Journal of Musculoskeletal Research, Vol. 16, No.

4 (2013) 1330003 (10 pages)

World Scientic Publishing Company
DOI: 10.1142/S0218957713300032

LATERAL ANKLE SPRAIN AN UPDATE

Shibli Nuhmani
Department of Rehabilitation Sciences
Jamia Hamdard University, Hamdard Nagar
New Delhi, India

Moazzam Hussain Khan

Jamia Millia Islamia University
New Delhi, India
drmhk5881@gmail.com

Received 4 September 2013

Accepted 23 January 2014
Published 12 March 2014
ABSTRACT
Ankle sprain injuries are the most common injury sustained during sporting activities. One-sixth of all
sports injury loss time is from ankle sprains. Each year, an estimated 1 million people present to
physicians with acute ankle injuries. Three-quarters of ankle injuries involve the lateral ligamentous
complex, comprised of the anterior talobular ligament (ATFL), the calcaneobular ligament (CFL)
and the posterior talobular ligament (PTFL). Lateral ankle sprains typically occur when the rearfoot
undergoes excessive supination on an externally rotated lower leg. The diagnosis of a sprain relies on
the medical history including symptoms, as well as making a differential diagnosis mainly in distinguishing it from strains or bone fractures. Despite their prevalence in society, ankle sprains still
remain a difcult diagnostic and therapeutic challenge in the athlete, as well as in society in general.
The high incidence of ligamentous ankle injuries requires clearly dened acute care and a broad
knowledge of new methods in rehabilitation. In addition to rapid pain relief, the main objective of
treatment is to quickly restore the range of motion of the ankle without any major loss of proprioception, thereby restoring full activity as soon as possible. The purpose of this article is to review the
anatomy, pathomechanics, investigation, diagnosis and management of lateral ankle sprains.
Keywords: Lateral ankle sprain; Lateral collateral ligaments; Functional rehabilitation.
*Correspondence

to: Moazzam Hussain Khan, Jamia Millia Islamia (Central University), New Delhi, India. E-mail: drmhk5881

@gmail.com
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S. Nuhmani & M. H. Khan

INTRODUCTION
Injuries to the lateral ligaments of the ankle
complex are the most common musculo skeletal
injuries seen among the recreational and competitive athletes.21,44 It creates long-term disabilities. It has signicant impact on cost, athletic
participation and activities of daily life.22
Since most sports activities involve running,
jumping and turning, high stresses are often put
on the joints of the lower limbs, including the
ankle. Hansen et al.23 reported that 67.3% of their
football players had sprained their ankles during
sports. Smith and Reischl49 reported that 70% of
their basketball players had a history of ankle
sprain and 80% of them had multiple sprains.
Chronic ankle problems such as chronic pain,
muscular weaknesses and ease of giving way
were not uncommon for those athletes with a
history of ankle sprain.19,50
Traditionally, the diagnosis of ankle sprain is
based on history and delayed physical examination, 57 days after initial trauma.55 The most
common injury mechanisms are supination and
adduction (called inversion) with the foot plantar
exed. Any additional X-rays are used only to
exclude other diagnoses, such as a fracture or
disturbance of the joint congruency, based on the
Ottawa ankle rules.2 Generally, the prognosis of
ankle injuries is good, whatever treatment is followed.63 Zeegers has showed that at least 80% of
patients in all compared treatment groups were
free of complaints after one year.42 However,
there is still potential for improvement in 20% of
these patients.

ANATOMY AND PATHOMECHANICS

The ankle joint comprises of three major articulations: the talocrural joint, the subtalar joint
and the distal tibiobular syndesmosis.25 The
talocrural joint is also termed as the tibiotalar
joint or the mortise joint, and is formed by the

articulation of the dome of talus, the tibial plafond, the medial malleolus and the lateral malleolus. This joint, in isolation, behaves rather like
a hinge joint that allows mainly plantarexion
and dorsiexion. The bula extends further to the
lateral malleolus than the tibia does to the medial
malleolus, thus creating a block to eversion.1
Such body feature mainly allows larger range of
inversion than eversion, thus, inversion sprains
are more common than eversion ones.24
The ligaments that surround the ankle joint
consist of the lateral collateral ligaments, syndesmotic ligaments and the medial collateral
ligaments (MCLs). The lateral collateral ligaments consist of the anterior talobular ligament
(ATFL), calcaneobular ligament (CFL) and the
posterior talobular ligament (PTFL).11,57 Generally, the lateral collateral ligaments are weaker
and more prone to injury than MCL. The ATFL is
the most frequently damaged lateral collateral
ligament followed by CFL and then PTFL which
is rarely injured. The ATFL extend from the anterior portion of the distal bula stretching forward to insert on the talus. Its role in the ankle
mechanics is checking plantar exion and inversion of the ankle. Thus, it is these movements that
stress the ligaments most and cause it to be
damaged.27,31,53,60
The higher incidence of inversion trauma over
eversion sprain injuries can be partially explained
by two anatomical considerations. First, is medial
malleolus is shorter than lateral malleolus which
allow the talus to invert than evert. Second, the
ligament structures on the lateral side of the joint
occur as a discrete fascicular bundle and therefore
are not strong as the broader, expansive deltoid
ligament on the medial side and hence rupture.

MECHANISM OF INJURY
Lateral ankle sprains most commonly occur due
to excessive supination of the rear foot about an

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Lateral Ankle Sprain

externally rotated lower leg soon after initial

contact of the rear foot during gait or landing
from a jump.3,18 The ATFL is the rst to rupture
with such forced inversion of the ankle. Rupture
of the ATFL is always associated with rupture of
the joint capsule because the ligament is incorporated into capsule.
Rupture of ATFL because of forced inversion
allows the anterior subluxation of the talus out of
the ankle mortise. Forced plantar exion in
combination with adduction causes rupture of
the ATFL, followed by partial rupture of CFL. If
the continued force is applied the CFL ruptures
completely followed by the rupture of PTFL.

CLASSIFICATION
Lateral ankle sprains are based on a grade 1 to 3
classication. A grade 1 ankle sprain usually
entails microscopic tearing of the ATFL. Symptoms may include minimal swelling and point
tenderness directly over the ATFL; however,
there is no instability, and the athlete can ambulate with little or no pain. A grade 2 ankle
sprain involves microscopic tearing of a larger
cross-sectional portion of the ATFL. Symptoms
may include a broader region of point tenderness
over the lateral aspect of the ankle, a painful
limp if able to ambulate and bruising and localized swelling due to tearing of the anterior joint
capsule, ATFL, and surrounding soft tissue
structures. A grade 3 ankle sprain entails a
complete rupture of the ATFL and may also involve microscopic or complete failure of the CFL.
The PTFL is rarely injured during inversion
ankle sprains. Symptoms may include diffuse
swelling that obliterates the margins of the
Achilles tendon, inability to ambulate and tenderness on the lateral and medial aspects of the
ankle joint.6,43,57
The following orthopedic tests may prove
useful in aiding diagnosis.4,5,28,37,40,45,51,62

Anterior drawer test: Stabilizing the tibia

and bula, the foot is held in 20  of plantar
exion while the talus is drawn forward in the
ankle mortise. This tests the integrity of the ATFL
and anterior joint capsule. A positive test result
would be greater than 5 mm of anterior motion of
the STJ as compared with the noninjured ankle,
and an audible clunk may be elicited. If the ankle
is inverted while conducting the anterior drawer
test, it also evaluates the integrity of the CFL.
Talar tilt test: The ankle is held in anatomical position, and the talus is tilted into adduction
and abduction. This primarily tests the integrity
of the CFL when the foot is in a neutral position;
when the test is performed with plantar exion, it
also evaluates the integrity of the ATFL. A positive test result would be 5  to 10  of increased
inversion as compared with the noninjured ankle
and would be indicative of a tear of the CFL.
External rotation test: Manual passive external rotation of the foot and ankle in a neutral
or slightly dorsiexed position would widen the
ankle mortise. Pain over the distal syndesmosis is
positive for a syndesmotic injury.
Tibia=fibula squeeze test: Result is positive
for a syndesmotic sprain if compression of the
tibia and bula in the midcalf region produces
pain over the distal syndesmosis.
Stabilization test: Tape is applied around the
distal syndesmotic region for support. A positive
test result for syndesmotic injury would reduce
pain over the distal syndesmosis during ambulation or when performing a heel raise.

INVESTIGATION
Plane radiograph: Radiographs are taken to rule
out fracture of the medial and lateral malleoli, the
talus and the fth metatarsal layer.
Stress radiograph: It is helpful in determining the completeness of the ligamentous tear or
determining the presence of avulsed fragments of

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S. Nuhmani & M. H. Khan

the bone. Traction forces are applied to the ankle

to promote tilt or drawer effect and comparison
are made between injured and uninjured side.
Arthrography: It is performed within 48 h of
the injury to evaluate multiple ligament injury.
Tenography: It is used for detecting multiple
ligament rupture but an isolated ATFL injury
cannot be detected by this technique.
MRI: It is the highly reliable and accurate
imaging modality for evaluation of precise location and extends of partial to complete tear of
collateral ligaments.

DIFFERENTIAL DIAGNOSIS
Medial ligament sprain
Syndesmosis sprain
Bifurcate ligament injury
Achillus tendon rupture
Peroneal tendon suluxation or dislocation
Flexor hallucis longus injury
Lateral periostitis
Ostrigonum injury
Anterior tibial tendon injury
Fractures

MANAGEMENT
Acute phase: Early management includes rest,
ice, compression and elevation (RICE). Cryotherapy should be used immediately after the
injury. Heat should not be applied to an acutely
injured ankle joint because it encourages swelling
and inammation through hyperaemia.30 Crushed ice in a plastic bag may be applied to the
medial and lateral ankle over a thin layer of cloth.
Alternatively, the foot and ankle may be cooled
by immersion in water at a temperature of
approximately 12.7  C (55  F). The foot and ankle
should be cooled for approximately 20 min every
two to three h for the rst 48 h or until edema
and inammation have stabilized. Benets of

cryotherapy include a decrease in metabolism

that limits secondary hypoxic injury.30 In sub
acute phase, the goals include continued reduction of swelling, inammation and pain while
some motion strengthening and appropriate
controlled weight bearing are started. The rehabilitative phase focuses on improving strength,
endurance, tolerance and weight bearing proprioception.
Treatment modalities during functional rehabilitation focus upon improving ankle mobilization and proprioception. The stationary bicycle
and swimming can be useful to improve the ankle
range of motion. Strengthening is begun only
after normal weight bearing and pain-free range
of motion. Therapy focused on improving proprioception can utilize the tilt board and trampoline as a means to increase balance and
neuromuscular control. Boyce et al.10 reported
that the use of an Aircast ankle brace produced
signicant improvement in ankle joint function in
10 days and one month compared with an elastic
support bandage. Madras and Barr34 reported
that ankle disk training on wobble board were
effective in enhancing single leg balance and reducing recurrent sprain injury, while Osborne
and co-workers41 and Sheth and co-workers48
reported the effect of ankle disk training in enhancing peroneal muscle reaction time. De Simoni
and co-workers16 suggested that a 12-week prescription of orthosis was effective in improving
functional stability at the ankle joint. Recently,
Christakou et al.13 suggested that imagery may be
effective in improving muscle endurance in the
rehabilitation of grade 2 ankle sprain.

Treatment of Grade 1 and 2 Ankle

Sprains for Which Types/Severity
of Injuries?
The goals of therapy are to accentuate the normal
healing process and protect the ligament from

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Lateral Ankle Sprain

further injury. The acronym PRICESMMS stands

for proprioception training, rest/modied activity, ice, compression, elevation, stabilization,
medications (nonsteroidal anti-inammatory
drugs), mobilization and strength training.12
These rehabilitation techniques should be applied
appropriately during each phase of treatment.
Progression of the treatment plan depends on
the severity of injury, the patients response to
therapy and the achievement of goals during
each treatment phase.52,57

Acute Inammatory Phase (2472 h)

.

Ice therapy should be applied for 20 min on/1 h

off throughout the day, with a compression
bandage and the leg elevated above the heart.
Cryotherapy reduces pain, edema and secondary hypoxic damage to injured tissues.8,9,37,43
Nonsteroidal anti-inammatory drugs, electric
muscle stimulation, pulsed ultrasound, antiedema massage and low-level laser therapy
may help in reducing inammation.43,47,57
Ankle pumps, 10 to 20 pumps per hour, should
be conducted in a pain-free range to decrease
edema and increase circulation.57
Ambulate weight bearing as tolerated with
axillary crutches if necessary. A semirigid orthosis, laceup style brace or tape provides mechanical joint stability in the frontal plane14,15
Depending on the severity of injury, pain-free
modied activity can be used to maintain cardiovascular tness. Examples of modied
activity may include deep-water pool running,
swimming with a pool buoy between the legs
or stationary cycling.7,35,57
Several studies were conducted on grade 1 and
grade 2 ankle inversion injuries using manipulation of the TCJ. Two studies showed manipulation of the talus in an anterior to
posterior vector improved range of motion in
dorsiexion at the ankle mortise.20,32 Another

study showed that manipulation of the joints

and soft tissue improved dorsiexion as well as
reduced pain and edema.17
Active or passive soft tissue techniques such as
Active Release Technique, Graston Technique,
muscle energy technique and transverse friction massage can be applied directly to the
ligament and surrounding soft tissue structures
to facilitate early ligament healing.

Numerous clinical studies support the use of

transverse friction massage in the treatment of
ligament sprains.58 Recently, Loghmani and
Warden33 conducted a study on instrumentassisted crossber massage (IACFM) and its effect on ligament healing. Bilateral MCL injuries
were induced on the knees of 51 rodents. The
IACFM was commenced with a Graston handheld tool on one of the rodents MCLs one week
post injury, at a frequency of three sessions per
week and for duration of a minute. The contra
lateral MCL was used as the nontreated control.
Histological sections were obtained four weeks
post-injury. The scar region of the IACFM-treated
ligaments, as compared with the contra-lateral
nontreated ligaments, appeared to have greater
cellularity; and the collagen bers appeared to be
aligned more longitudinally. This study suggests
that IACFM may accelerate early tissue-level
healing.33
A more cautious approach to treatment may be
necessary if there is suspicion of a grade 3 lateral
ankle sprain.57 In the opinion of one of the authors,
if the initial examination reveals severe swelling,
pain and inability to bear weight, the athlete
should be placed in a functional walking orthosis
and instructed to ambulate with crutches in a
nonweight bearing gait. Nonsteroidal anti-inammatory drugs, ice, compression and elevation
should be used to attempt to reduce swelling and
pain. A re-examination should be conducted three
days later. If there is no observable improvement,

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S. Nuhmani & M. H. Khan

an MRI study should be used to assess the severity

of injury. If the MRI indicates a completely torn
ligament, the athlete should continue to follow the
above regimen for approximately four more days,
thereby allowing the retracted ligament ends to
heal appropriately before progressing to the next
stage of treatment.

Reparative Phase (35 days, Collagen

Production Intensies 1014 days)
Goals include reducing inammation, facilitating
the ligament healing process, restoring active and
passive ranges of motion, minimizing loss of
strength, maintaining cardiovascular tness and
starting Propioceptive rehabilitation.7,46,57
.

Joint mobilization and soft tissue techniques

of the TCJ and the STJ to free up joint restrictions and aid in improving range of
motion.17,20,32,43,57
Passive stretch of the gastrocnemius and soleus
musculature with a towel, 3 sets of 30-s holds.
Stretching on a slant board or with a prostretch can be incorporated when the patient
can at least partially bear weight with minimal
pain.
Isometric exercise should be conducted as soon
as the patient can tolerate it to prevent muscle
atrophy.47 Active and passive range of motion
can be conducted with minimal pain in dorsiexion, plantar exion, eversion and the painfree range of inversion. The therapist may
conduct 3 sets of 10 with a 3- to 5-s hold at the
passive end range. The patient can conduct
isometric exercises at home.
Strengthen the peroneii, tibialis anterior and
extensors, and the triceps surae with theraBand, 3 sets of 10 to 15 reps for each muscle
group57 also strengthen the gluteus medius
musculature to prevent lateral sway61 once the
patient can fully weight bear without pain, he
can add resistance greater than body weight as

tolerated. This may include standing and

seated calf raises. If no weights are available,
teach the patient to go up on the toes on both
feet and then shift all the weight to the injured
side and lower down on that leg.
Standing proprioception training can be conducted on the oor, a wobble board or an airlled cushion. Start with single-leg standing on
a at surface, 3 times with 30-s holds; use
upper extremity support from a counter if
necessary. Progress to eyes closed. Progress to
exercises on an air-lled cushion. Have patient
balance on a wobble board for 30 to 60 s conducting various drills.35,56,59 Proprioception
training has been shown to reduce the occurrence and reoccurrence of ankle sprains38,54
Proprioception training in the seated position
with the biomechanical ankle platform system
(BAPS) board.
Shoe gear modication depending on the
athletes foot structure and the playing surface.5
At the end of each treatment session, apply
ice therapy and other modalities to control
Inammation.43

The above exercises should be conducted relatively pain-free and progressed based on the
patients response to therapy and based on the
principles of ligament healing. After demonstrating prociency in conducting the exercises
under the supervision of a therapist, the patient
can be given a home exercise routine. If there is
an excessive increase in swelling or pain, temporarily reduce the intensity or duration of the
exercises followed by inammation control.

Remodeling Phase (1528 Days, 3 Weeks

Regain 60% Strength, 3 Months Regain
100% Strength)
Goals include restoration of tensile strength,
proprioception and return to sport.46,57

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Lateral Ankle Sprain

.

Modied training may progress and include

activities such as jumping rope, higher-intensity
training runs or sprints.
Incorporation of multidirectional agility drills
can begin at this stage. Start with controlled
exercises that are on both legs; then progress to
single leg. Progress to jumping over a height,
such as a low cone. Progress to increasing in
speed. It is important to vary the speed and
intensity of sport-specic exercises to continually challenge the proprioceptive system.36 All
progressions should be performed only as pain,
comfort and stability allow.
 Begin jumping forward and backward over a
line.
 Progress to jumping laterally over a line.
 Progress to box drills.
 Incorporate multidirectional sport-specic
proprioceptive exercises.

After being discharged from care, the athlete

should be encouraged to continue a home exercise
program to ensure full restoration of impairments
and to prevent reinjury. McHugh et al.39 had
football players with a history of ankle sprains
perform single-leg stance on a foam stability pad
for 5 min each leg. This was done ve days a week
for four weeks of pre-season and two days a week
for nine weeks during the season. This was the
only preventative exercise used and was done on
their own. The study showed a 77% decrease in
injury incidence. A study by Hupperts et al.26
showed a similar decrease in injury risk with unsupervised exercises, demonstrating that a home
program can be an effective tool in rehabilitation.

immobilization for treatment of ankle sprains.29

Five of the trials showed that, compared with
immobilization, more patients undergoing functional treatment returned to sports during the
study period, and two trials showed that these
patients returned to sports 4.6 days sooner (95%
condence interval (CI), 1.5 to 7.6). Seven of the
trials showed that patients undergoing functional
treatment returned to work 7.1 days sooner than
those treated with immobilization (95% CI, 5.6 to
8.7). Although the extent and type of benet associated with functional treatment varied among
individual studies, no benets were seen with
immobilization.
Functional treatment usually consists of three
phases: (1) the PRICE protocol is initiated within
24 h of injury to minimize pain and swelling and
limit the spread of injury; (2) exercises to restore
motion and strength usually begin within 48 to
72 h of injury (see accompanying patient handout
for exercise descriptions); and (3) endurance
training, sport-specic drills and training to
improve balance begin when the second phase is
well underway.

CONCLUSION
This paper summarizes the current knowledge on
lateral ankle sprain which is the one of the most
common sports related injury. An accurate diagnosis and prompt treatment can minimize an
athletes time lost from sport and prevent future re
injury. Key points of rehabilitation are control of
pain and swelling acutely with nonsteroidal antiinammatories and RICE, then restoring normal
range of motion, strengthening muscle groups
and retraining proprioception of the ankle joint.

Functional Treatment
Although the overall quality of studies on functional treatment is somewhat limited, a systematic review of 21 trials (2184 total participants)
showed that functional treatment is superior to

ACKNOWLEDGMENT
We represent that this submission is original
work, and is not under consideration for publication with any other journal.

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S. Nuhmani & M. H. Khan

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