The ankle is one of the most frequently injured joints for those who
participate in sports. An ankle sprain is an injury of one of the supporting
ligaments, usually due to overstretching or tearing.
Your ankle joint includes the bottom of the shin bone (the tibia), representing
the inner portion of the ankle, the smaller leg bone (the fibula), the outer
portion of the ankle, and the Talus (below the ankle joint) bone of the foot.
The joint allows for the upwards (dorsiflexion) and downwards (plantarflexion)
motion. Joint instability may develop after damage occurs to one or more of the
bones surrounding the joint. This type of damage is termed a fracture. The joint
may also become unstable when the surrounding ligaments are damaged.
There are three major ligaments of the ankle that hold these bones together:
Anterior talo-fibular ligament (goes from the talus to the
Calcaneo-fibular ligament (goes from the calcaneus to the fibula)
Posterior talo-fibular ligament (goes from the talus to the
These ligaments also allow ankle motion, but only within certain limits.
When does it occur?
Ankle Sprains, more often occurs in sports where there is side-to-side movement,
such as basketball, soccer, tennis, squash, and racquetball. But it occurs in
other activities, especially when the ground is uneven and the ankle turns on
The risk of ankle
injuries varies by sport; they make up 45% of all injuries in
basketball, 31% in soccer, and 25% in volleyball. In professional,
college, and high school football, ankle sprains account for 10% to
15% of all time lost to injury. Yet these injuries are often
When this occurs, there is
Blood vessels can rupture and
Bleed around the joint, and
The ankle becomes less stable.
Also, tendons from the muscles of the leg can be stretched and damaged,
A fracture of the ends of the tibia and/or fibula and the metatarsal
foot bones can occur.
of the injury is determined by examination of the location of the bruising (ecchymosis),
swelling, and tenderness. It is also necessary to perform stress testing of the
ligaments to determine whether the ligament has been torn. Stress testing of the
ligaments is done by pushing on the ankle and attempting to determine if there
is any abnormal motion at the joint which would indicate that a ligament has
been torn. In addition, x-rays are often performed to check for the possibility
of a chipped bone or fracture.
When performing a stress test of the ligaments, a posterior directed force is
applied to the front of the tibia (shin bone). If the ankle ligaments are
completely torn, the tibia will visibly shift backwards at the ankle joint. When
the force is removed, the tibia will snap back into its proper position at the
ankle joint. When this abnormal motion occurs, the anterior talo-fibular
ligament (ATFL) has been torn.
Useful Tests for Various Ankle Injuries
Lateral malleolus fracture
Peroneal tendon subluxation
Bifurcate ligament avulsion
Anterior drawer, talar tilt
X-ray as per Ottawa ankle rules
Mortise view ankle x-rays
Resisted dorsiflexion and eversion
Medial ankle sprain
Medial malleolus fracture
Posterior tibialis tendon injury
Flexor hallucis longus tendinitis
X-ray as per Ottawa ankle rules
Single heel-rise test
Resisted first-toe flexion
Achilles tendon rupture
Os trigonum fracture
Thompson's Weight-bearing lateral
x-ray, tenderness on passive plantar flexion
Anterior tibialis tendon injury
"Squeeze," external rotation
Avulsion fracture, 5th metatarsal
Palpation tenderness, foot
Palpation tenderness, fibula
Levels of ankle sprains
There are three different levels of ankle sprains, based on the severity of
damage. Returning to the activity should be done only when you are pain free,
have regained a full range of motion, and have sufficient ankle strength. It is
very important to strengthen your ankle after a sprain to help prevent another
Grade I - stretch and/or minor tear of the ligament without
Grade II - tear of ligament plus some laxity
Grade III - complete tear of the affected ligament (very loose)
I ankle sprains involve excessive
stretching of one or more ankle ligaments, but the ligament is not torn.
Usually blood vessels are not damaged, and there is no bruising around your
ankle. Rest, icing the ankle with a compression bandage (like an ace wrap), and
elevating your ankle on several pillows is all that is necessary. When the
sprain first occurs, apply the ice for 10 to 15 minutes, then allow another 10
to 15 minutes to pass without ice. Re-apply the ice to your ankle, off and on
for 10 to 15 minutes for the next several hours. This is called RICE therapy
(rest, ice, compression, elevation), and it will reduce swelling and limit pain.
The time of recovery depends on the extent of the damage. Usually a few days to
two weeks of healing are needed, followed by ankle strengthening and stretching
ankle sprain means there is a tear of one or more of your ankle
ligaments, but the ankle is not unstable. Some ligaments of your leg are often
injured or torn. Bleeding occurs with this injury and you will see bluish
bruising by one day after the sprain. RICE therapy should be the initial
treatment, similar to grade I sprains. However, for many grade II sprains, a
removable splint or brace that prevents excessive side-to-side ankle movement is
often used for four to five days. Avoid placing weight on your injured ankle if
there is significant pain. Use of crutches for a few days may help speed the
healing process by giving your ankle some needed rest. As the ankle pain
diminishes, remove the splint or brace and begin range of
motion exercises. But do not force your ankle to move in pain.
Start by moving your joint up and down, as if you were stepping on and easing
off the gas pedal of an automobile. As your ankle joint becomes more limber,
moving your foot in small circles and increasing the size of the circles will
help restore mobility. As healing progresses, try drawing numbers (1 through 9)
in the air with your toes, keeping your knee and hip motionless. Other exercises
(Table A.2) can be done, using surgical tubing that is available at most drug
and athletic stores. A physical therapist or your physician can help you
initiate this type of training. Swimming is a great way to improve strength and
aid in ankle flexibility before you attempt running or participation in other
Grade III sprains are the most severe: you have ligament tear and an
unstable ankle. A physician needs to immobilize your ankle joint. The ankle is
usually positioned so as to enhance correct healing of the ligaments. A walking
cast is often used, with weight placed on the cast as tolerated. After the cast
is removed, about three weeks later, rehabilitation of the ankle is started to
regain motion and strength. In addition, because we can lose the sense of where
our ankle is after a severe ankle sprain, specialized exercises are used with a
shifting flat surface, known as a BAPS, or biomechanic ankle proprioceptive
system board, as one of the rehabilitation devices. This type of exercise can
help you prevent your next ankle sprain. Swimming before weight-bearing exercise
often is recommended. This will aid ankle flexibility and strengthening, without
Remember, you should be pain free with normal ankle movement before progressing
exercises such as rope
skipping and jogging on level
ground. Surgery is rarely needed after ankle sprains, but may be necessary to
repair severely damaged ligaments and tendons.
Depending on the
severity of the sprain, treatment may range from simply wearing a
supportive brace, to using a walking cast, or even having the ankle
operated on. The type of treatment depends on several factors
including severity of injury, presence of associated injuries, the
routine stresses that are placed upon the ankle, and the general
medical condition of the injured patient.
All lateral sprains can be treated conservatively with protection, rest, ice,
compression, and elevation (PRICEMMM)
with ankle bracing to prevent reinjury while ligament heals
Rest for injured ankle until normal heel-toe gait is restored
Ice on ankle to decrease swelling and relieve pain
Compression as soon as possible to decrease swelling
Elevation: the initial step for reducing swelling
Medication: NSAIDs or acetominophen for pain relief
Mobilization early on when pain free to expedite return to play
Modalities: exercise and proprioception training to prevent re-injury
Crutches may be beneficial until pain-free weight bearing is achieved. A felt
horseshoe, taped with an open basket weave technique or secured with elastic
bandage, around the ankle initially will decrease swelling and aid in recovery.
Ankle taping or bracing and proprioception retraining are often needed.
Preventing Ankle Sprain
To prevent recurrent ankle injuries in the
future, ankle supports, or wearing high-top athletic shoes can help. This is
especially true for activities that call for rapid changes in direction or
training on uneven ground. If you have had ankle sprains before, prevent
recurrent problems by using an ankle support along with ankle-strengthening
Exercises to Strengthen Your Ankles
While sitting in a chair, loop one end of the elastic tubing around the ball of
your foot, keeping your heel on the floor and hold the ends of the tubing in
your hand. Push on the tubing with the ball of your foot as if you are stepping
on the gas pedal of your automobile. Repeat this 10 times, rest for 60 seconds.
Do this four times, three times each day. Increase the number of repetitions as
your ankle strength improves.
Tie surgical tubing in a knot and place it around the leg of a table. Sit on a
chair and loop the surgical tubing around the top of your foot, just below your
toes, keeping your heel on the floor. Pull back your foot, as if you were easing
off the gas pedal of your automobile, keeping tension on the tubing. Repeat this
10 times, rest for 60 seconds. Do this four times, three times each day.
Increase the number of repetitions as your ankle strength improves.
Take the tied surgical tubing, as in exercise 2 and loop it around the leg of a
table. Sit on a chair, looping the tubing around the outside of your foot just
below your toes, keeping your foot flat on the floor. Stretch the tubing by
moving your foot sideways, away from your other leg using your foot flat on the
floor. Stretch the tubing by moving your foot sideways toward your other leg,
using your heel as a pivot. As in exercises 1 and 2, perform each exercise 10
times and repeat three more times, four times each day, increasing the number of
repetitions as your ankle strength improves.
Safe Return to Play
Many ankle injuries will not prevent an immediate return to action, but return
to play is a case-specific decision. Occasionally, when the ligaments heal, they
are weaker or looser then prior to the injury. This results in an ankle that is
more likely to be unstable and twist more easily. A few guidelines will help
with this complex decision:
A patient who has a stable injury should not return to play if that
injury may become unstable.
The athlete needs to complete functional testing pain free. Example:
walking, jogging (forward and
backward), figure eights, zigzags, and one-foot hops.
Using these guidelines and knowing the differential diagnosis, the team
physician will be able to return a player to competition safely.
Dated 29 November 2011