eMedicine Specialties > Sports Medicine > Foot and Ankle

Ankle Sprain

Author: Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Contributor Information and Disclosures

Updated: Apr 28, 2009

Introduction

Background

The ankle joint has many functions, one of which is to allow the body to adapt to uneven terrain during ambulation. Failure to compensate for uneven footing may result in an ankle injury.

Eighty-five percent of ankle injuries are sprains, and of those sprains, 85% are lateral inversion sprains. Although athletes usually recover quickly from ankle sprains, failure to appropriately rehabilitate these injuries imposes an increased risk for future injury.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains - First Aid and Emergency Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.

Related eMedicine topics:
 Ankle Injury, Soft Tissue 
Ankle Sprain
Ankle Taping and Bracing

Frequency

United States

The most common ankle injury is a lateral sprain that is caused by inversion of the foot, with more than 25,000 occurring each day.1  Lateral inversion sprains are also the most commonly seen sports injury, comprising 14-21% of sports injuries.2,3  Athletes who participate in basketball, volleyball, soccer, and football are at especially high risk for ankle sprains, comprising 25-45% of the injuries in these sports.3,4,5,6,7,8,9,10,11

International

In the United Kingdom's general population, the prevalence of ankle sprains is reportedly 52.7 cases per 10,000 patients.12

Functional Anatomy

The bony and soft tissue anatomy of the ankle place the lateral side of the ankle at higher risk for injury than the medial side. The distal end of the fibula (ie, the lateral malleolus) extends further inferiorly than the distal end of the tibia (ie, the medial malleolus). This discrepancy in length gives the medial ankle superior stability by improving bony resistance to eversion.

The ligaments of the medial ankle, collectively known as the deltoid ligament complex, form a broad, strong, thick ligamentous stability to prevent eversion and provide medial ankle stability. On the lateral side, there is only minimal bony stability, which comes from 3 relatively small ligaments, the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). 

Although many classification systems for grading lateral ankle sprains exist, perhaps the most common system is based on the clinical examination. In this system, grade I ankle sprains are painful, but they have no increased laxity when compared with the uninjured side. This correlates with mild stretching of the ATFL. Grade II ankle sprains are painful and have an increased laxity on testing. This correlates with a complete tear of the ATFL and a partial tear of the CFL. Grade III ankle sprains are usually painful and have an unstable ankle joint on examination. This correlates with complete ruptures of both the ATFL and CFL.

A sprain of the syndesmotic ligament complex is sometimes called a "high ankle sprain" (a type of inversion sprain) and often presents with anterior ankle pain. The syndesmotic ligament complex consists of the ATFL, the PTFL, and the distal interosseous membrane between the tibia and the fibula.

In plantar flexion, the talus of the ankle is more susceptible to inversion forces compared with dorsiflexion, in which the talus is more stable because of bony stabilization in the mortise. In plantar flexion, the ATFL is under tension and is susceptible to injury.

Sport-Specific Biomechanics

Jumping, cutting, and pivoting place the ankle at risk for inversion injuries. Close body contact between athletes also places the athlete's ankle at risk for an inversion injury (eg, stepping on the opponent's foot).

Clinical

History

  • Generally, the athlete is able to describe a history of "rolling the ankle in" after changing direction, stepping down from a height, or landing on the outside of the affected foot at the time of the injury. If the athlete is unable to describe the mechanism of injury, the physician should have a high index of suspicion for either an atypical ankle sprain or an alternative cause of ankle pain.
  • The initial area of pain is in the region of the ATFL and, in more severe sprains, the CFL as well. Eventually, the pain may be relatively diffuse, reflecting the development of generalized swelling throughout the foot and ankle.

Physical

  • The maximal points of tenderness for a lateral ankle sprain should be at the ATFL and/or CFL areas; areas of swelling and ecchymosis are also tender, and the quantity and area of swelling and ecchymosis often correlate to the amount of elevation the patient has been able to use for treatment. Thus, these findings do not necessarily correlate with the severity of the injury.
  • No bony point tenderness should be present; pay particular attention to the medial malleolus, lateral malleolus, base of the fifth metatarsal, and midfoot bones. Point bony tenderness at one of these areas, as well as bony deformity or crepitus, suggests the possible presence of a fracture. Pain should not be increased by either a squeeze test (the fibula and tibia are squeezed together in the mid-shaft regions) or an external rotation test (the ankle is externally rotated). If either test increases pain, consider a high ankle sprain, which involves the syndesmosis and tibiofibular ligaments and usually takes longer to heal than a lateral ankle sprain, or a Maisonneuve fracture of the proximal fibula.
  • Pain localized to the medial aspect of the ankle suggests a medial ankle sprain.
  • An anterior drawer test can help the clinician assess the stability of the ATFL. Cup the heel in one hand, pull it forward, and stabilize the tibia with the other hand (see Image 1). Translation of more than 10 mm or a 3-mm difference between the ankles suggests ATFL disruption.3  Comparison of the affected side to the uninjured side is critical because the amount of laxity is highly variable among patients.
  • The talar tilt test is used to assess the ATFL and CFL. Invert the ankle and compare the laxity with the uninjured side (see Image 2). A complete rupture of the ATFL and CFL, as evidenced by a talar tilt of (1) at least a 20° opening and (2) at least 10° greater than the uninjured side, is considered a third-degree ankle sprain.13

Causes

One cause of ankle injury is a previous injury; inadequately rehabilitated ankle sprains place the ankle at risk for subsequent injuries.14,15  The use of narrow cleats with minimal arch support or the use of running shoes for a court sport can also place an athlete at risk for ankle sprains.

More on Ankle Sprain

Overview: Ankle Sprain
Differential Diagnoses & Workup: Ankle Sprain
Treatment & Medication: Ankle Sprain
Follow-up: Ankle Sprain
Multimedia: Ankle Sprain
References
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Further Reading

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Keywords

ankle sprain, sprained ankle, twisted ankle, ankle injury, rolled ankle, anterior talofibular ligament sprain, deltoid ligament sprain, high ankle sprain, lateral ankle sprain, medial ankle sprain, syndesmosis sprain, turned ankle

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Contributor Information and Disclosures

Author

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics, University of Wisconsin
David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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