Ankle sprains are common injuries that can range from mild to severe depending on the ligament damage. The most common type is a lateral ankle sprain caused by foot inversion. Treatment involves RICE (rest, ice, compression, and elevation) followed by rehabilitation exercises and bracing. For severe or recurrent sprains, surgery may be considered to repair ruptured ligaments and reduce instability. Proper rehabilitation is important to aid recovery and prevent chronic issues.

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Ankle Sprain
Dr. Ahmed Rashad
PGY 2 Family Medicine

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Introduction
 Ankle injuries are among the most common injuries presenting
to primary care offices and emergency departments [1].
 Ankle ligaments provide mechanical stability, proprioceptive
information, and directed motion for the joint.
 Recurrent ankle sprains can lead to functional instability and
loss of normal ankle kinematics and proprioception, which can
result in recurrent injury, chronic instability, and early
degenerative bony changes.[2]

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Anatomy

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Classification
Lateral ankle sprain
 The most common mechanism of
ankle injury is inversion of the
plantar-flexed foot.
 The anterior talofibular ligament is
the first or only ligament to be
injured in the majority of ankle
sprains. Stronger forces lead to
combined ruptures of the anterior
talofibular ligament and the
calcaneofibular ligament, which can
result in significant ankle joint
instability, usually accompanied with
nerve injury. [3]

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Medial ankle sprain
 The medial deltoid ligament
complex is the strongest of
the ankle ligaments and is
infrequently injured.
 Forced eversion of the ankle
can cause damage to this
structure but more commonly
results in an avulsion fracture
of the medial malleolus
because of the strength of the
deltoid ligament.

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Syndesmotic sprain
 Dorsiflexion and/or eversion of
the ankle may cause sprain of
the syndesmotic structures,
which include the anterior
tibiofibular, posterior tibiofibular,
and transverse tibiofibular
ligaments, and the
interosseous membrane.These
structures are critical to ankle
stability.
 Syndesmotic ligament injuries
contribute to chronic ankle
instability and are more likely to
result in recurrent ankle sprain
and the formation of
heterotopic ossification. [4]

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Grading
 Grade I sprain:
a. It results from mild stretching of a ligament with microscopic
tears.
b. Patients have mild swelling and tenderness.
c. There is no joint instability on examination, and the patient is
able to bear weight and ambulate with minimal pain

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 Grade II sprain
a. Is more severe injury involving an incomplete tear of a
ligament.
b. Patients have moderate pain, swelling, tenderness, and
ecchymosis.
c. There is mild to moderate joint instability on exam with some
restriction of the range of motion and loss of function.
d. Weightbearing and ambulation are painful

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 Grade III sprain
a. involves a complete tear of a ligament.
b. Patients have severe pain, swelling, tenderness, and
ecchymosis.
c. There is significant mechanical instability on exam and
significant loss of function and motion. Patients are unable to
bear weight or ambulate

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Ottawa ankle rules
 Clinicians should
remember that multiple
systematic reviews
have found the Ottawa
ankle rules to be highly
sensitive. [5]

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 The rules are as follows :
i. An ankle series is only indicated for patients who have pain in
the malleolar zone AND
ii. Have bone tenderness at the posterior edge or tip of the lateral
or medial malleolus OR
iii. Are unable to bear weight both immediately after the injury and
for four steps in the emergency department or doctor's office.
iv. A foot series is only indicated for patients who have pain in the
midfoot zone AND
v. Have bone tenderness at the base of the fifth metatarsal or at
the navicular OR
vi. Are unable to bear weight both immediately after the injury and
for four steps in the emergency department or doctor's office.

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Examination ( Special tests)
Squeeze test
 The squeeze test consists of
compression of the fibula
against the tibia at the mid-
calf level. This maneuver
elicits pain in the region of the
anterior tibiofibular ligament
(anterior to the lateral
malleolus and proximal to the
ankle joint) when a
syndesmotic sprain has
occurred.

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Talar tilt test
 The talar tilt test detects
excessive ankle inversion. If
the ligamentous tear extends
posteriorly into the
calcaneofibular portion of the
lateral ligament, the lateral
ankle is unstable and talar tilt
occurs.
 With the ankle in the neutral
position, gentle inversion
force is applied to the affected
ankle, and the degree of
inversion is observed and
compared with the uninjured
side.

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External rotation stress test
 The external rotation stress
test can also help identify a
syndesmotic sprain.
 The clinician stabilizes the leg
proximal to the ankle joint
while grasping the plantar
aspect of the foot and rotating
the foot externally relative to
the tibia. The test is positive if
pain is elicited in the region of
the anterior tibiofibular
ligament (anterior to the
lateral malleolus and proximal
to the ankle joint

16. + Anterior drawer test
 The anterior drawer test detects
excessive anterior displacement
of the talus on the tibia. The test
is performed with the patient's
foot in the neutral position
(slightly plantar flexed and
inverted).
 The lower leg is stabilized by
the examiner with one hand,
and with the opposite hand, the
examiner grasps the heel while
the patient's foot rests on the
anterior aspect of the
examiner's arm.
 An anterior force is gently but
steadily applied to the heel
while holding the distal anterior
leg fixed.

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Management
Immediate therapy
Rest
Ice
Compression
Elevation

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 Exercises including plantar flexion, dorsiflexion, and foot circles
should be started early, once acute pain and swelling subside,
to maintain range of motion.
 The intensity of rehabilitation is increased gradually.
 Ankle splints or braces can limit extremes of joint motion and
allow early weightbearing while protecting against reinjury.
 The treatment of severe (grade III) ankle sprains is
controversial. A brief period of immobilization may be helpful in
some instances.

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Rehabilitation
 Functional rehabilitation is of great importance in aiding the return
to activity and preventing chronic instability.
 Early functional rehabilitation includes :
a. Range of motion exercises (Achilles tendon stretch, foot
circles , alphabet exercises; have the patient trace letters in the
air with his big toe)
b. Muscle strengthening exercises (isometric and isotonic
plantar flexion, dorsiflexion, inversion, eversion, toe curls and
marble pickups, heel walks and toe walks), and proceeds to
c. Proprioceptive training (circular wobble board and walking on
different surfaces) and [6] [7]
d. activity-specific training (walk-jog, jog-run).

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Splints and braces
 During functional rehabilitation, it may be of benefit to use
splints, braces, elastic bandages, or taping to try to reduce
instability, protect the ankle from further injury, and to limit
swelling. Studies have shown that:
i. Lace-up ankle supports were superior to semi-rigid ankle
supports, elastic bandages, and tape in preventing persistent
swelling.
ii. Semi-rigid ankle supports resulted in a quicker return to work
and to sports, and less instability at short-term follow-up,
than elastic bandages.
iii. Tape caused more skin irritation than elastic bandages. [8]

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Surgery
 Surgical repair of ruptured ankle ligaments is sometimes
considered in patients with ankle sprains.
 A meta-analysis that looked at controlled trials of surgery for
acute ruptures of lateral ankle ligaments found that compared
with functional treatment, patients treated with surgery were
significantly less likely to experience giving-way of the ankle
(relative risk 0.23, 95% CI 0.17-0.31). [9]

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Resources
 [1] Boruta PM, Bishop JO, Braly WG, Tullos HS. Acute lateral
ankle ligament injuries: a literature review. Foot Ankle 1990;
11:107.
 [2]Anandacoomarasamy A, Barnsley L. Long term outcomes of
inversion ankle injuries. Br J Sports Med 2005; 39:e14;
discussion e14.
 [3] Nitz AJ, Dobner JJ, Kersey D. Nerve injury and grades II
and III ankle sprains. Am J Sports Med 1985; 13:177.
 [4] Taylor, DC, Englehardt, DL, Bassett, FH III. Syndesmosis
sprains of the ankle: The influence of heterotopic ossification.
Am J Sports Med 1992; 20:146.

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Resources
 [5] Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa
ankle rules to exclude fractures of the ankle and mid-foot:
systematic review. BMJ 2003; 326:417.
 [6] Wester JU, Jespersen SM, Nielsen KD, Neumann L.
Wobble board training after partial sprains of the lateral
ligaments of the ankle: a prospective randomized study. J
Orthop Sports Phys Ther 1996; 23:332.
 [7] 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 2004; 32:1385.

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Resources
 [8] Seah R, Mani-Babu S. Managing ankle sprains in primary
care: what is best practice? A systematic review of the last 10
years of evidence. Br Med Bull 2011; 97:105
 [9] Pijnenburg AC, Van Dijk CN, Bossuyt PM, Marti RK.
Treatment of ruptures of the lateral ankle ligaments: a meta-
analysis. J Bone Joint Surg Am 2000; 82:761

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