Inversion/Lateral ankle sprains are the most common injury in sport and often go untreated. 40% of lateral ankle sprains results in chronic instability. Ankle injuries account for one-third of the total cost of sports injuries. Most athletes have experienced a sprained ankle; unfortunately, most athletes lack appropriate management which leads to lingering problems when not rehabilitated adequately. A major cause of re-injury is due to decreased proprioception (balance receptors) after the ligament is torn.
When rolling or twisting the ankle, the most likely position is excessive inversion and plantar flexion. The foot ends up in this position in a variety of situations, including losing their footing, running on an uneven surface, landing awkwardly from a jump or stepping on another player’s foot; all of which occur commonly in sport. The most commonly involved ligaments (in order) are the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL). image
How severe is my injury?
These ligaments maintain the stability of the lateral ankle joint and prevent excess varus motion. If a joint is stressed beyond its normal anatomical range of motion, ligament stretching/tearing will occur. Ligament sprains can be graded based on the amount of tearing that occurs. These grades range from a stretched ligament, grade one, to a total rupture of the ligament, which is known as a grade three or 3rd degree sprain. The force and positioning of the foot and ankle at the time of injury can determine the severity of injury based on the degree of ligamentous disruption, which also correlates to both functional limitations and recovery time.
Classification/Severity of lateral ankle sprain
-Stretch/micro tear of a ligament
Signs and Symptoms
Mild tenderness and swelling
Slight or no functional loss (patient is able to weight-bear and ambulate with minimal pain) on effected affected ankle
No mechanical instability (negative on all stress examination)
-Incomplete tear of a ligament, with moderate functional impairment
Signs and Symptoms
Mild/moderate ecchymosis (discoloration)
Tenderness over the involved structures on the lateral aspect of the ankle
Some loss of range of motion and function (patient has pain with weight-bearing and ambulation) on affected ankle
Hearing a “pop”
-Stretch/micro tear of a ligament
Signs and Symptoms
Severe ecchymosis (discoloration)
Loss of range of motion and function (patient is unable to weight-bear or ambulate) on affected ankle
In addition to ligament damage, ankle musculature can be overstretched during inversion ankle sprains; specifically the peroneal muscles, which also run on the outside of the ankle and help with dynamic stability of the ankle and actively everts and dorsiflexes the ankle.
Treatment and RTP
Returning to sport following a lateral ankle sprain ranges from days for Grade 1 to weeks/months for grades 2 and 3. Your clinician will work with you to design a specific treatment program that meets your needs and goals.
The Ottawa Foot and Ankle rules are a commonly used guideline for obtaining x-rays in acute ankle injuries. These guidelines state that x-rays should be obtained if the patient has tenderness over certain osseous (bony) structures (posterior edge of distal 6 cm or tip of the medial/lateral malleolus, fifth metatarsal, or navicular), or if the patient is unable to bear weight (4 steps) immediately after injury or at time of examination. In athletes with persistent pain, an MRI is used to further evaluate the soft tissue structures. image
Immediately after injury, addressing the athlete’s pain, swelling, and regaining full functional ROM range of motion is necessary. To allow proper healing, modification of daily activities and athletics is mandatory.
For acute phase management, POLICE (protect, optimal loading, ice, compression, elevate) and short term immobilization (brace with crutches or walking boot for 3-5 days) are used to protect the injury and allow proper healing. After the acute phase, pain free range of motion can be restored by gradually lengthening the tissue to full range of motion with myofascial release and pain free stretching.
Research has shown that talocrural distraction mobilization (grade V) performed by a skilled physical therapist both diminishes pain and increased range of motion. Early ankle joint mobilizations and range of motion exercises aimed at dorsiflexion are essential in preventing gait deviations, long-term pain, recurrent injury and ankle instability. Once pain free range of motion is achieved and swelling is controlled, the patient is progressed to the strengthening phase of rehabilitation. Strengthening of the small muscles of the foot and ankle in full range of motion is needed to increase the dynamic stability of the ankle. Exercises should focus on improving the strength of the peroneal muscles because insufficient strength in this group has been associated with chronic ankle instability and recurrent injury.
In the subacute phase (3-4 days post injury until 3-4 weeks post injury), the patient achieves full weight-bearing without pain and proprioceptive training is initiated. The weight bearing activity and proprioceptive training allows for balance and postural control to be regained. A common progression when performing balance exercise is to move from bilateral (double leg) stance to unilateral (single leg) stance, eyes open to eyes closed, firm surface to unstable surface, and uneven or moving surface.
In the rapid progression phase, rehabilitation activities should focus on regaining normal function. Functional exercises may include low level plyometrics and multiplanner agility movements in full range of motion. Gradually increase rate of force development and introduce dynamic eccentric activities (running, bounding-hopping-jumping , jog-run-sprint) and sport specific training that will prepare the athlete to return to their respective sport.
The decision to return to play following an ankle injury is a multifactorial process. Functional testing may be utilized to gauge an athlete’s progression through the rehabilitation process. Testing includes balance, proprioception, strength, range of motion, and agility assessments to determine physical readiness to return to sport safely.
Staying educated is your responsibility, providing evidence based information is ours
Bachmann, L.M., et al., Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ, 2003. 326(7386): p. 417. Retrieved 1/20/19
Mattacola, C.G. and M.K. Dwyer, Rehabilitation of the ankle after acute sprain or chronic instability. Journal of athletic training, 2002. 37(4): p. 413. Retrieved 1/5/19
Loudon, J.K., M.P. Reiman, and J. Sylvain, The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review. Br J Sports Med, 2014. 48(5): p. 365-370. Retrieved 12/20/18
Denegar, C.R., J. Hertel, and J. Fonseca, The Effect of Lateral Ankle Sprain on Dorsiflexion Range of Motion, Posterior Talar Glide, and Joint Laxity. Journal of Orthopaedic & Sports Physical Therapy, 2002. 32(4): p. 166-173. Retrieved 1/17/19
Van Ochten, J.M., et al., Chronic complaints after ankle sprains: a systematic review on effectiveness of treatments. journal of orthopaedic & sports physical therapy, 2014. 44(11): p. 862-C23. Retrieved 1/20/19