LE ORTHOPEDIC CONDITIONS
ANKLE – ANKLE SPRAIN
DEFINITION1
o ankle sprain may be defined as injury to the
ligaments of the ankle joint, most commonly
the lateral ligament
o ankle sprains are classified according to
severity
o Table 1: Grading System for ankle sprain
Grade Characteristics
I o Mild sprain, mild pain, little
swelling, and joint stiffness
may be apparent
o Stretch or minor tear of the
ligament without laxity (i.e.,
loosening) Usually affects the
anterior talofibular ligament
Minimal or no loss of function
o Can return to activity within a
few days of the injury (with a
brace or taping)
II o Moderate to severe pain,
swelling, and joint stiffness are
present
o Partial tear of one or more
lateral ligaments
o Moderate loss of function with
difficulty on toe raises and
walking
o Takes up to 2 to 3 months
before regaining close to full
strength and stability in the
joint
III o Severe pain may be present
initially, followed by little or no
pain due to total disruption of
the nerve fibers.
o Swelling may be profuse and
joint becomes stiff some hours
after the injury
o Complete rupture of the
ligaments of the lateral
complex (i.e., severe laxity)
o Usually requires some form of
immobilization lasting several
weeks
o Complete loss of function (i.e.,
functional disability) and
necessity for crutches
o Usually managed
conservatively with
rehabilitation exercises, but a
small percentage may require
surgery
o Recovery can be as long as 4
months
ETIOLOGY1,2,3
o The usual mechanism of injury is inversion
and adduction (usually referred to as
supination) of the plantar flexed foot.
o Predisposing factors are a history of ankle
sprains, ligament hyperlaxity syndrome, and
specific malalignment, such as crus varum
and pes cavo-varus.
Risk factors1
o Lack of physical conditioning or sedentary
lifestyle
o Failure to stretch or warm up properly before
physical activity
o Improper or inadequate footwear
o Performing physical activities on uneven
ground or other surfaces
o History of previous ankle sprain
o Certain sports activities, such as basketball,
cross-country running, and football, which
are associated with a higher risk for ankle
injury
EPIDEMIOLOGY1
o the ankle is the most common injured joint
among athletes
o ankle sprain is a frequent cause of morbidity
in the general population
o Age
 No specific age group appears to be
affected, although most ankle
sprains tend to occur in younger
people and among athletically
inclined individuals
 Individuals who are older or
physically inactive are more at risk
for ankle injury.
o Gender
 Both sexes are affected.
 Significant gender differences have
not been reported
o Prevalence
 Sprains account for about 85% of
ankle injuries.
 It is estimated that acute ankle injury
accounts for about 10% to 30% of
sports-related injuries.
 Annually, an estimated 1 million
patients present to physicians with
acute ankle trauma
 More than 40% of ankle sprains are
severe enough to potentially
become chronic problems
o Natural Clinical course
 LE ORTHOPEDIC CONDITIONS
ANKLE – ANKLE SPRAIN
 Most ankle injuries are mild and are tibiocalcaneal
thought to be self-treated ligament
 The most severe ankle injuries tibionavicular
(grade III) may require casting or ligament
surgery anterior tibiotalar
 3Yeung et al, 1994, in an ligament
epidemiological study of unilateral
ankle sprains, reported that the
dominant leg is 2.4 times more High ER + DF anterior-inferior
vulnerable to sprain than the non- tibiofibular ligament
dominant one. posterior-inferior
 A less common mechanism of injury tibiofibular ligamen
involves forceful eversion movement transverse
at the ankle injuring the strong tibiofibular ligament
deltoid ligament. interosseous
membrane
PATHOPHYSIOLOGY3 interosseous
ligament
inferior transverse
ligament

o Ankle sprains have been characterized as

grade I, grade II, or grade III (see Table 1)
o The most commonly injured ligament is the
anterior talofibular, followed by 
calcaneofibular ligament.
o The posterior talofibular ligament is rarely
injured.
o The most common MOI in ankle sprains is a
combination of plantar flexion and inversion.
o Excessive external rotation of the ankle
results in a syndesmotic, or high, ankle
sprain. These injuries are much less
common than inversion injuries; however,
they tend to be more disabling, and the
recovery period from such an injury is longer
SIGNS/SYMPTOMS AND CLINICAL
MANIFESTATION
Physical examination findings may include the
following:
o Bruising
o Edema
o Inability to bear weight on the affected foot
o Tenderness on palpation
o Normal ankle and subtalar movement (grade
Aspect MOI Ligaments I)
Lateral Inversion + anterior talofibular o Avulsion or hairline fractures of the fibula,
PF ligament tibia, calcaneus, fifth metatarsal, cuboid, or
calcaneo-fibular talus
ligament o Patient presents with inversion injury or
posterior talofibular forceful eversion injury to the ankle. May
ligament have previous history of ankle injuries or
instability.
o Able to partial weight-bear only on the
Medial Eversion posterior tibiotalar affected side.
ligament
 LE ORTHOPEDIC CONDITIONS
ANKLE – ANKLE SPRAIN
o If patient presents with description of cold
foot or paraesthesia, suspect neurovascular COMPLICATION2
compromise of peroneal nerve. Failing to treat a sprained ankle properly, engaging
o No bony tenderness, deformity or crepitus in activities too soon after spraining your ankle or
present. spraining your ankle repeatedly might lead to the
o Passive inversion or plantar flexion with following complications:
inversion should replicate symptoms for a
o Chronic ankle pain
lateral ligament sprain. Passive eversion
o Chronic ankle joint instability
should replicate symptoms for a medial
ligament sprain. o Arthritis in the ankle joint

DIFFERENTIAL DIAGNOSIS
The Ottawa Ankle Clinical Prediction Rules are an accurate tool to exclude fractures within the first week after an
ankle injury.

MEDICAL ASSESSMENT o Magnetic resonance imaging (MRI)

No laboratory studies are indicated for isolated  determines the integrity of the
ankle sprains collateral ligaments of the ankle
 MRI is usually not indicated
o The Ottawa ankle unless unusual features (e.g.
 used to determine when extensive swelling, ecchymosis,
radiographic studies are pain) are present.
indicated in the patient with o Arthrography of the ankle
ankle trauma  useful in determining the exact
o Stress radiographs of the ankle site and extent of ligamentous
 useful in determining the extent injury.
of ligamentous injury
 LE ORTHOPEDIC CONDITIONS
ANKLE – ANKLE SPRAIN
 indicated only when
contemplating surgical correction
of a ruptured ligament
MEDICAL MANAGEMENT18
o Medication
 Nonsteroidal anti-inflammatory
drugs (NSAIDs) can help control
pain and swelling. Because they
improve function by both
reducing swelling and controlling
pain, they are a better option for
mild sprains than narcotic pain
medicines
 ibuprofen
 naproxen
SURGICAL MANAGEMENT18
o Surgical treatment for ankle sprains is
rare.
o Surgery is reserved for injuries that fail to
respond to nonsurgical treatment, and for
patients who experience persistent ankle
instability after months of rehabilitation
and nonsurgical treatment.
o Arthroscopy
 During arthroscopy, your doctor
uses a small camera, called an
arthroscope, to look inside your
ankle joint.
 Miniature instruments are used to
remove any loose fragments of
bone or cartilage, or parts of the
ligament that may be caught in the
joint.
o Reconstruction
 Your doctor may be able to repair
the torn ligament with stitches or
sutures.
 In some cases, he or she will
reconstruct the damaged ligament
by replacing it with a tissue graft
obtained from other ligaments
and/or tendons found in the foot and
around the ankle.
PT ASSESSMENT15,16
Observation
o Possible gait abnormalities
o Look for deformity, swelling and discoloration
o Location and degree of swelling and bruising
Range of Motion
o Active, passive and resisted ROM in plantar
flexion, dorsiflexion, inversion and eversion
should be performed
o Differences from one side to another should be
noted
o AROM
 Plantar flexion = 50º
 Dorsiflexion = 20º
 Inversion = 35º
 Eversion = 15º
o Limited ROM d/t an intra – articular lesion or
swelling within the joint
o Pain with passive ROM helps to identify injured
joint structures, whereas active and resisted
ROM may be used to identify musculotendinous
damage, muscle inhibition associated with joint
injury, or both
Accessory Joint Motion
o Talocrural: distraction, anterior and posterior
glide
o Subtalar: distraction, medial and lateral tilt and
glide, tilt medially and laterally
o Cuboid: passive physiologic motion and
accessory joint glide
o Tarsometatarsal, MTP
Strength
o Test the hip, knee and ankle motions
o If patient is unable to tolerate MMT due to acute
sprain or ability to weight – bear resistive
isometrics can be used to test plantarflexion,
dorsiflexion, eversion, inversion, toe flexion and
extension in neutral
Posture/Alignment
o Particularly note lumbar, hip, knee, ankle and
foot alignment
Static Palpation/Palpation
o All the musculature of the lower leg as well as
the length the fibular and tibia should be
palpated
o It is important to include palpation of the
proximal tibiofibular joint can be injured in
dorsiflexion injuries and the proximal fibula
which can be the location of a Maisonneuve
fracture associated with syndesmotic injuries
 Note: Patient may not complain of pain at the
proximal fibula until it is palpated
o The Achilles tendon is also important to palpate
for pain or deformity since a patient with an
Achilles injury may present reporting a sprained
ankle
o Palpation of the foot includes the metatarsals
and the base of the 5th metatarsal
o Palpation of the navicular and cuboid should be
performed followed by the ankle ligaments,
beginning at the deltoid ligament and the
tendons of the medial compartment and
 LE ORTHOPEDIC CONDITIONS
ANKLE – ANKLE SPRAIN
proceeding to the peroneal tendons and the
posterior talofibular ligament
o If swelling is minimal, palpation of the lateral
tubercle of the posterior talus is possible
o Palpation should include the bifurcate ligament
and the sinus tarsi, the anterior inferior
tibiofibular, calcaneofibular and anterior
talofibular ligaments
o Note: o Result:
 Point tenderness over ligaments id good  Positive test is excessive anterior translation
indicator of the injured structures of the talus or the sensation of a clunk
 Bony tenderness over the fibular attachment  Anterior translation id more than 4 – 5 mm
sites of the anterior talofibular ligament more on the injured side than the uninjured
should not raise suspicion of a fracture side
Measuring Edema  Tear of the ATFL

o Used the figure of 8 method Inversion Talar Tilt

o A tape measure is placed around the ankle,
crossing over the navicular tuberosity, the tip of
the lateral malleolus, the tip of the medial
malleolus, and the base of the 5th metatarsal
Neurovascular Assessment (if necessary)
o Indication: Integrity of the lateral ankle
ligaments
o Procedure: stabilizing the distal leg while
inverting the rearfoot. Should be done in both a
neutral and a plantarflexed position

o Sensory testing (light touch, sharp & dull)

o Motor testing of big toe and ankle
o Capillary refill at the toes
o Dorsal pedal & posterior tibialis pulses
 Nerve injuries are common in moderate to
severe ankle sprains
– 86%  severe sprains involve the
peroneal nerve
– 83%  tibial nerve
 17% of moderate ankle sprain involves injury
to the peroneal nerve and 10% to the tibial o Results:
nerve
 In neutral position = calcaneofibular ligament
 Nerve involvement is postulated to result
(CFL)
from mild nerve traction or hematoma
 Plantarflexed position = ATFL integrity
 Concomitant motor loss d/t nerve
 (+) pain in the area of the ligament or the
involvement can prolong rehabilitation time
sensation of a clunk
Special/Orthopedic Test for Inversion and – Spongy or indefinite end feel may indicate
Eversion Sprains compete rupture
Anterior Drawer Test  (+) 5º – 6º more motion is seen on the injured
side compared to the uninjured side
o Indication: Integrity of ankle ligaments, o Note:
especially ATFL  Increased inversion of 5º to 10º can indicate
o Procedure: Stabilizing the tibia and fibular with a tear of CFL
one hand while the other hand holds the  Palpate the CFL or ATFL ligaments and feel
calcaneus with the ankle in neutral position. A it pushing against the fingertip if its intact
shear force is applied pulling the calcaneus
anteriorly while pushing the tibia and fibula The Eversion Talar Tilt
posteriorly. Should be done in neutral and in a
plantar flexed position o Indication: integrity of deltoid ligament
o Procedure: Performed by stabilizing the distal
leg while everting the rearfoot
 LE ORTHOPEDIC CONDITIONS
ANKLE – ANKLE SPRAIN
then externally rotating the foot (transverse
plane abduction) with the ankle in maximal
dorsiflexion

o Results:
o Result:
 (+) pain in the area of the deltoid ligament
 Reproduction of pain in the area of the
which would indicate damage to the ligament
tibiofibular syndesmosis indicates to injury to
 Spongy or indefinite end feel may indicate a
the tibiofibular ligaments
complete rupture
 Medial ankle pain indicates deltoid ligament
o Note: While performing the test, one can palpate
involvement
the deltoid ligament and feel it pushing against
the fingertip if its intact The Cotton Test (aka Side to Side or Shuck)
Special/Orthopedic Test for Syndesmotic Injuries o Indication: integrity of the distal tibiofibular
(High Ankle Sprains) ligaments
The Squeeze Test o Procedure: is performed by translating the talus
o Indication: Integrity of the distal tibiofibular within the mortise from medial to lateral in a
neutral position
ligaments
o Procedure: Performed by squeezing the
proximal third of the leg firmly enough to cause a
reciprocal splaying at the distal end of the tibia
and fibula

o Results:
 Increased in translation or pain may suggest
o Result: (+) replication of pain in the area of the syndesmosis involvement, as well as deltoid
anterior inferior tibiofibular ligament ligament injury depending on the location of
the pain
The Dorsiflexion – External Rotational Test  (+) with a distal fibula fracture
(Kleiger’s)
Outcome Measure
o Indication: Integrity of the distal tibiofibular
ligaments o Lower Extremity Functional Scale (LEFS)
o Procedure: Performed by stabilizing the leg just o Foot and Ankle Ability Measure (FAAM)
above the ankle (avoid o Foot and Ankle Disability Index (FADI)
compressing/approximating the distal tib/fib) and
 LE ORTHOPEDIC CONDITIONS
ANKLE – ANKLE SPRAIN
PT MANAGEMENT14,16,17,18
A three-phase program guides treatment for all ankle
sprains—from mild to severe:
o Phase 1 
 resting, protecting the ankle and
reducing the swelling.
o Phase 2 
 restoring range of motion, strength
and flexibility.
o Phase 3
 maintenance exercises and the
gradual return to activities that do
not require turning or twisting the
ankle.
 This will be followed later by being o Taping
able to do activities that require  can be open basketweave for acute
sharp, sudden turns (cutting injuries in athletes
activities)—such as tennis,  Taping does not provide same
basketball, or football. degree of protection as strong
evertor muscles but muscles may
This three-phase treatment program may take just 2 fail to protect against inversion injury
weeks to complete for minor sprains, or up to 6 to 12 due to muscle onset latency
weeks for more severe injuries. therefore external devices may
Modalities: provide protection by doubling
o RICES resistance to inversion
o Ultrasound
 can transfer heat throughout your
body
 elevate the temperature of your
tissues
 help reduce the pain and stiffness in
your ankle.
 Parameters:
 Motion: 2-3sec/cycle
 Duration: 5-10min
 Intensity:
 acute: 0.1-0.5
w/cm2
 subacute: 0.5-1
w/cm2
 chronic: 1-2w/cm2
 Acute: pulsed US; chronic:
continuous US
 Frequency
 1mhz (deep mm)
 3 mhz (superficial)
o Electrical stimulators
 can also effectively treat the
symptoms of ankle sprains
 These devices can generate
o Pneumatic walking boot or even a cast may
electrical currents, circulate medical
nutrients throughout your ankle, and be needed for severe injuries or fracture
help repair and strengthen the  restricts motion and protects
damaged ligaments healing ligamentous tissues but
 NMES  used to decrease swelling allows weightbearing may help
in early period after ankle sprain recovery and return to activity
 LE ORTHOPEDIC CONDITIONS
ANKLE – ANKLE SPRAIN
 also allows non weight-bearing
exercise such as ROM out of the
boot
Acute Ankle sprain: Management – Protection
phase
o Goals
 decreasing effusion and pain
 protecting from further injury
 and allowing protected gait as
tolerated
 Early mobilization
 can lead to earlier return to
work and patient comfort
 early mobilization of joints
following ligamentous injury
actually stimulates collagen
bundle orientation
 and promotes healing
although full ligamentous
strength is not re-
established for several
months
o RICES
 To minimize the swelling
 The ankle should be immobilized in
neutral or in slight dorsiflexion and
eversion
o The RICE protocol.   scrunching paper or a towel
 Rest your ankle by not walking on it
 Ice should be immediately applied to
keep the swelling down. It can be
used for 20 to 30 minutes, three or
four times daily. Do not apply ice
directly to your skin.
 Compression dressings, bandages
or ace-wraps will immobilize and
support your injured ankle.
 Elevate your ankle above the level
of your heart as often as possible
during the first 48 hours.
o Gentle joint mobilization techniques
 to maintain mobility and inhibit pain
o Patient education
 Teach the patient the importance of
RICE (rest, ice, compression, and
elevation), and instruct the patient to
apply ice every 2 hours during the
first 24 to 48 hours.
 Teach partial weight bearing with
crutches to decrease the stress of
ambulation
 Teach muscle-setting techniques
and active toe curls to help maintain
muscle integrity and assist with
circulation.
Ankle Sprain: Management— Controlled Motion
Phase
o Splint weight bearing
 Fabricating a stirrup out of
thermoplastic material and holding it
in place with an elastic wrap or
Velcro straps provides stability to
the joint structures while allowing for
the stimulus of weight bearing for
proprioceptive feedback and proper
healing.
 Commercial splints, such as an air
splint, are also available to provide
medial-lateral stability while allowing
dorsiflexion and plantarflexion
o Cross-fiber massage to the ligaments as
tolerated
o Grade II joint mobilization techniques
 to maintain mobility of the joint
o Teach the patient exercises to be done
within tissue tolerance at least three times
per day
Suggestions include:
 Nonweight-bearing AROM into
 dorsiflexion and plantarflexion
 inversion and eversion
 toe curls
 and writing the alphabet in the
air with the foot
 Sitting with the heel on floor
 picking up marbles with the toes
o If adhesions are developing in the healing
ligament, have the patient actively move the
foot in the direction opposite the line of pull
of the ligament.
 anterior talofibular ligament
 the motion is plantarflexion and
inversion
 stretch the gastrocnemius-soleus
muscle group for adequate
dorsiflexion
 Progress to weight- bearing
stretches when the patient’s
recovery allows.
o As swelling decreases and weight-bearing
tolerance increases, progress to:
 Strengthening
 endurance,
 and stabilization exercises;
 include isometric resistance to
the peroneal
 bicycle ergometry
 and partial to full weight-
bearing balance board
exercises
o Have the patient wear a brace or splint that
restricts end-range motion to control the
range and prevent excessive stress on the
healing ligament.
 LE ORTHOPEDIC CONDITIONS
ANKLE – ANKLE SPRAIN
Ankle Sprain: Management—Return to Function
Phase
o Progress strengthening exercises
 by adding elastic resistance to foot
movements in long-sitting (open-
chain)
 sitting with the heel on the floor for
partial weight bearing
o Use isokinetic resistance if a unit is
available.
o Progress postural/stabilization and
proprioceptive/balance training for ankle
stability, coordination, and neuromuscular
response with full weight-bearing activities.
o Incorporate movement patterns, such as:
 forward/ backward walking
o and cross-over side stepping with elastic
resistance secured around the unaffected
lower extremity
o Utilize an unstable surface, such as a
BOSU® or BAPS® board
o Depending on the final goals of
rehabilitation, train the ankle with weight-
bearing activities, such as:
 Walking
 Jogging
 Jumping
 Hopping and running,
o and with agility activities, such as controlled
twisting, turning, and lateral weight shifting
o When the patient is involved in sports
activities, the ankle should be:
o splinted, taped, or wrapped, and proper
shoes should be worn to protect the
ligament from reinjury
References
1. Michael A. Seffinger, DO, FAAFP, and
Raymond J. Hruby, DO, FAAO, MS (Eds.) -
Evidence-Based Manual Medicine. A
Problem-Oriented Approach-Saunders
(2007).pdf
2. Struijs, P. A., & Kerkhoffs, G. M. (2010).
Ankle sprain. BMJ clinical evidence, 2010,
1115.
3. https://www.physio-pedia.com/Ankle_Sprain
4. https://www.mayoclinic.org/diseases-
conditions/sprained-ankle/symptoms-
causes/syc-20353225
5. https://www.choosept.com/symptomsconditi
onsdetail/physical-therapy-guide-to-ankle-
impingment
6. https://www.hopkinsmedicine.org/health/con
ditions-and-diseases/tarsal-tunnel-syndrome
7. Helgeson K. (2009). Examination and
intervention for sinus tarsi syndrome. North
American journal of sports physical therapy :
NAJSPT, 4(1), 29–37.
8. https://www.choosept.com/symptomsconditi
onsdetail/physical-therapy-guide-to-
peroneal-tendinopathy
9. Walt J, Massey P. Peroneal Tendon
Syndromes. [Updated 2021 Jun 4]. In:
StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2021 Jan-. Available
from:
https://www.ncbi.nlm.nih.gov/books/NBK544
354/
10. Bubra, P. S., Keighley, G., Rateesh, S., &
Carmody, D. (2015). Posterior tibial tendon
dysfunction: an overlooked cause of foot
deformity. Journal of family medicine and
primary care, 4(1), 26–29.
https://doi.org/10.4103/2249-4863.152245
11. https://www.physio-
pedia.com/Ankle_and_Foot_Fractures
12. Shamrock AG, Varacallo M. Achilles Tendon
Rupture. [Updated 2021 Aug 9]. In:
StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2021 Jan-. Available
from:
https://www.ncbi.nlm.nih.gov/books/NBK430
844/
13. https://www.mayoclinic.org/diseases-
conditions/sprained-ankle/diagnosis-
treatment/drc-20353231
14. Kisner
15. https://ftp.uws.edu/udocs/public/CSPE_Prot
ocols_and_Care_Pathways/Protocols/Ankle
_Sprains_Assessment.pdf
16. https://www.brighamandwomens.org/assets/
BWH/patients-and-families/rehabilitation-
services/pdfs/ankle-sprain-bwh.pdf
17. https://northplattept.com/blog/4602/Physical-
Therapy-Treatments-for-Ankle-Sprains
18. orthoinfo