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Everything You Ever Wanted to Know About Ankle Sprains. Rodney S. Gonzalez, MD MAJ, MC, USA Adapted from: Sean T. Mullendore Maj, MC, USAF. Objectives. Describe incidence of ankle sprains Diagnosis and classification Acute, subacute, & prophylactic treatment Workup of persistent pain.

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everything you ever wanted to know about ankle sprains

Everything You Ever Wanted to Know About Ankle Sprains

Rodney S. Gonzalez, MD


Adapted from:

Sean T. Mullendore


  • Describe incidence of ankle sprains
  • Diagnosis and classification
  • Acute, subacute, & prophylactic treatment
  • Workup of persistent pain
incidence of ankle sprains
Incidence of Ankle Sprains
  • Estimated 1 million present to physicians with acute ankle injuries each year
  • Sprains account for 25% of all sports-related injuries and 75% of all ankle injuries
  • Lateral ankle ligaments are the most commonly injured structures in young athletes
  • More than 40% of ankle sprains have potential to cause chronic problems

Military SpecificGerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998 Oct;19(10):653-60.

  • Over 2 month period, there were 104 ankle injuries accounting for 23% of all injuries
  • 93% of all ankle injuries were sprains
  • 40% of cadets had persistent pain &/or functional disability 6 months after injury

Military SpecificMiser WF, Lillegard WA, Doukas WC. Injuries and Illnesses Incurred by an Army Ranger Unit During Operation Just Cause. Mil Med. 1995 Aug; 160(8):373-80.

  • Retrospective interview of 471 U.S. Army Rangers returning from military action
  • Injury rate = 35%
  • 19.6% of all injuries = ankle injuries
  • 80% of ankle injuries = sprains
  • 66% of all ankle injuries led to limitations of mission completion
  • Ankle injuries caused 3 times more Rangers to be out of duty than GSW and open fractures combined
  • History
    • Where’s the pain?
    • Able to bear weight?
    • Swelling? How soon?
    • Prior injury to foot/ankle?
    • History is often vague
    • Usual mechanism is combination of plantarflexion and inversion of foot
physical exam
Physical Exam
  • Inspection
    • Obvious deformity?
    • Ecchymosis?
    • Swelling?
physical exam1
Physical Exam
  • Palpation
    • Bones
    • Lateral ligaments – ATFL, CFL, PTFL
    • Medial ligaments
    • Syndesmosis
    • Tendons – achilles, peroneal
    • Neurovascular status
range of motion
Range of Motion
  • Plantarflexion
    • 50 °
  • Dorsiflexion
    • 20 °
  • Inversion
  • Eversion
special tests
Special Tests
  • Anterior drawer
  • Talar tilt
  • Squeeze test
  • External rotation
anterior drawer test
Anterior Drawer Test
  • Tests integrity of ATFL
  • Performed with foot in neutral and slightly plantarflexed positions
  • A few millimeters of translation is normal
  • Compare to contralateral side
  • “Suction Sign” is positive if dimple in the anterolateral ankle with maneuver
talar tilt
Talar Tilt
  • Tests integrity of CFL and ATFL
  • Performed with foot neutral and plantarflexed
  • Neutral position tests CFL
  • Plantarflexed position tests ATFL
  • Compare to other side
squeeze test
Squeeze Test
  • Tests integrity of syndesmosis & distal tib-fib joint
  • Pain at anterior-inferior aspect of ankle suggests anterior inferior tibiofibular ligament injury
external rotation test
External Rotation Test
  • Tests integrity of syndesmosis & distal tib-fib joint
  • Pain over anterior or medial ankle suggests syndesmotic injury
ottawa ankle rules
Ottawa Ankle Rules
  • Purpose: to determine which patients with ankle trauma need radiographs
  • Strengths:
    • Decrease unnecessary x-rays, patient waiting times, & diagnostic costs
    • Sensitivity near 100% for detecting malleolar and midfoot fractures
  • Limitations:
    • Only for skeletally mature patients
    • Only applies if seen within 10 days of injury
ottawa ankle rules1
Ottawa Ankle Rules


  • A-P, lateral, mortise views – WEIGHT BEARING
  • Looking for fracture, dislocation, abnormal widening of “clear space”
  • Don’t forget to image the foot if clinically indicated

A-P View of Ankle


Lateral View of Ankle

Mortise View of Ankle

mortise view normals
Mortise View Normals
  • E-F Tib-Talo “clear space” should be ≤ 5 mm
  • A-B Tib-Fib “clear space” should be ≤ 5 mm
classification of lateral ankle sprains by anatomic findings
Classification of Lateral Ankle Sprainsby Anatomic Findings
  • A. Grade I sprain
    • Stretching of ATFL & CFL
  • B. Grade II sprain
    • Partial tear of ATFL & stretching of CFL
  • C. Grade III sprain
    • Rupture of ATFL/CFL & partial tear of PTFL+/- partial tear of tibiofibular ligaments
other than lateral ankle sprains
Other (than lateral) Ankle Sprains
  • Syndesmotic or high ankle sprain
    • Stretching/tearing of syndesmosis and/or inferior tibiofibular ligaments
    • Common mechanism forced external rotation of foot or internal rotation of tibia on planted foot
  • Isolated deltoid ligament sprain
    • Rare, usually accompanied by lateral malleolar fx and/or syndesmotic injury
  • Rehabilitation similar to lateral sprains but more likely to require immobilization and have residual symptoms
other foot ankle injuries and associated problems
Other Foot/Ankle Injuriesand Associated Problems
  • 5th Metatarsal Fractures
    • Avulsion Fracture
    • Jones Fracture
  • Weber or Lauge-Hansen Fractures
    • Weber A
    • Weber B
    • Weber C
  • Masonneuve Fracture
  • Ankle Dislocation
  • Lisfranc Injury
treatment phase i acute
Treatment – Phase IAcute
    • Protection – stirrup splint, walking cast/boot, crutches if unable to bear weight due to pain
    • Rest
    • Ice – 20 min every 2-3 hours for first 48-72 hours
    • Compression
    • Elevation
treatment phase ii subacute
Treatment – Phase IISubacute
  • Weight bearing as soon as tolerated
  • Passive/active ROM
  • Resistance exercises
    • Isometric
    • Isotonic
  • +/- Proprioceptive exercises
treatment phase iii iv rehabilitative functional
Treatment – Phase III-IVRehabilitative/Functional
  • Proprioceptive training
    • Standing on single leg
    • Biomechanical ankle platform system (BAPS)
    • Monitored plyometrics
  • Strength training with gradual progression of resistance from stress-free position to stressful position (i.e. neutral/DF to inversion/PF)
  • Sport-specific exercises
treatment phase v prophylactic
Treatment – Phase VProphylactic
  • Emphasis on functional drills, prophylactic strengthening
  • Protective taping/bracing
    • Non-rigid lace up brace
    • Semi-rigid pneumatic brace
    • Ankle taping?
  • Most patients respond to non-operative management
  • Subjective and objective outcomes similar among operative and non-operative treatment
  • Some recommend surgery for the “high demand athlete” with grade III sprain
  • Delayed reconstruction produces results similar to repair of acute injury
non healing ankle sprains
Non-Healing Ankle Sprains
  • Symptoms not improving after 6 weeks
  • Pain and/or recurrent instability
  • Top 3 causes:
    • Inadequate rehabilitation
    • Inadequate rehabilitation
    • Inadequate rehabilitation
  • Other causes
    • Talar dome OCD, peroneal tendon injury, anterolateral impingement, loose body, OA, tarsal coalition, complex regional pain syndrome

Main problem is instability

Treatment of functional instability. Proprioception exercises, peroneal strengthening

Surgical reconstruction of lateral ligaments




  • Lateral ankle sprains are very common
  • Ottawa ankle rules don’t apply to everyone
  • Radiographs should be weight-bearing
  • Degree of sprain better determined by exam findings than ligament pathology
  • Rehabilitation is key to decrease sxs and return to play
  • Workup of recurrent “sprain” dictated by predominant sx – instability vs. pain