AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

The ankle joint has many functions, one of which is to allow the body to adapt to uneven terrain during ambulation. Failure to compensate for uneven footing may result in an ankle injury.

Eighty-five percent of ankle injuries are sprains, and of those sprains, 85% are lateral inversion sprains. Although athletes usually recover quickly from ankle sprains, failure to appropriately rehabilitate these injuries imposes an increased risk for future injury.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains - First Aid and Emergency Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.

See also the following on eMedicine:
Ankle Injury, Soft Tissue 
Ankle Sprain
Ankle Taping and Bracing

See also the following on Medscape:
Resource Center Exercise and Sports Medicine
Interventions for Preventing Ankle Ligament Injuries 
Interventions for Treating Chronic Ankle Instability
Surgical Versus Conservative Treatment for Acute Injuries of the Lateral Ligament Complex of the Ankle in Adults
Therapeutic Ultrasound for Acute Ankle Sprains

Frequency

United States

The most common ankle injury is a lateral sprain that is caused by inversion of the foot, with more than 25,000 occurring each day.¹ Lateral inversion sprains are also the most commonly seen sports injury, comprising 14-21% of sports injuries.^{2, 3} Athletes who participate in basketball, volleyball, soccer, and football are at especially high risk for ankle sprains, comprising 25-45% of the injuries in these sports.^{3, 4, 5, 6, 7, 8, 9, 10, 11}

International

In the United Kingdom's general population, the prevalence of ankle sprains is reportedly 52.7 cases per 10,000 patients.¹²

Functional Anatomy

The bony and soft tissue anatomy of the ankle place the lateral side of the ankle at higher risk for injury than the medial side. The distal end of the fibula (ie, the lateral malleolus) extends further inferiorly than the distal end of the tibia (ie, the medial malleolus). This discrepancy in length gives the medial ankle superior stability by improving bony resistance to eversion.

The ligaments of the medial ankle, collectively known as the deltoid ligament complex, form a broad, strong, thick ligamentous stability to prevent eversion and provide medial ankle stability. On the lateral side, there is only minimal bony stability, which comes from 3 relatively small ligaments, the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). 

Although many classification systems for grading lateral ankle sprains exist, perhaps the most common system is based on the clinical examination. In this system, grade I ankle sprains are painful, but they have no increased laxity when compared with the uninjured side. This correlates with mild stretching of the ATFL. Grade II ankle sprains are painful and have an increased laxity on testing. This correlates with a complete tear of the ATFL and a partial tear of the CFL. Grade III ankle sprains are usually painful and have an unstable ankle joint on examination. This correlates with complete ruptures of both the ATFL and CFL.

A sprain of the syndesmotic ligament complex is sometimes called a "high ankle sprain" (a type of inversion sprain) and often presents with anterior ankle pain. The syndesmotic ligament complex consists of the ATFL, the PTFL, and the distal interosseous membrane between the tibia and the fibula.

In plantar flexion, the talus of the ankle is more susceptible to inversion forces compared with dorsiflexion, in which the talus is more stable because of bony stabilization in the mortise. In plantar flexion, the ATFL is under tension and is susceptible to injury.

Sport-Specific Biomechanics

Jumping, cutting, and pivoting place the ankle at risk for inversion injuries. Close body contact between athletes also places the athlete's ankle at risk for an inversion injury (eg, stepping on the opponent's foot).

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• Generally, the athlete is able to describe a history of "rolling the ankle in" after changing direction, stepping down from a height, or landing on the outside of the affected foot at the time of the injury. If the athlete is unable to describe the mechanism of injury, the physician should have a high index of suspicion for either an atypical ankle sprain or an alternative cause of ankle pain.
• The initial area of pain is in the region of the ATFL and, in more severe sprains, the CFL as well. Eventually, the pain may be relatively diffuse, reflecting the development of generalized swelling throughout the foot and ankle.

Physical

• The maximal points of tenderness for a lateral ankle sprain should be at the ATFL and/or CFL areas; areas of swelling and ecchymosis are also tender, and the quantity and area of swelling and ecchymosis often correlate to the amount of elevation the patient has been able to use for treatment. Thus, these findings do not necessarily correlate with the severity of the injury.
• No bony point tenderness should be present; pay particular attention to the medial malleolus, lateral malleolus, base of the fifth metatarsal, and midfoot bones. Point bony tenderness at one of these areas, as well as bony deformity or crepitus, suggests the possible presence of a fracture. Pain should not be increased by either a squeeze test (the fibula and tibia are squeezed together in the mid-shaft regions) or an external rotation test (the ankle is externally rotated). If either test increases pain, consider a high ankle sprain, which involves the syndesmosis and tibiofibular ligaments and usually takes longer to heal than a lateral ankle sprain, or a Maisonneuve fracture of the proximal fibula.
• Pain localized to the medial aspect of the ankle suggests a medial ankle sprain.
• An anterior drawer test can help the clinician assess the stability of the ATFL. Cup the heel in one hand, pull it forward, and stabilize the tibia with the other hand (see Image 1). Translation of more than 10 mm or a 3-mm difference between the ankles suggests ATFL disruption.³ Comparison of the affected side to the uninjured side is critical because the amount of laxity is highly variable among patients.
• The talar tilt test is used to assess the ATFL and CFL. Invert the ankle and compare the laxity with the uninjured side (see Image 2). A complete rupture of the ATFL and CFL, as evidenced by a talar tilt of (1) at least a 20° opening and (2) at least 10° greater than the uninjured side, is considered a third-degree ankle sprain.¹³

Causes

One cause of ankle injury is a previous injury; inadequately rehabilitated ankle sprains place the ankle at risk for subsequent injuries.^{14, 15} The use of narrow cleats with minimal arch support or the use of running shoes for a court sport can also place an athlete at risk for ankle sprains.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to Be Considered

Ankle instability
Calcaneus bone injuries
Referred pain from midfoot and forefoot
Subtalar joint sprain or instability
Tumors

See also the following on eMedicine:
Ankle, Fractures [in the Radiology section]
Calcaneus, Fractures
Dislocations, Foot
Fractures, Ankle [in the Emergency Medicine section]
Fractures, Foot
Osteochondritis Dissecans [in the Radiology section]
Osteochondritis Dissecans [in the Orthopedic Surgery section]
Talus, Fractures

WORKUP

Section 5 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Laboratory studies are not indicated for the diagnosis of ankle sprain injuries.

Imaging Studies

• Plain radiography
• • If the athlete is aged 18-65 years, consider the Ottawa ankle rules when deciding whether to obtain a plain radiograph or not.^{16, 17, 18} These guidelines state that an examiner is unlikely to miss a clinically significant fracture if the patient has no bony tenderness and can bear weight for at least 4 steps. Obtain a radiograph if either of the following situations occurs:
  • • The history or physical is clinically suspicious for an injury other than an ankle sprain
    • Injuries have been diagnosed as ankle sprains but are not improving as would be expected  
  • Stress radiographs are rarely needed to evaluate ankle injuries. However, in cases of a chronic ankle instability that is not responding to treatment, a stress radiograph may be considered. Stress views include the talar tilt test and anterior drawer test (see Clinical, Physical, above). Because of the high variability of normal ankle laxity, comparison views of the uninjured side are usually needed. Although the figures used by clinicians vary, generally a 3-5º difference more in laxity than the uninjured side or an absolute value of 10º is considered a positive finding.
• Bone scanning is useful for evaluating stress fractures, infections, and tumors.
• Computed tomography (CT) scanning is useful for evaluating osteochondritis dissecans (OCD) and stress fractures.
• Magnetic resonance imaging (MRI) is useful for evaluating OCD, fractures, ankle impingement, and soft-tissue injuries.

TREATMENT

Section 6 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Acute Phase

Rehabilitation Program

Physical Therapy

Rest, ice, compression, and elevation (ie, RICE) are the mainstays of the acute treatment of lateral ankle sprains (see Acute Phase, Other Treatment, below). The goal of acute treatment is to control pain and to maintain or regain range of motion (ROM). Athletes are encouraged to take their ankle out of their brace and to move it through a pain-free ROM. Aggressive pain-free ROM is recommended. Having the athlete spell the letters of the alphabet with his/her foot and ankle several times per day is one simple activity to recommend even in an acute care setting.

Medical Issues/Complications

Pain control is the initial treatment goal for ankle sprains.

• The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is somewhat controversial.¹⁹ Some physicians argue that the anti-inflammatory effects of NSAIDs are helpful in decreasing swelling, which ultimately increases the speed of recovery. Others believe that acutely used NSAIDs may increase swelling by increasing potential bleeding through platelet inhibition.^{19, 20}
• If NSAIDs are not used, acetaminophen or other pain medicines may be required for pain control in some athletes with moderate to severe ankle sprains.²¹

Surgical Intervention

Surgical intervention may be considered for the treatment of third-degree ankle sprains in high-level athletes and for chronic ankle instability.²² In most cases, normal biomechanical function is not completely restored, but for most patients with chronic ankle instability, satisfactory results can be obtained with various surgical procedures.^{23, 24, 25}

Other Treatment

Rest, ice, compression, and elevation are the mainstays of treatment; rest is especially critical. Athletes must modify activities that aggravate the ankle sprain; this modification may be as simple as decreasing the amount, frequency, or intensity of sports activities. Often, athletes are more compliant with a decreased level of activity if they are allowed to increase other nonaggravating activities.²⁶

• An ice pack is the first-line anti-inflammatory treatment; used appropriately, icing has been shown to significantly decrease healing time.¹³ The ice pack can be made by placing crushed ice in a plastic bag that is wrapped in a towel; a good alternative is using a bag of prepackaged frozen corn kernels wrapped in a towel. Such an ice pack allows it to mold to the foot, thereby increasing the contact area. Ice packs (which should be used after completing exercise, stretching, and strengthening) are usually placed for 15-20 minutes.
• Placing a compression dressing over the ankle and elevating the ankle as soon as possible after the injury (for 24 h) are important to minimize the swelling. Some useful commercial devices combine compression and ice treatments.

• Ankle braces
• • Immobilization can both help and hinder healing. Acutely protecting the weakened, painful area is appropriate, but prolonged immobilization leads to muscle atrophy and loss of motion. Limited stress creates a stronger scar formation because the collagen fibers line up parallel to the stress instead of at random. For these reasons, limited immobilization with a stirrup or lace-up ankle brace is usually used (see Image 5) whereas casting is avoided.
  • Occasionally, the use of posterior splinting and crutches with nonweight-bearing ambulation is useful for more severe ankle sprains (ie, when foot motion and weight bearing is extremely painful). Usually, the use of a posterior splint is limited to a few days, and weight bearing as tolerated is encouraged.
  • Ankle braces have been shown to be effective at preventing some types of ankle sprains.^{5, 27, 28, 29, 30, 31, 32} The use of high-top shoes has been proposed to prevent ankle injuries, but study results have been mixed.^{31, 32, 33, 34}

• Ankle taping
• • Ankle taping can increase ankle stability by at least 2 mechanisms: limitation of motion and proprioception.³⁵ For a single treatment, ankle taping is less expensive than either a brace or an athletic shoe. Initially, the effectiveness of ankle taping is similar to bracing.^{11, 14} However, studies have demonstrated a significant loss of effectiveness after 24 minutes of activity³⁶; moreover, ankle taping becomes virtually ineffective after periods as short as 40 minutes.³⁷
  • The effectiveness of ankle taping is highly dependent on the expertise of the individual who performs the taping. Although the primary effect is improved proprioceptive function, taping may also cause variable effects on motor performance. Ankle taping has the potential to either enhance or hinder the function of the peroneal muscles, depending on the location and technique with which the ankle was taped. Thus, having an experienced certified athletic trainer (ATC) or physical therapist do the taping usually produces optimal results. In general, athletes without easy access to an ATC or physical therapist may find an ankle brace easier to use and more effective.

Recovery Phase

Rehabilitation Program

Physical Therapy

The treatment plan during the recovery phase is aimed at the athlete regaining full ROM, strength, and proprioceptive abilities. Strengthening is started with isometric exercises and advanced to the use of elastic bands or surgical tubing (see Image 4). Strengthening is performed in the following 4 cardinal ankle motions: dorsiflexion, plantar flexion, eversion, and inversion. Strengthening of the peroneals, which act as dynamic stabilizers of the ankle, is critical.

• Proprioception rehabilitation begins with single-leg stance exercises in a single plane and progresses to multiplanar exercises.
• • The athlete stands on the injured side with the foot and arch in a neutral position and holds the foot of the uninjured side off the ground. For safety, this exercise should be completed near a wall.
  • Initially, the athlete looks at the feet and attempts to hold the position. When the athlete can comfortably and easily hold the position for 3 minutes, he/she changes the focus of the eyes to a location in front of the body. When the athlete can comfortably and easily hold the position with the eyes looking forward for 3 minutes, the position is then held with the eyes closed. A modified Romberg test may be useful in evaluating the progression of proprioceptive rehabilitation.
• Other useful exercises include the use of a balance or tilt board (see Image 3); these can be made by attaching a dowel or half of a croquet ball to the bottom of a piece of plywood. The athlete stands on the board and attempts to control balance while touching the board to the floor in a controlled manner to complete various patterns (eg, 4 points of the compass). Finally, the athlete advances to functional drills, jogging, sprinting, cutting, and then progresses to figure-of-eight and carioca drills.³⁸

Surgical Intervention

Surgical intervention may be considered for the treatment of third-degree ankle sprains in high-level athletes and for chronic ankle instability.²² In most cases, normal biomechanical function is not completely restored, but for most patients with chronic ankle instability, satisfactory results can be obtained with various surgical procedures.^{23, 24, 25} Symptoms of chronic instability may include chronic pain and instability despite a course of adequate physical and pharmacologic therapy.

Maintenance Phase

Rehabilitation Program

Physical Therapy

A maintenance program of ankle strengthening, stretching, and proprioception exercises helps to decrease the risk of future ankle sprains, particularly in individuals with a history of multiple ankle sprains or of chronic instability.^{10, 29, 38, 39, 40}

Other Treatment

Please see Acute Phase, Other Treatment for a discussion of ankle taping and bracing.

MEDICATION

Section 7 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

The use of NSAIDs in acute musculoskeletal injuries is somewhat controversial.¹⁹ These drugs may or may not be beneficial to the physiologic processes of soft-tissue healing. NSAIDs have been found to be useful in controlling pain and allowing more rapid progression in physical therapy. Disadvantages of these agents include the risk of gastrointestinal (GI) bleeding, gastric pain, and renal damage.²⁰

Drug Category: Nonsteroidal anti-inflammatory drugs

NSAIDs are used to control acute inflammation and pain. These agents may also be used for pain control as an adjunct to physical therapy.

FOLLOW-UP

Section 8 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Return to Play

Athletes with ankle sprains may return to activities as limited by their symptoms. The physician may have to design a strict regimen (of activities) because many athletes have a tendency to ignore pain during activities. In general, individuals should start with in-line activities (eg, jogging) and then progress to forward-backward and side-to-side activities. Pivoting and cutting activities are added only when the athlete is minimally symptomatic with the previous activities.

Complications

Studies have shown that at least 40% of acute ankle sprains result in residual ankle symptoms at 6 months.^{41, 42} At least 10-20% of acute ankle sprains result in residual ankle instability, pain, or other chronic symptoms.^{15, 43, 44}

Prevention

Studies that document prevention of sprains are lacking in terms of warm-up activity and stretching. Athletes with a previous history of sprains should be encouraged to continue a strengthening and proprioceptive program on a continuing basis. Appropriate shoe wear should also be encouraged.

Prognosis

Athletes with mild ankle sprains usually recover relatively quickly. Athletes with moderate to severe lateral ankle sprains, medial ankle sprains, and high ankle sprains may take 4-8 weeks or longer to recover completely.

Education

Educate athletes about the importance of ankle strengthening and proprioceptive training to decrease the risk of future injury. Athletes who choose to use prophylactic lace-up type ankle braces must be educated about the importance of retightening the braces after warm-up.

MISCELLANEOUS

Section 9 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• The major medical pitfall with regard to ankle sprains is to miss a clinically significant fracture. If a physician is following the Ottawa ankle rules and using appropriate clinical judgment, the chance of missing a clinically significant fracture is minimal.¹⁸
• When a patient who has been diagnosed with an ankle sprain is not responding to appropriate treatment, a plain radiograph is mandatory to ensure that a tumor or fracture is not missed. Repeat plain radiographs, MRI, and/or orthopedic consultation may be warranted for an athlete who is not responding to the usual treatment guidelines in the expected time frame.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Anterior drawer test.
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Media file 2:  Talar tilt test.
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Media file 3:  Tilt board.
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Media file 4:  Eversion strengthening using an elastic band.
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Media file 5:  Ankle brace.
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REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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27. Meana M, Alegre LM, Elvira JL, Aguado X. Kinematics of ankle taping after a training session. Int J Sports Med. Jul 5 2007;epub ahead of print. [Medline].
28. Anderson DL, Sanderson DJ, Hennig EM. The role of external nonrigid ankle bracing in limiting ankle inversion. Clin J Sport Med. 1995;5(1):18-24. [Medline].
29. Sitler M, Ryan J, Wheeler B, et al. The efficacy of a semirigid ankle stabilizer to reduce acute ankle injuries in basketball. A randomized clinical study at West Point. Am J Sports Med. Jul-Aug 1994;22(4):454-61. [Medline].
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31. Rovere GD, Clarke TJ, Yates CS, Burley K. Retrospective comparison of taping and ankle stabilizers in preventing ankle injuries. Am J Sports Med. May-Jun 1988;16(3):228-33. [Medline].
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35. Lephart SM, Pincivero DM, Rozzi SL. Proprioception of the ankle and knee. Sports Med. Mar 1998;25(3):149-55. [Medline].
36. Lohrer H, Alt W, Gollhofer A. Neuromuscular properties and functional aspects of taped ankles. Am J Sports Med. Jan-Feb 1999;27(1):69-75. [Medline].
37. Manfroy PP, Ashton-Miller JA, Wojtys EM. The effect of exercise, prewrap, and athletic tape on the maximal active and passive ankle resistance of ankle inversion. Am J Sports Med. Mar-Apr 1997;25(2):156-63. [Medline].
38. Osborne MD, Rizzo TD Jr. Prevention and treatment of ankle sprain in athletes. Sports Med. 2003;33(15):1145-50. [Medline].
39. Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. Jan-Feb 1997;25(1):130-7. [Medline].
40. Verhagen E, van der Beek A, Twisk J, et al. The effect of a proprioceptive balance board training program for the prevention of ankle sprains: a prospective controlled trial. Am J Sports Med. Sep 2004;32(6):1385-93. [Medline].
41. Braun BL. Effects of ankle sprain in a general clinic population 6 to 18 months after medical evaluation. Arch Fam Med. Mar-Apr 1999;8(2):143-8. [Medline]. [Full Text].
42. 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. Oct 1998;19(10):653-60. [Medline].
43. Freeman MA, Dean MR, Hanham IW. The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br. Nov 1965;47(4):678-85. [Medline]. [Full Text].
44. Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprains. J Bone Joint Surg Am. Dec 1955;37-A(6):1237-43. [Medline].
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Article Last Updated: Jan 7, 2008