot and ankle. Early, controlled activity and rehabilitation may prevent the development of CRPS.

Related eMedicine topic:
Complex Regional Pain Syndromes

Prognosis

• Outcomes following ankle sprains are usually very favorable; however, more severe sprains, especially grade III sprains with complete ligament disruption, may result in prolonged or permanent ankle instability and symptoms. Strict adherence to the previously outlined rehabilitation principles maximizes the potential for a proper recovery.

Patient Education

• Review the self-care techniques of acute sprain with patients so that they can take an active part in their care. Teach them the mnemonic PRICES.
• Provide information on when to call for advice. Instruct the patient to call a doctor or nurse if one of the following conditions is observed:
• • The joint is wobbly or moves past its normal ROM.
  • The bone is deformed or bends abnormally.
  • Pain prevents putting weight on the injured area after 24 hours.
  • Weight bearing still is difficult after 4 days.
  • Extreme pain, bruising, or severe swelling is present.
  • The toes below the injury feel cold to the touch or become numb or blue.
• These instructions can be tailored to each practice and by no means should be construed as all-inclusive.
• For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.

MISCELLANEOUS

Section 9 of 11  

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• References

Medical/Legal Pitfalls

• Failure to perform a thorough examination following a traumatic ankle injury
• Failure to diagnose 1 or more of the following represents a typical medicolegal pitfall¹⁷:
  • Peroneal nerve injury
  • Severe peroneal tendon injury
  • Occult fracture⁸
  • Compartment syndrome

MULTIMEDIA

Section 10 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Example of a lace-up ankle support. Courtesy of Swede-O, Inc.
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Media file 2:  Example of a brace for immobilization or functional purposes. Courtesy of Swede-O, Inc.
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Media file 3:  Example of a brace that can be used for functional purposes. Courtesy of Swede-O, Inc.
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Media file 4:  Example of a brace secured with Velcro straps. Courtesy of Swede-O, Inc.
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Media file 5:  Example of a lace-up ankle support brace with figure-8 straps. Courtesy of Swede-O, Inc.
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REFERENCES

Section 11 of 11

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1. DeLee JC, Drez D Jr, eds. Orthopaedic Sports Medicine: Principles and Practice. vol 2. Philadelphia, Pa: WB Saunders; 1994:1718-24.
2. Singer KM, Jones DC. Ligament injuries of the ankle and foot. In: Nicholas JA, Hershman EB, eds. The Lower Extremity and Spine in Sports Medicine. vol 2. 2^nd ed. St Louis, Mo: Mosby; 1995:475-97.
3. Windsor RE. Overuse injuries of the leg, ankle and foot. Phys Med Rehabil Clin North Am. 1994;195-214.
4. Ivins D. Acute ankle sprain: an update. Am Fam Physician. Nov 15 2006;74(10):1714-20. [Medline]. [Full Text].
5. LeBlanc KE. Ankle problems masquerading as sprains. Prim Care. Dec 2004;31(4):1055-67. [Medline].
6. Gross MT, Liu HY. The role of ankle bracing for prevention of ankle sprain injuries. J Orthop Sports Phys Ther. Oct 2003;33(10):572-7. [Medline].
7. Brown C, Padua D, Marshall SW, et al. Individuals with mechanical ankle instability exhibit different motion patterns than those with functional ankle instability and ankle sprain copers. Clin Biomech (Bristol, Avon). Jul 2008;23(6):822-31. [Medline].
8. Singh-Ranger G, Marathias A. Comparison of current local practice and the Ottawa Ankle Rules to determine the need for radiography in acute ankle injury. Accid Emerg Nurs. Oct 1999;7(4):201-6. [Medline].
9. Bencardino J, Rosenberg ZS, Delfaut E. MR imaging in sports injuries of the foot and ankle. Magn Reson Imaging Clin N Am. Feb 1999;7(1):131-49, ix. [Medline].
10. Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue injury?. J Athl Train. Sep 2004;39(3):278-9. [Medline]. [Full Text].
11. Rehabilitation of the ankle and foot. In: Kibler WB, Herring SA, Press JM, eds. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, Md: Aspen Pub; 1998:273-9.
12. Laufer Y, Rotem-Lehrer N, Ronen Z, et al. Effect of attention focus on acquisition and retention of postural control following ankle sprain. Arch Phys Med Rehabil. Jan 2007;88(1):105-8. [Medline].
13. Man IO, Morrissey MC. Relationship between ankle-foot swelling and self-assessed function after ankle sprain. Med Sci Sports Exerc. Mar 2005;37(3):360-3. [Medline].
14. Fong DT, Hong Y, Chan LK, et al. A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007;37(1):73-94. [Medline].
15. Curtis CK, Laudner KG, McLoda TA, et al. The role of shoe design in ankle sprain rates among collegiate basketball players. J Athl Train. May-Jun 2008;43(3):230-3. [Medline]. [Full Text].
16. Fong DT, Man CY, Yung PS, et al. Sport-related ankle injuries attending an accident and emergency department. Injury. Jun 5 2008;[Medline].
17. Foster AP, Thompson NW, Crone MD, et al. Rupture of the tibialis posterior tendon: an important differential in the assessment of ankle injuries. Emerg Med J. Dec 2005;22(12):915-6. [Medline].

Article Last Updated: Jun 20, 2008