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Ankle sprain

Background

Overview

Definition
An ankle sprain is an injury to the lateral ligament complex of the ankle joint.
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Pathophysiology
A traumatic inversion and adduction of the plantar flexed foot is the most common cause of an ankle sprain. Risk factors include a previous ankle sprain, a history of ligament hyperlaxity syndrome, and anatomical misalignments (crus varum and pes cavo-varus).
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Disease course
The inversion and supination of plantar flexed foot result in an ankle sprain, which causes clinical manifestations of pain, intermittent swelling localized to the lateral side of the affected ankle, mechanical instability, and stiffness. Persistent or recurrent instability can lead to degenerative changes in the cartilage.
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Prognosis and risk of recurrence
An ankle sprain is not associated with an increase in mortality.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of ankle sprain are prepared by our editorial team based on guidelines from the American Physical Therapy Association (APTA 2021), the Dutch Consensus Group on Ankle Sprain (DCG-AS 2018), the National Athletic Trainers' Association (NATA 2013), and the American Academy of Family Physicians (AAFP 2012). ...
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Diagnostic investigations

History and physical examination, general principles: as per APTA 2021 guidelines, elicit a thorough history and perform a physical examination to aid in the diagnosis of a lateral ankle sprain.
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  • History and physical examination (special tests)

  • Diagnostic imaging (Ottawa ankle rule)

  • Diagnostic imaging (choice of modality)

Medical management

NSAIDs: as per APTA 2021 guidelines, consider offering NSAIDs (as physical therapy practice acts allow) to reduce pain and swelling in patients with an acute lateral ankle sprain.
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Nonpharmacologic interventions

General principles
As per APTA 2021 guidelines:
Consider offering multiple interventions to supplement balance training over an episode of care in patients with chronic ankle instability, including a combination of exercise and manual therapy procedures as guided by the patient's values and goals, the clinician's judgment, and evidence-based clinical recommendations.
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Consider offering psychologically informed techniques, such as motivational interviewing, to maximize the patient's self-efficacy and to address uncomplicated psychological correlates and mediators of injury adjustment and recovery in order to maximize the effects of treatment positively in patients with a lateral ankle sprain or chronic ankle instability.
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  • Rest, ice, compression, and elevation

  • Taping and bracing

  • Footwear

  • Exercise therapy

  • Manual therapy

  • Acupuncture and dry needling

Therapeutic procedures

Pulsed shortwave diathermy: as per APTA 2021 guidelines, consider offering pulsating shortwave diathermy for reducing edema and gait deviations associated with acute ankle sprains.
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  • Laser therapy

  • Electrotherapy

  • Therapies with no evidence for benefit

Specific circumstances

Patients with syndesmotic ankle sprain: as per NATA 2013 guidelines, recognize that syndesmotic ankle sprains ("high" ankle sprains) are characterized by symptoms proximal to the talocrural joint, including prolonged pain, functional disability, and heterotopic ossification.
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Preventative measures

Training programs: as per NATA 2013 guidelines, implement a multi-intervention injury prevention program of at least 3 months focusing on balance and neuromuscular control to reduce the risk of ankle injury in athletes. Consider offering this type of training in athletes with a history of ankle injury.
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  • Taping and bracing

Follow-up and surveillance

Rehabilitation
As per APTA 2021 guidelines:
Offer rehabilitation programs with a structured therapeutic exercise component, including protected active ROM, stretching exercises, neuromuscular training, postural re-education, and balance training, both in a clinic and at home, as determined by injury severity, identified impairments, preferences, learning needs, and social barriers in patients with a lateral ankle sprain.
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Consider augmenting the unsupervised components of a home program with written instructions, exercise-based video games, or app-based instruction, determined by the patient's specific learning needs and access to relevant technology, in patients with a lateral ankle sprain.
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  • Return to work

  • Return to sport