Ankle Sprains:
What is this condition? What causes this condition?
Ankle sprains occur when one or more of the ligaments of the ankle are completely or partially torn. This is a very common injury and up to 85% of all ankle sprains are accounted for by inversion-type lateral ligament injuries (Roos, Mauntel, Djoko & Dompier, 2016). The incidence of ankle sprain is highest amongst sports population and is the second most likely body part to be injured in sport (Fong et al, 2007). A meta-analysis by Doherty et al (2014), found that indoor sports carry the greatest risk of ankle sprain with an incidence of 7 per 1,000 cumulative exposures.
Lateral ankle sprains usually result from a rapid shift of the body’s centre of mass over the weight bearing foot causing the ankle to roll outwards whilst the foot turns inward and thus placing the lateral ligament in a position to stretch and tear. Reports have proposed a increased plantar flexion at the ankle increases likelihood of ankle sprain (Wright et al, 2000). A less common cause of this condition is forceful eversion at the ankle placing increased stretch on the medial deltoid ligament. High ankle sprains may also occur during excessive external rotation and dorsi flexion.
Classification/grades (Lynch, 2002):
• Grade 1 – mild: Minimal swelling and tenderness with little impact on function.
• Grade 2 – Moderate: Moderate swelling, instability, pain and impact on function. Reduced proprioception and ROM.
• Grade 3 – Severe: Complete rupture, large swelling, high tenderness loss of function and marked instability
Risk Factors?
There are several risk factors that predispose an individual to ankle sprains. A major risk factor is previous history of ankle sprain as this compromises the integrity and strength of ankle stabilisers. Other risk factors include sex, height, weight, limb dominance. Studies of unilateral ankle sprains suggest that the dominant leg is 2.4 times more vulnerable to sprain than the non-dominant one Yeung et al, 1994). Extrinsic risk factors may include shoe type, bracing, taping as well as competition intensity, type and duration.
Differential Diagnosis
• Peroneal tendinopathy or subluxation
• Posterior tibial tendon dysfunction
• Tarsal tunnel syndrome
• Sinus tarsi syndrome
Common symptoms / signs
– Only able to tolerate partial weight bearing
– Tenderness, swelling, bruising may present on either side of the ankle.
– No bony tenderness, deformity or crepitus present.
– Passive inversion or plantar flexion with inversion should replicate symptoms for a lateral ligament sprain. Passive eversion should replicate symptoms for a medial ligament sprain.
– Positive findings on anterior draw, talar tilt and/or squeeze tests.
How is it treated?
Inflammatory period (0-3 days):
• Focuses on reducing pain and swelling as well as improving circulation and partial foot support.
• PRICE protocol:
o Protection: Protect from further injury by avoiding aggravating activity.
o Rest: Rest for first 24 hours after injury to offload injured ankle and altering work and sport requirements as needed.
o Ice: Apply 20 minutes at a time 1-3 times per day. Be cautious regarding skin integrity by placing towel between ice and skin if using ice-pack.
o Compression: Apply compression bandage to control swelling
o Elevation: Elevate ankle above the level of the heart. Avoid positions where the ankle is in a dependent position relative to the body.
• Improve AROM within pain-free limits for toes/ankles to improve local circulation.
Proliferative phase (4-10 days):
• Focus directed at recovering foot and ankle function and improving load carrying tolerance.
• Patient education to facilitate gradual increases in activity level.
• Increasing range of motion, active stability and motor coordination.
• Exercise consideration may include:
o Ankle pumps/circles 3×8-20 reps
o Tandem stance balance 3x30sec-1min.
o Walking as able
o Seated calf raise 3×8-15
• Taping and bracing (e.g. Aircast ankle brace) may be considered when swelling subsided for additional support (Boyce, Quigley & Cambell, 2005)
Remodelling: (commences approximately 11 days post injury)
• When pain and swelling are well controlled, goals then aim to improve muscle strength, active functional stability and mobility.
• Dynamic stability commences as soon as weight bearing capacity permits.
• Strength/stability exercises may include:
o Calf raise 3×6-12
o Band resisted eversion 3×6-12
o Band resisted dorsiflexion 3×6-12
o Calf raise from wall seated position 3×6-12
o Single stand +/- balance board 5x20sec-1min
o Bulgarian split squat +/- band medial or lateral glide at knee increasing stability demand at the ankle. 3×6-12
o 5 star excursion x5-10 taps each point of star
o Single leg mini squat +/- chair behind 3×6-12
• Mobility:
o Aim for symmetrical gait pattern.
o Commence straight line jogging as tolerable.
o Practicing on stairs
Late remodelling and maturation:
• Goals aim to maximise weight bearing, ankle strength and improve goal/sport specific skills to pre-injury levels.
• Increase complexity of motor coordination exercises
• Progress resistance, difficulty and volume of strength training.
• Introduce plyometrics:
o Directional hopping
o Lateral bounding both directions
o Agility
o Jump to SL land
o Box jumps
1. Roos KG, Kerr ZY, Mauntel TC, Djoko A, Dompier TP, Wickstrom EA. The epidemiology of lateral ligament complex ankle sprains in National Collegiate Athletic Association sports. American journal of sports medicine. 2016.The American Journal of Sports Medicine Vol 45, Issue 1, pp. 201 – 209
2. Fong, D. T. P., Hong, Y., Chan, L. K., Yung, P. S. H., & Chan, K. M. (2007).
3. Doherty, C., Delahunt, E., Caulfield, B., Hertel, J., Ryan, J., & Bleakley, C. (2014). The incidence and prevalence of ankle sprain injury: A systematic review and meta-analysis of prospective epidemiological studies. Sports medicine, 44(1), 123-140.
4. Wright, I. C., Neptune, R. R., van den Bogert, A. J., & Nigg, B. M. (2000). The influence of foot positioning on ankle sprains. Journal of biomechanics, 33(5), 513-519.
5. Yeung, M. S., Chan, K. M., So, C. H., & Yuan, W. Y. (1994). An epidemiological survey on ankle sprain. British journal of sports medicine, 28(2), 112-116.
6. Lynch S. (2002). Assessment of the injured ankle in the athlete. J Athl Train, 37(4), 406-412.
7. Boyce SH, Quigley MA, Campbell S. (2005). Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med.39(2), 91-6.