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Disease/ Disorder


Ankle sprain is the stretching or tearing of ankle ligaments. In grade 1 (mild) sprains, a few fibers are torn but there is no laxity or residual instability. Grade 2 (moderate) sprains involve an incomplete tear of the ligament with mild laxity and instability. Grade 3 (severe) sprains are characterized by complete disruption of the ligament with gross instability and laxity.1


Lateral ligament sprains are most common (85% of sprains)2,3 and occur from subtalar supination/inversion, talocrural plantarflexion, and tibial external rotation. As the foot rotates, the anterior talofibular ligament (ATFL) is injured first, then the calcaneofibular ligament (CFL) and posterior talofibular ligaments (PTFL) tend to tear in that sequence, depending on severity of the injury. Eversion sprains are caused by extreme external foot rotation, injuring the deltoid ligament that helps to stabilize the medial ankle. High ankle sprains occur via more severe eversion injuries affecting the tibiofibular syndesmosis and/or the anterior tibiofibular ligament.5

Epidemiology including risk factors and primary prevention

Lateral ankle sprains are the most common athletic injury, comprising 2%-25% of all sports injuries. Up to 25,000 occur in the United States daily, and up to 40% of ankle sprains become chronic. Female athletes are at higher risk than male athletes.  Children are also shown to be at higher risk compared to adolescents and adults.4 The highest prevalence of lateral ankle sprains is seen in basketball, volleyball, and field sports.  Collegiate men’s and women’s soccer, men’s football, and women’s gymnastics have the highest incidence of medial ankle sprain.  High ankle sprains are most commonly seen in football, wrestling, and ice hockey.3

Grade 1 sprains typically heal in 12 days, grade 2 in 2 weeks, and grade 3 from 4.5 to 26 weeks. Risk factors and primary prevention strategies address poor ankle proprioception, weak ankle dorsiflexors and invertors, and poor flexibility. Additionally, body mass index, slow eccentric inversion strength, fast concentric plantar flexion strength, passive inversion joint position sense, and peroneus brevis reaction time correlated with lateral ankle sprains.6,7  Certain high ankle sprains, and, more rarely, lateral sprains may ultimately require surgery for chronic ankle instability.


Lateral Ankle Sprains

As the ankle moves from dorsiflexion to plantar flexion, bony stability decreases and forces on the ankle ligaments increase.5 The ATFL generally consists of two bands that are separated by branches of the perforating peroneal artery.8 The ATFL is intracapsular, has the lowest failure resistance, and is the most important ligament in talofibular stability. It is under maximal stress with the ankle in plantarflexion.  The CFL is extracapsular, thicker, and stronger than the ATFL, and the next to tear in a plantarflexion/inversion injury. The PTFL is the strongest of the three ligaments and, because it is only taut in extremes of dorsiflexion, the least likely to fail.5

High Ankle Sprains

An injury to the ankle syndesmosis is known as a high ankle sprain.  The syndesmosis encompasses several structures in the distal ankle, including the anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament, interosseous ligament, and the transverse tibiofibular ligament.  Together, these ligaments stabilize the distal tibiofibular architecture and prevent separation, which contributes significant stability to the ankle.  The most common mechanism of injury is forced external rotation with the foot in dorsiflexion.  This injury may coexist with either medial or lateral ankle sprains, with medial ankle sprains being more common.9

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

New onset/acute
There is swelling and hemorrhage at the site of ligament disruption. The typical inflammatory cascade ensues with the release of painful inflammatory mediators, such as prostaglandins and interleukins. Capillary endothelial permeability increases, and monocytes migrate to the area. There is pain, often an antalgic gait, and decreased range of motion (ROM).10.11

Ecchymosis, swelling, and ROM may worsen before starting to improve. There is fibrous exudation and scar tissue formation as early as 3 weeks post-injury if the ligament ends are well-approximated. The scar has roughly 75% of the strength of native tissue but retains the ability to support weight bearing.10,11

Chronic ankle instability is characterized by persistent pain, swelling, feelings of “giving way,” and recurrent ankle sprains that continue at least 12 months after initial injury.  Swelling may take several months to completely resolve. ROM deficits and muscular and ligamentous weakness may persist to varying degrees. Functional instability, proprioceptive deficits, and loss of normal ankle kinematics increase the risk of persistent symptoms, recurrent injury, and early degenerative changes.10,11,12

Specific secondary or associated conditions and complications

Ankle dislocation, bony contusion, osteochondral defects (especially in the talar dome), distal lateral malleolar avulsion or spiral fracture, medial malleolar fracture, avulsion of the 5th metatarsal head, talar neck or medial compression fractures, extensor digitorum brevis injuries, peroneal tendon injuries, and calcaneal-cuboid ligament injuries may occur. Sural or peroneal nerve neurapraxia or neuritis may develop, particularly notable with Maisonneuve fractures (proximal fibular fracture and syndesmotic injury) that are sometimes seen concomitantly with high ankle sprains. Knee, hip, low back, or contralateral lower limb pain may develop from altered gait kinematics. Patients who use axillary crutches to offload the affected ankle are at risk for radial nerve injury.13,14,15

Essentials of Assessment


A detailed history of the mechanism of injury is critical.  Patients typically report a history of walking on an uneven surface (e.g., pothole) and suffering an inversion injury.  They may also relate a history of jumping and landing with the foot plantarflexed and inverted. In sport, this often occurs when landing on another player’s foot. Patients may complain of feeling a pop, swelling, limited range of motion, and ankle weakness or instability. Pain is typically worse with weight bearing.  It is important to note the patient’s ability to bear weight both immediately after the injury and at the time of the examination.1,5

Physical examination

Physical examination for lateral ankle sprains should include the fundamental components of a peripheral joint examination, which include inspection, palpation, range of motion, strength testing, sensory testing, reflexes, gait analysis, and special tests.1  Inspection may reveal soft tissue swelling or ecchymosis.  Note that effusion of the tibiotalar joint in grade 2 sprains can occur due to the intracapsular location of the ATFL.  

Palpation may reveal tenderness along the course of the ligaments involved.  It is crucial to palpate bony structures as point tenderness can indicate the need for imaging, as indicated by the Ottawa Ankle Rules.16  Specifically, X-ray imaging of the ankle is indicated if any of the following are present: inability to bear weight for four steps either immediately after imaging or on emergency department examination, tenderness of the posterior aspect of the distal 6 centimeters of the medial or lateral malleoli, tenderness of the navicular bone, or tenderness of the base of the fifth metatarsal bone. 

It is important to assess bilateral ankle ROM in all planes, keeping in mind that normal ankle dorsiflexion is 10 degrees with the knee extended and approximately 20 degrees with the knee flexed.17  Manual muscle testing of dorsiflexion, plantarflexion, inversion, and eversion should be performed and compared to the contralateral side, especially given that inversion and eversion are particularly variable between different individuals.17

Perhaps most importantly, stability of the involved ligaments should be assessed. The anterior drawer test, when performed in plantarflexion, assesses the integrity of the ATFL by applying a force anteriorly, displacing the talus from the tibia. The anterior drawer test has a sensitivity of 80% to 95% and a specificity of 74% to 84% for ligament rupture.17  Note that the optimal timing to perform the anterior drawer test in order to maximize sensitivity and specificity is 4 to 5 days post-injury.18 The CFL can be assessed by performing the anterior drawer test in dorsiflexion, or with the talar tilt test, which also assesses for subtalar instability.  The talar tilt test applies an inversion force to the foot while maintaining position of the lower leg.  Up to 25 degrees of tilt between the articular surfaces of the tibia and talus may be considered normal, though comparison to the unaffected side is critical.17

Sensory testing, reflexes, and palpation of distal pulses can assess for concomitant neurovascular injury.  This should include assessment of the peroneal nerve (superficial and deep branches), sural nerve, dorsalis pedis pulse, and posterior tibial pulse. 

Functional assessment

A full gait and kinetic chain assessment should be performed, as ankle pain and instability can place undue stress on other more proximal joints. The unaffected ankle should be assessed, as inherent laxity, decreased strength, or limited flexibility are underlying risk factors for ankle injury.  Proprioception and balance should be assessed.  Static and dynamic hip abduction strength, single-leg stance assessment, single-leg squat, and stepdown tests can be useful in formulating an appropriate treatment protocol to minimize risk factors.

Laboratory studies

Laboratory studies are not typically indicated in cases of ankle sprain.


Plain radiographs may be indicated to rule out avulsion fractures, osteochondral defects of the talar dome, and fractures of the base of the 5th metatarsal.  Decisions to obtain X-rays should follow the Ottawa Ankle Rules, as described above.16 Specifically, anteroposterior and lateral ankle views should be obtained.  In addition, talar stress views are useful in assessing lateral ankle instability by placing the ankle in an inverted and plantarflexed position, though this is unnecessary in confirming the diagnosis of a lateral ankle sprain.19

Ultrasound may be used to assess the integrity of the ATFL, CFL and PTFL, to assess for tibiotalar effusion, and to potentially identify loose bodies or defects of the talar dome. Ultrasound has the advantage of assessing ankle stability with real-time dynamic stress views.20 It has been demonstrated that ultrasound is as accurate as MRI in the diagnosis of major ankle ligament injury in the emergency department setting, though the accuracy is operator-dependent.19,21

Magnetic resonance imaging (MRI) is typically the study of choice and gold standard to assess both intra-articular and extra-articular manifestations of lateral ankle sprains.  However, it can be less cost-effective and have inferior resolution for partial tears compared to ultrasound.  Overall, MRI is rarely indicated for acute sprains, but is useful in cases of persistent symptoms or chronic ankle instability or to assess for osteochondral defects, syndesmotic injuries, and other bony pathology not identified on radiographs.19


Risk factors for ankle sprain should be assessed, including the types of surfaces on which the patient works or on which the athlete competes. Footwear should be assessed for proper fit, wear, stability, and appropriate arch support.  If necessary, high-top sneakers or high work boots can be utilized to provide increased medial-lateral support and reduce risk of re-injury.

Social role and social support system

Highly competitive athletes and performing artists may require psychological support to cope with the stress of not being able to perform. Injured workers may have better outcomes if they return to work sooner with restrictions or limited duty rather than remaining out of work completely.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Although no specific guidelines exist, treatment approaches are fairly standardized, but also diverge along two pathways. The first pathway is more conservative in that bracing and rest dominate the early parts of treatment, possibly including casting in select cases. The second approach emphasizes mobilization as soon as possible, which can occur with effective early edema control and range of motion exercises. Studies have shown the early mobilization approach to be superior to “standard” care involving relative rest and PRICE protocol for improving pain and functional outcomes in the short term.22

Additional aspects of treatment at different disease stages


  1. Potential curative interventions:
    The clinician should assess for clinical and radiographic signs of syndesmotic instability or fractures that may require surgical intervention. Rarely, high-energy trauma can lead to ankle dislocation or neurovascular compromise that could require urgent surgical intervention.  High-grade syndesmosis injuries with significant tibiofibular diastasis or concurrent disruption of the deltoid ligament may benefit from surgical stabilization.  Syndesmosis injury associated with malleolar fracture requires surgical stabilization of the bony fracture.  However, concurrent repair of the syndesmosis injury is controversial.28
  2. Symptom Management:
    Most ankle sprains receive PRICE therapy as the mainstay of acute care, which consists of protection, relative rest, ice, compression, and elevation.  The goal is to reduce swelling, minimize pain, and minimize loss of ROM. There is relatively strong evidence for both NSAIDs23 and early mobilization, and moderate evidence supporting exercise and manual therapy techniques, in reducing pain and swelling and promoting function.  NSAIDs should be used judiciously given the risk of cardiovascular, renal, and gastrointestinal side effects.  Note that acetaminophen is equally effective as NSAIDs in reducing pain in the first two weeks after an ankle sprain.18
  3. Immobilization:
    Rarely, a walking boot is indicated for severe sprains or if radiographs are not available to rule out fracture.  In general, evidence favors early mobilization and bracing or taping over rigid immobilization, with decreased time to return to play, decreased swelling, and decreased instability.24 However, some data does suggest that short periods of immobilization (no greater than 10 days) can be beneficial for reducing edema and pain.18 Crutches may be needed for protected weight bearing, but long-term use should be discouraged in the absence of fracture or other bony injury. 
  4. Rehabilitation:
    Strategies are intended to stabilize or optimize function and prepare for potential interventions at later disease stages.  Functional rehabilitation should be stressed.  Patients are typically instructed in “alphabet exercises” to maintain ROM and resistance band exercises for strengthening.  Dorsiflexion and eversion strengthening should be stressed for lateral ankle sprains.  Static stretching as a standard component of a rehabilitation program was shown to yield the greatest effects on restoring dorsiflexion after ankle sprains.  Implementation of neuromuscular training within the first week of injury results in higher overall activity levels without increasing pain, swelling, or the rate of reinjury when compared with traditional RICE therapy.22 In addition, proprioceptive exercises improve ankle outcome measures, such as the Functional Ankle Disability Index and Excursion Balance Test.25
  5. Return-to-Play:
    An athlete may return to play when full, painless range of motion and full strength is attained.  A gradual return to sport-specific activities should occur without recurrence of symptoms.  Though full ligament healing takes place over a period of 6 to 12 weeks,11 observational studies show that 90% of high school athletes return to play within 1 week of initial or recurrent ankle sprain.27

Subacute to Chronic/Stable

  1. Secondary prevention and disease management strategies:
    Continuation of proprioceptive and neuromuscular training exercises is critical, as chronic pain may result from incomplete rehabilitation.  Surgical intervention for uncomplicated lateral ankle sprains without associated fracture or syndesmotic injury is reserved for cases with persistent symptoms or instability despite conservative care.  The modified Broström procedure can directly repair injured lateral ligaments and reinforce the extensor retinaculum.  This can be done along with ankle arthroscopy to assess for concomitant intra-articular pathology.29
  2. Symptom Management:
    Control of pain and edema can continue with oral or topical anti-inflammatories as well as cryotherapy. This includes the rehabilitation strategies previously discussed that intend to optimize function and reduce risk of symptom recurrence.
  3. Immobilization:
    Functional bracing can help to reduce pain and swelling in subacute and chronic phases.  This can include elastic bandages, tape, lace-up ankle supports, or semi-rigid ankle supports.  Semi-rigid ankle supports (e.g. stirrup braces) are often used to permit flexion and extension while minimizing inversion & eversion stress on injured ligaments.  When compared head-to-head, bracing and taping performed similarly, though cost analysis favors bracing over taping.26

Pre-terminal or end of life care

  1. Symptom relief:
    For patients with limited mobility or cognitive deficits and a history of chronic ankle instability, a removable cast or walking boot may be necessary to maintain functional mobility. 

Coordination of care

Professional athletes have contractual obligations to fulfill their team roles. Physicians may feel pressure from coaches, athletic trainers, the public, or the athlete to return to play prematurely, often resulting in re-injury. It is the physician’s role to design and ensure completion of a proper ankle rehabilitation program. For injured workers, there may be pressure from the employer to return to work. It is the physician’s job to ensure safe accommodations at work, possibly coordinating work-specific rehabilitation.  Patients may also have less incentive to improve if there is pending litigation.

  1. Parallel practice: Patients may be continuing rehabilitation but still working, competing, or performing.
  2. Coordinated: Employers, coaches, and family may need to be involved to promote a successful outcome.
  3. Multidisciplinary: Athletic trainers, physical therapists, and orthotists may be utilized.
  4. Interdisciplinary: Orthopedic surgeons or podiatrists can be consulted in refractory cases.

Patient & family education

It is important to encourage early mobility, to review the home exercise program, and to discuss balance training. The patient should be well-versed in proprioceptive and sports-specific programs. The role of the family is often pivotal in encouraging adherence to home exercises.

Emerging/unique Interventions

Impairment-based measurement

Time off from work or performance in athletics can be used to estimate severity of symptoms or to chart treatment outcomes.

Measurement of patient outcomes

Outcome measures for research purposes include the Foot and Ankle Outcome Score (FAOS), Functional Ankle Disability Index, Excursion Balance Test, Karlsson’s scale, return to work or sport, or the more generalized SF-36 or PROMIS scales.  VAS scores are often used to track pain.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Often, disagreements exist among clinicians about how aggressively to treat ankle sprains, or when to transition the patient from ice and rest to the mobilization and rehabilitation phases of treatment.  After injury, use of the Ottawa Ankle Rules delineates the need for radiographs to assess for possible ankle fracture.  RICE therapy, electrical stimulation, pain control with NSAIDs or acetaminophen, and ice application do not accelerate recovery by can improve pain control in the short term.  Regarding rehabilitation, early mobilization including neuromuscular and proprioceptive training is preferred to accelerate return to play and reduce risk of recurrence in athletes with ankle sprains.  For chronic instability, functional, non-rigid bracing can reduce the risk of recurrent injury. 

Cutting Edge/ Emerging and Unique Concepts and Practice

Cutting edge concepts and practice

Ultrasound is being used more frequently for point-of-care diagnosis and to guide interventions such as prolotherapy, platelet-rich plasma (PRP), and autologous stem cell treatments.

Emerging/unique interventions

There may be a role for regenerative therapy for torn ligaments, such as prolotherapy, platelet-rich plasma, bone marrow aspirates, or lipoaspirates.  However, the effectiveness of these treatments is not yet fully proven.  A 2020 journal article in Foot and Ankle surgery compared PRP to standard care for patients with grade 2 lateral ankle sprains after a period of immobilization.  There was initial improvement in the PRP group at 8 weeks, but no statistically significant difference between the groups at 24 weeks, suggesting possible benefit in the short term.30 A randomized controlled trial by Laver et al. compared standard rehabilitation to rehabilitation plus a one-time ultrasound-guided PRP injection to the AITFL and tibiofibular joint in patients with high ankle sprain, and found faster return-to-play and lower pain scores in their intervention group.31 Finally, a double-blind, randomized, placebo-controlled study evaluating the use of PRP for acute ankle sprains in the emergency department showed no difference in VAS or lower extremity functional scale (LEFS) after 8 days, though the study was limited by the short follow-up period.32

Gaps in the Evidence- Based Knowledge

Evidence on the role of surgery for chronic ankle instability is conflicting.  Kerkhoffs et al. found similar functional and subjective symptom outcomes when comparing surgical intervention versus conservative management of lateral ligament complex ankle injuries.12 Evidence on regenerative therapies to improve ligament healing is still incomplete and currently not standard of care.


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Original Version of the Topic

Jonathan Kirschner, MD. Ankle Sprain. 11/4/2012.

Previous Revision(s) of the Topic

Jonathan Kirschner, MD. Ankle Sprain. 8/23/2016.

Author Disclosure

Jonathan Kirschner, MD
Selct Medical Corp; Honoraria; Lecture
USBJI; Member of the board, representing AAPMR; Non-remunerative Positions of Influence
Springer; Book royalties; Editor
Elsevier; Book royalties; Editor

Roderick Geer, MD
Nothing to Disclose