Ankle Sprain 

Updated: Jan 14, 2019
Author: Craig C Young, MD; Chief Editor: Sherwin SW Ho, MD 

Overview

Practice Essentials

An ankle sprain is usually that of an inversion-type twist of the foot, followed by pain and swelling. The most commonly injured site is the lateral ankle complex, which is composed of the anterior talofibular, calcaneofibular, and posterior talofibular ligaments.[1, 2, 3, 4]

Signs and symptoms

Signs and symptoms of an ankle sprain include the following:

  • Pain/tenderness

  • Swelling and/or bruising

  • Cold foot or paresthesia (possible neurovascular compromise)[1]

  • Muscle spasm

See Clinical Presentation for more detail.

Diagnosis

The physical examination confirms a diagnosis made on the basis of patient history and differentiates an ankle sprain from a fracture. Examination in patients may include the following tests:

  • Anterior drawer test: To assess for ankle instability (see the image below)

    Anterior drawer test. Anterior drawer test.
  • Prone anterior drawer test: Also tests for ligamentous instability

  • Talar tilt test (or inversion stress maneuver): To assess integrity of the calcaneofibular ligament (see the image below)

    Talar tilt test. Talar tilt test.
  • External rotation test: To evaluate the integrity of the syndesmotic ligaments

  • Kleiger test: Variation of the external rotation test; to assess the integrity of the deltoid ligament

  • Squeeze test (or fibular compression test): To evaluate for syndesmotic or fibular injury

  • Neurovascular evaluation: To assess neurovascular status of the affected limb

Imaging studies

The following radiologic studies may be used to evaluate ankle sprains:

  • Plain radiography: Guided by the Ottawa Ankle Rules to diagnose ankle or foot fractures

  • Stress-view radiography: May provide further assessment for ankle stability; accuracy of study increases with use of local anesthesia

  • Computed tomography scanning: May be indicated for imaging of soft tissues or for bone imaging beyond radiography; useful for evaluating osteochondritis dissecans and stress fractures

  • Magnetic resonance imaging: May be useful to assess a suspected syndesmotic or high ankle sprain or if osteochondrosis or meniscoid injury is suspected in patients with a history of recurrent ankle sprains and chronic pain[5, 6]

  • Ankle arthrography: May be useful for determining capsular damage and the number of ankle ligaments damaged

  • Bone scanning: To detect subtle bone abnormalities (eg, stress fracture, osteochondral defects) and syndesmotic disruptions

See Workup for more detail.

Management

Conservative therapy

Conservative therapy for acute ankle sprains may be described by the acronyms RICE (rest, ice, compression, and elevation) and PRICES (combination of protection, relative rest, ice, compression, elevation, and support). Protective devices include air splints or plastic and Velcro braces. Ankle taping can also increase ankle stability, but its effectiveness is highly dependent on the expertise of the individual who performs the taping.

Physical therapy during the recovery phase is aimed at the patient regaining full range of motion, strength, and proprioceptive abilities, and may include the following:

  • Strengthening exercises: Starts with isometric exercises, then advances to use of elastic bands or surgical tubing

  • Proprioception rehabilitation: Starts with single-leg-stance exercise in a single plane, then progresses to multiplanar exercises

  • Other exercises: Uses a balance or tilt board, then advances to functional drills, jogging, sprinting, and cutting, and then progresses to figure-of-eight and carioca drills[7]

Pharmacotherapy

The following medications are used in the management of ankle sprain:

  • Analgesics (eg, acetaminophen)

  • Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen)

Surgery

In most patients, there is no improved outcome with operative repair of third-degree anterior talofibular ligament tears and medial ankle ligament tears.

Indications for operative intervention in patients with an ankle sprain include the following:

  • Distal talofibular ligament third-degree sprain that causes widening of the ankle mortise

  • Deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise

  • In selected young patients with high athletic demands who have both anterior talofibular and calcaneofibular complete ruptures

Surgical procedures for chronic ankle instability and sprains include the Watson-Jones procedure, the Evans procedure, and the Chrisman-Snook procedure.

See Treatment and Medication for more detail.

Background

The history of an ankle sprain is usually that of an inversion-type twist of the foot followed by pain and swelling. An individual with an ankle sprain can almost always walk on the foot, albeit carefully and with pain.

In an individual with normal local sensation and cerebral function, the ability to walk on the foot usually excludes a fracture. (See Clinical Presentation.) Suspect neurovascular compromise if the patient reports a cold foot or describes paresthesias.[1] Bone tenderness in the posterior half of the lower 6 cm of the fibula or tibia and the inability to bear weight immediately after the injury and in the emergency department are indications to obtain radiographic imaging. These Ottawa ankle rules have been validated for patients aged 5-55 years.[8, 9]

Ankle sprains are classified into the following 3 grades:

  • Grade 1 injuries involve a stretch of the ligament with microscopic tearing but not macroscopic tearing. Generally, little swelling is present, with little or no functional loss and no joint instability. The patient is able to fully or partially bear weight.

  • Grade 2 injuries stretch the ligament with partial tearing, moderate-to-severe swelling, ecchymosis, moderate functional loss, and mild-to-moderate joint instability. Patients usually have difficulty bearing weight.

  • Grade 3 injuries involve complete rupture of the ligament, with immediate and severe swelling, ecchymosis, an inability to bear weight, and moderate-to-severe instability of the joint. Typically, patients cannot bear weight without experiencing severe pain.

Drawer and talar tilt examination techniques are used to assess ankle instability; however, the use of these techniques in acute injuries is in question because of pain, edema, and muscle spasm.

Pain reduction is essential, but improvement of any loss of motion, strength, and/or proprioception is equally important.[10, 11, 12] Rest, ice, compression, and elevation (ie, RICE) are the mainstays of acute treatment; more comprehensively, the combination of protection, relative rest, ice, compression, elevation, and support (PRICES) is used.[1] (See Treatment.)

Physical therapy during the recovery phase is aimed at the patient regaining full range of motion (ROM), strength, and proprioceptive abilities.

For recurrent lateral ankle sprains, treatment should begin with a trial of conservative therapy for approximately 2-3 months. The recurrence rate for lateral ankle sprains has been reported to be as high as 80%.[13, 14]

It is generally accepted that for most patients, operative repair of third-degree anterior talofibular ligament (ATFL) tears and medial ankle ligament tears does not contribute to an improved outcome. One of the few absolute indications for surgery in patients with a sprained ankle is a distal talofibular ligament third-degree sprain that causes widening of the ankle mortise. A second indication is a deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise.

Anatomy

The ankle joint is a hinged synovial joint with primarily up-and-down movement (plantar flexion and dorsiflexion). The other joints around the ankle are responsible for other movements, giving the ankle a total range of motion (ROM) comparable to that of a ball and socket. The combined movement in the dorsiflexion and plantarflexion directions is greater than 100°; bone-on-bone abutment beyond this range protects the anterior and posterior ankle capsular ligaments from injury. The anterior and posterior ankle capsular ligaments are relatively thin compared with the medial and lateral ankle ligaments.

Pathophysiology

The lateral ankle complex, which is composed of the anterior talofibular, calcaneofibular, and posterior talofibular ligaments, is the most commonly injured site.[1, 2, 3, 4] Approximately 85% of such sprains are inversion sprains of the lateral ligaments, 5% are eversion sprains of the deltoid or medial ligament, and 10% are syndesmotic injuries. The ATFL is the most likely component of the lateral ankle complex to be injured in a lateral ankle sprain. Osteochondral or chondral injuries of the talar dome should be considered when diagnosing an ankle injury.

During forced dorsiflexion, the PTFL can rupture. With forced internal rotation, ATFL rupture is followed by injury to the PTFL. Extreme external rotation disrupts the deep deltoid ligament on the medial side, and adduction in neutral and dorsiflexed positions can disrupt the CFL. In plantarflexion, the ATFL can be injured.

The strongest ankle capsule-ligament complex is the deltoid ligament, which has 2 parts: the superficial component and the deep component. The superficial component runs the farthest from the medial malleolus to the medial aspect of the calcaneus, posteriorly. The medial malleolus usually fractures before the deltoid ligament fails mechanically.

Ankle spurs may occur at any of the bony ligament attachments. On lateral radiographs, it is not uncommon to see an anterior spur at the neck of the talus, where the anterior ankle capsule attaches. This is caused by ossification of the hematoma organization associated with anterior ligament sprains.

Because of its great strength, the syndesmotic ligament, which has a deep portion between the bones and superficial, anterior, and posterior portions, is rarely sprained. This distal tibiofibular ligament holds the distal tibia and fibular bones together at the ankle joint and maintains the integrity of the ankle mortise. It takes a great amount of force to strain this ligament, which normally does not have much excursion. A significant tear of this ligament requires surgical treatment. Severe posttraumatic arthritis of the tibiotalar joint (ankle) can result quickly if a syndesmosis tear remains unrecognized and untreated. A syndesmotic ligament tear is usually a part of an ankle fracture that needs to be treated specifically. This is not generally true of the other ankle ligament tears.

Etiology

Mechanical forces exceeding the tensile limits of the ankle joint capsule and supportive ligaments cause ankle sprains.

There are a number of contributing factors, which can be classified as either predisposing or provocative, as follows:

  • Predisposing factors can result from a lack of physical conditioning; they include poor muscle tone and shortened and/or contracted joint capsule or tendons. Poor proprioception can also be a factor, as can inadequate training or experience with the physical activity being performed.

  • Provocative factors include accidents and other unforeseen circumstances that result in mechanical stresses that exceed the tensile limits of the ankle joint capsule and ligaments. Obesity can contribute to sprains by increasing kinetic energy to a point that exceeds joint-design stress limits.

A cohort study analyzed risk factors in ankle injuries from the Cadet Illness and Injury Tracking System (CIITS) database at the United States Military Academy (USMA) from 2005-2009. The results found higher risk of syndesmotic ankle sprains in males who performed at a higher level of athletic competition; male athletes were 3 times more likely to experience medial ankle sprains than female athletes.[15]

Recurrent sprains

The exact etiology of recurrent ankle sprains is unknown; however, many factors may play a role.

One possibility is that recurrent sprains result primarily from ligaments healing in a lengthened position due to scar tissue filling in the gap between the torn, separated ends. Furthermore, the weakness of the healed ligament may be due to the inherent weakness of the scar.

In a study by Bosien et al, 22% of patients with recurrent ankle sprains had persistent peroneal weakness.[16] The authors believed that this contributed to recurrent injury, especially in incompletely rehabilitated ankle sprains.

An unrecognized disruption of the distal tibiofibular ligament has been cited as a potential culprit. This condition is diagnosed based on tenderness over the anterior syndesmosis and pain when the fibula is squeezed against the tibia at midshaft, with dorsiflexion and external rotation or with excessive medial-lateral motion of the tibiotalar joint.

Freeman et al suspected that functional instability that resulted in recurrent sprains was secondary to loss of proprioception in the foot.[17] Mechanoreceptors and their afferent nerve fibers have been shown to exist in the ligaments and capsule of the ankle. Furthermore, disruption of the ligaments and joint capsule with a grade 3 sprain (a complete ligament tear; see Clinical Presentation) leads to impairment of the reflex stabilization of the foot, causing the foot to give way.[18] In addition, dysfunction of the peroneal nerve can result in delayed muscle response, causing a delay in the activation of the peroneal muscles and leading to functional instability.

Impingement by the distal fascicle of the AITF ligament and/or impingement of the capsular scar tissue in the talofibular joint is another cause, and hereditary hypermobility of joints is an additional suggested etiologic factor.

Epidemiology

Most ankle sprains are probably self-treated and are never reported to a health care provider; therefore, many ankle sprains are not documented. Sprained ankles have been estimated to constitute up to 30% of injuries seen in sports medicine clinics and are the most frequently seen musculoskeletal injury seen by primary care providers.[19] More than 23,000 people per day in the United States, including athletes and nonathletes, require medical care for ankle sprains. Stated another way, incident cases have been estimated at 1 case per 10,000 persons per day.[20] A U.S. Army study found that ankle sprains are the most common foot and ankle injury in active-duty Army personal with a rate of 103 sprains per 1000 persons per year.[21]

Female athletes are 25% more likely to sustain ankle injuries than male athletes. Female basketball players are at a higher risk of a first-time inversion injury than those participating in other sports.[22] Soccer and volleyball are other leading causes of ankle sprains in high school and college female athletes.[23, 24] Some studies attribute a higher incidence of ankle injuries in high school football, basketball, and soccer players.[23, 25, 26] Other studies conclude that in college men, the risk of suffering an ankle sprain appears to be similar with basketball, soccer, and football.[22]

A cohort study analyzed risk factors in ankle injuries from the Cadet Illness and Injury Tracking System (CIITS) database at the United States Military Academy (USMA) from 2005-2009. The results found higher risk of syndesmotic ankle sprains in males who performed at a higher level of athletic competition; male athletes were 3 times more likely to experience medial ankle sprains than female athletes.[15]

Ankle injuries are very common, with ankle sprain being the most common injury. Most individuals have complete recovery; however, a substantial number have chronic problems that usually lead to modification of physical activity.[27]

Prognosis

Acute injuries

The prognosis for isolated and adequately treated ankle sprains is excellent. The prognosis for a patient with ankle sprains and other traumatic injuries is related to the prognosis for the other injuries.

In a systematic literature review, 36-85% of patients with acute ankle sprains reported full recovery at 2 weeks to 36 months, independent of the initial grade of sprain,[28] with most recovery occurring within the first 6 months.[29] After 12 months, the risk of recurrent ankle sprain returns to preinjury levels.[30] However, 3-34% of patients reported re-sprains at 2 weeks to 96 months after the initial injury. Furthermore, after 3 years, some patients still had residual pain and instability. One risk factor for residual symptoms seems to be participation in competitive sports.[28]

Recurrent sprains

If recurrent ankle sprains are treated early and appropriate rehabilitation is initiated, the prognosis is excellent with conservative treatment.[31, 32, 33] The prognosis becomes even more important to consider for patients who require surgical correction. Reconstructive procedures can vary significantly in their ability to correct any persistent instability.

With respect to chronic syndesmotic sprains, long-term outcome studies are few in number. In a study conducted at West Point, all patients who were studied returned to full duty without further problems. One of these patients was surgically treated, and all had full ROM of the ankle.[34]

In 6 cases of frank diastasis over 4- to 60-month follow-up, 4 cases had good results, and 2 had fair results in that the patients had residual mild ankle pain and restricted ROM, according to Edwards and DeLee. There was 1 case of postoperative skin slough that healed uneventfully, and 1 fixation device failed.[35]

In 5 patients with subacute or chronic syndesmotic injury, all of the affected ankles achieved fusion with no complications within 10 weeks, in a study by Katznelson et al. Each patient was treated with operative stabilization and bone grafting to the tibiofibular joint, which formed a synostosis. One patient developed traumaticosteoporosis that resolved in 6 months; this patient had mild loss of dorsiflexion.[36]

Results are limited for subtalar instability, because this condition is mostly recognized during surgery for chronic lateral ligamentous instability. Most of the available results are intermingled with the results of lateral ankle procedures.

Chrisman and Snook had 3 patients with subtalar and ankle instability that were treated by their eponymous procedure.[37] One patient had a failed Watson-Jones procedure with persistent instability. The 3 patients with subtalar instability had a 20° limitation of inversion compared with the opposite, normal side. These patients had no symptoms of instability at 2- to 6 year follow-up.[38]

Posttraumatic osteoarthritis is common in patients with repetitive ankle injuries. One study estimates that approximately 12% of the overall prevalence of osteoarthritis (OA) is in fact posttraumatic OA of the hip, knee, or ankle. The financial burden is significant, estimated at $3.06 billion dollars annually.[39]

Patient Education

Review the self-care techniques of acute sprain with patients so that they can take an active part in their care. Teach them the mnemonic PRICES, as follows:

  • Protection

  • Relative rest

  • Ice

  • Compression

  • Elevation

  • Support

Provide patients with information on when to call for advice. Instruct them to call a doctor or nurse if one of the following conditions is observed:

  • The joint is wobbly or moves past its normal ROM

  • The bone is deformed or bends abnormally

  • Pain prevents putting weight on the injured area after 24 hours

  • Weight-bearing still is difficult after 4 days

  • Extreme pain, bruising, or severe swelling is present

  • The toes below the injury feel cold to the touch or become numb or blue

These instructions can be tailored to each practice and by no means should be construed as all-inclusive.

For patient education resources, see the patient education articles Ankle Sprain and Sprains and Strains.

 

Presentation

History

The history of an ankle sprain is usually of an inversion-type twist of the foot followed by pain and swelling. Ask the patient about the mechanism of injury, as well as why, when, where, and how it occurred. Often, however, the patient's account of the mechanism does not correlate with the structures that have been damaged.

An individual with an ankle sprain can almost always walk on the foot, albeit carefully and with pain. In an individual with normal local sensation and cerebral function, the ability to walk on the foot usually excludes a fracture. Sudden, intense pain and rapid onset of swelling and bruising suggest a ruptured ligament. Suspect neurovascular compromise if the patient complains of a cold foot or describes paresthesia.[1]

Ask patients about any past ankle injuries, their goals regarding functional results, the level and intensity of their sports and activity, and their medical history. Determine the presence of any complicating conditions, such as arthritis, connective tissue disease, diabetes, neuropathy, or trauma.

Physical Examination

The physical examination confirms a diagnosis made on the basis of patient history and differentiates an ankle sprain from a fracture. The examiner should look for areas of tenderness and swelling. The maximal points of tenderness for a lateral ankle sprain should be at the ATFL and/or CFL ligament areas.

Ecchymosis may be present and may be tender. The degree of swelling or ecchymosis may be proportional to the likelihood of fracture. Note, however, that blood usually settles along the medial or lateral aspects of the heels. Thus, the location of the ecchymosis may not correlate with the location of the injury. In addition, prompt treatment with ice, compression, and elevation of the ankle may reduce swelling and ecchymosis; thus, these findings do not necessarily correlate with the severity of the injury.

No bony point tenderness should be present; particular attention should be given 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 localized to the medial aspect of the ankle suggests a medial ankle sprain. Active ROM must be assessed, because Achilles tendon ruptures can mimic ankle sprains. In lateral sprains, passive inversion should reproduce the symptoms. Plantar flexion should also exacerbate the symptoms, because this motion stretches the ATFL to its maximum.

Anterior drawer test

Anterior drawer and talar tilt examinations are used to assess ankle instability; however, the use of these tests in acute injuries is in question because of pain, edema, and muscle spasm.

For the anterior drawer test (as shown in the image below), the patient's knee must be flexed to relax the gastrocsoleus complex, and the foot should be in 10° of plantar flexion. Grasp the heel and pull forward while, with the other hand, providing counterpressure over the front of the tibia at the level of the ankle. A firm endpoint will be absent. Repeat these steps for the other ankle, and compare results. In a person with lax joints, the presence of several millimeters of bilateral movement is a negative ankle drawer-sign finding. In a positive ankle drawer-sign finding, there is a difference in movement in a relaxed patient between the injured side and the uninjured side, with the injured side having more movement than the uninjured one.

Sometimes, a dimple appears over the area of the ATFL on anterior translation. This so-called dimple (or suction) sign indicates compromise of the ATFL. It may be accompanied by pain, but muscle spasms are minimal.

The anterior drawer test is not very reliable, especially if the findings are negative in a patient who is not under anesthesia, because of muscle guarding by the patient. The normal amount of translation is 2 mm. Reports indicate that 4 mm of laxity in the ATFL provides a clinically apparent test result.

Anterior drawer test. Anterior drawer test.

The prone anterior drawer test is another test for ligamentous instability. The patient must lie prone with the feet extending over the end of the examining table. The examiner then pushes the heel steadily forward with one hand. A positive test result consists of excessive anterior movement and a dimpling of the skin on both sides of the Achilles tendon.

Talar tilt test

The talar tilt test, or inversion stress maneuver, is performed with the patient supine or on his/her side, with the foot relaxed. The gastrocnemius must also be relaxed by flexion of the knee. The talus is then tilted from side to side into adduction and abduction. The findings should be compared with those for the contralateral side. Abduct and invert the heel. If a firm endpoint cannot be felt when compared with the opposite ankle, suspect damage to the CFL. Note that the degree of tilt ranges from 0-23°. In many cases, this test is difficult, if not impossible, to perform secondary to patient pain and swelling. The exam is demonstrated in the image below.

Talar tilt test. Talar tilt test.

External rotation test

The external rotation test can demonstrate the integrity of the syndesmotic ligaments. The patient sits with the knee flexed to 90°. The foot is gently grasped and rotated laterally with the ankle locked in neutral. A positive test result occurs when the patient has pain over the syndesmosis. The external rotation test has a sensitivity of 20% and a specificity of 84.8%.[5]

A variation on the external rotation test is the Kleiger test. This test can demonstrate the integrity of the deltoid ligament. The patient sits with the knee flexed to 90°. The foot must be relaxed and not bearing weight. The foot is gently grasped and rotated laterally. A positive test result occurs when the patient has pain medially and laterally. The talus may displace from the medial malleolus, indicating a tear of the deltoid ligament.

Squeeze test

The fibular compression test, or squeeze test, is used if a syndesmotic or fibular injury is suspected. To perform the squeeze test, place the thumb on the tibia and the fingers on the fibula at the midpoint of the lower leg; then squeeze the tibia and fibula together. Pain down the length of the fibula indicates a positive test result. Note that pain should not be felt at the site of the pressure but rather in the lower leg. A positive test suggests 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. The squeeze test has a sensitivity of 30% and a specificity of 93.5% for a high ankle sprain.[5]

Neurovascular assessment

As with all limb injuries, the neurovascular status of the limb must be assessed. This assessment consists of palpation of the dorsalis pedis and posterior tibial arterial pulses. Testing for sensation, especially over the sural nerve distribution, is also necessary; sural nerve and peroneal nerve palsies, although rare, may complicate a lateral ligamentous injury. Electromyographic examinations of individuals with severe ankle sprains have shown that 80% of these patients have some degree of peroneal nerve injury.

Staging

Ankle sprains are classified into the following 3 grades:

  • Grade 1 injuries involve a stretch of the ligament with microscopic tearing but not macroscopic tearing. Generally, little swelling is present, with little or no functional loss and no joint instability. The patient is able to fully or partially bear weight.

  • Grade 2 injuries stretch the ligament with partial tearing, moderate to severe swelling, ecchymosis, moderate functional loss, and mild to moderate joint instability. Patients usually have difficulty bearing weight.

  • Grade 3 injuries involve the complete rupture of the ligament, with immediate and severe swelling; ecchymosis; an inability to bear weight; and moderate to severe instability of the joint. Typically, patients cannot bear weight without experiencing severe pain.

Ankle sprain staging or grading is primarily done clinically. The clinician can determine whether the ankle ligaments are stretched without significant tear (grade 1), are partially torn (grade 2), or are completely torn (grade 3) on the basis of the degree of swelling and ecchymosis and on the clinical stability of the ankle. Arthrograms, stress radiographs, and magnetic resonance imaging (MRI) scans add little to the management of the ordinary ankle sprain. In order to have any significance, stress radiographs should be performed on both ankles.

This grading system fails to characterize ankle injuries involving 2 or more ligamentous structures and excludes consideration of nonligamentous injuries.

Evaluation for Chronic Instability

Functional instability of the ankle has been defined variously as the occurrence of frequent sprains, difficulty running on uneven surfaces, difficulty cutting or jumping, and recurrent giving-way for at least 6 months despite adequate nonsurgical therapy.[38] Instability may result from tibiotalar laxity or subtalar instability.

Patients with subtalar instability may report giving-way symptoms of the foot during activity and a history of recurrent instability, pain, swelling, and stiffness. The symptoms are often vague, and distinguishing between subtalar and tibiotalar instability is difficult. Patients may also have pain over the sinus tarsi or deep pain in the subtalar area.

This sinus tarsi syndrome can be a component of subtalar instability, with tenderness to palpation over the sinus tarsi and pain upon forced inversion of the foot. Increased internal rotation of the calcaneus is also a common finding, and excessive distal displacement of the calcaneus may occur in relation to the talus compared with the normal side. Subtalar instability should be regarded as contributing to the patient's symptoms, especially in a high-energy injury.

Chronic medial ligament instability is uncommon, but it produces discomfort on the medial side of the ankle and is associated with slight valgus and abduction of the ankle with each step.

 

DDx

Diagnostic Considerations

Fracture

An individual with an ankle sprain can almost always walk on the foot, albeit carefully and with pain. In an individual with normal local sensation and cerebral function, the ability to walk on the foot usually excludes a fracture.

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.

The Ottawa foot and ankle rules can be reliably used to exclude fractures in children older than 5 years and has been suggested as possibly accurate for children as young as 2 years.[8, 9]

Neurovascular compromise

Suspect neurovascular compromise if the patient complains of a cold foot or describes paresthesias.[1] Bone tenderness in the posterior half of the lower 6 cm of the fibula or tibia and the inability to bear weight immediately after the injury and in the emergency department are indications to obtain radiographic imaging.

As with all limb injuries, the neurovascular status of the limb must be assessed. This assessment consists of palpation of the dorsalis pedis and posterior tibial arterial pulses. Testing for sensation, especially over the sural nerve distribution, is also necessary; sural nerve and peroneal nerve palsies, although rare, may complicate a lateral ligamentous injury. Electromyographic examinations of individuals with severe ankle sprains have shown that 80% of these patients have some degree of peroneal nerve injury.

Continued pain after rehabilitation

If pain persists despite rehabilitation, diagnoses to consider include the following:

  • Intra-articular meniscoid lesions represent localized fibrotic synovitis in the lateral ankle following inversion sprains; the condition also is known as impingement syndrome.

  • Peroneal tendon subluxation is due to detachment of the peroneal retinaculum from its normal insertion on the posterior border of the fibula to the lateral surface of the fibula.

  • Talar dome fracture occurs with inversion and eversion injuries, but it may not be readily seen on radiographs.

  • Anterior process fracture of the calcaneus occurs with inversion injuries. Patients commonly display bony tenderness rather than ligamentous point tenderness.

  • Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy, can develop after ankle sprains. The reason for this is unknown; however, the condition may arise from an abnormal response to disuse and/or splinting of the foot and ankle. Early, controlled activity and rehabilitation may prevent the development of CRPS.

Other factors

Active ROM must be assessed, because Achilles tendon ruptures can mimic ankle sprains. Extensive swelling, ecchymosis, or pain may suggest an osteochondral lesion not observed on plain radiographs. CT scanning is useful for evaluating osteochondritis dissecans and stress fractures. MRI may be useful when osteochondrosis or meniscoid injury is suspected in patients with a history of recurrent ankle sprains and chronic pain.[6] A bone scan can detect subtle bone abnormalities (eg, stress fracture, osteochondral defects). A bone scan can also detect syndesmotic disruption.

Differential Diagnoses

 

Workup

Approach Considerations

Plain radiographs may be clinically indicated to diagnose a fracture of the ankle or foot. Ankle stress radiographs contribute little to the management of acute ankle sprains because surgical treatment of the acute sprain is rarely indicated. Abnormal swelling or clinical ankle instability in an acute sprain may be documented with bilateral stress radiographs of the ankle.

MRI is not indicated unless unusual features are present, such as extensive swelling, ecchymosis, or pain, that suggest an osteochondral lesion not observed on plain radiographs. Even if MRI scans demonstrate bone bruising or actual articular cartilage damage, conservative ankle sprain treatment is indicated initially.

The National Athletic Trainers’ Association (NATA) noted the following regarding imaging studies[40, 41] :

  • The Ottawa Ankle Rules remain valid for determining the need for x-rays

  • Stress radiography is unreliable for detecting acute injuries to the ankle and midfoot

  • Magnetic resonance imaging (MRI) and computed tomography (CT) scanning accurately detect talar osteochondral lesions; both techniques are also more accurate than arthrography and tenography for detecting lateral ligamentous injury, especially when arthrography and tenography are performed 48 hours post injury

  • MRI is reliable for detecting acute tears of the anterior talofibular ligament and calcaneofibular ligament; diagnostic ultrasonography is useful but less accurate and sensitive than MRI

  • MRI is highly sensitive, specific, and accurate after acute trauma for determining the level of injury to the ankle syndesmotic ligaments

Plain Radiographic Imaging

The use of radiographs in patients with ankle injuries is guided by the Ottawa Ankle Rules. These rules state that an ankle radiographic series is required only if the patient has pain in the malleolar zone and any of the following 3 findings[42, 43, 44] :

  • Bone tenderness at the posterior edge or tip of the lateral malleolus (ie, the lower 6 cm of the fibula)

  • Bone tenderness at the posterior edge or tip of the medial malleolus (ie, the lower 6 cm of the tibia)

  • Inability to bear weight immediately after the injury and in the emergency department

The Ottawa Ankle Rules state that a foot radiographic series is required only if the patient has any pain in the midfoot zone and any of the following 3 findings:

  • Bone tenderness at the base of the fifth metatarsal

  • Bone tenderness at the navicular bone

  • Inability to bear weight immediately after the injury and in the emergency department

The Ottawa Ankle Rules are contingent upon the patient presenting within 10 days of the injury. Although they were not originally intended for patients younger than age 18 years, a meta-analysis of 12 studies showed that the Ottawa foot and ankle rules can be reliably used to exclude fractures in children older than age 5 years. The studies included a total of 3,130 patients and identified 671 fractures, resulting in a prevalence of 21.4%. Demonstrating a pooled sensitivity of 98.5% and a missed fracture rate of 1.2%, the report indicated that the Ottawa foot and ankle rules are useful (level 2 evidence) for excluding fractures in children.[8] Another study suggests they may be useful for children as young as 2 years.[9]

Radiographic studies of the ankle should include the following views:

  • An anteroposterior (AP) film with the ankle in 5-15° of adduction

  • A true lateral film

  • A 45° oblique film with the ankle in dorsiflexion (ie, Mortise view)

Stress-View Radiographic Imaging

Stress radiographic films may provide further assessment for ankle stability; however, patient cooperation may be limited, depending on the severity of the injury. Stress-view exams include the talar tilt and anterior drawer tests. Because of muscular guarding due to patient pain, the accuracy of these tests is dramatically increased with the use of local anesthesia. Compare the stress views with those of the uninvolved ankle in both tests. Other variables in determining the reliability of these tests include the degree of patient relaxation and cooperation, the amount of force used, the angle of ankle flexion, and the amount of laxity in the uninvolved side. (See Clinical Presentation.)

Computed Tomography Scanning

Computed tomography (CT) scanning may be indicated if imaging of soft tissues is warranted or if bone imaging beyond radiography is indicated. CT scanning is useful for evaluating osteochondritis dissecans and stress fractures. In complex injuries, 3-dimensional CT scanning may be useful.

MRI

MRI may be a useful evaluation when a syndesmotic or high ankle sprain is suspected or if osteochondrosis or meniscoid injury is suspected in patients with a history of recurrent ankle sprains and chronic pain.[6, 5] However, caution must be used when evaluating the findings on MRI since a study of asymptomatic patients revealed that approximately 30% had findings consistent with abnormal anterior talofibular ligaments and peroneal muscles.[45]

Arthrographic Imaging

Ankle arthrograms may be useful for determining capsular damage and the number of ankle ligaments damaged; however, arthrography is indicated only if surgery is needed, and the criteria for surgery to repair double lateral ligament complete tears are still under debate. Staples found that arthrograms provide the most preoperative information.[46, 47]

Ankle arthrograms are not indicated in every patient considered for surgical treatment. Marked clinical instability in a young individual with great physical demands being considered for surgery requires an ankle arthrogram.

Bone Scanning

A bone scan can detect subtle bone abnormalities (e.g., stress fracture, osteochondral defects). A bone scan can also detect syndesmotic disruption.

 

Treatment

Approach Considerations

Pain reduction is essential, but improvement of any loss of motion, strength, and/or proprioception is equally important.[10, 11, 12] A meta-analysis found that neuromuscular rehabilitation results in more rapid improvements in function.[48] For recurrent lateral ankle sprains, treatment should begin with a trial of conservative therapy for approximately 2-3 months.

It is generally accepted that for most patients, operative repair of third-degree ATFL tears and medial ankle ligament tears does not contribute to an improved outcome. One of the few absolute indications for surgery in patients with sprained ankles is a distal talofibular ligament third-degree sprain that causes widening of the ankle mortise. A second indication is a deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise.

Physical therapy during the recovery phase is aimed at the patient regaining full ROM, strength, and proprioceptive abilities. While a formal physical therapy program is particularly important for athletes and other patients who need a quicker recovery, most low demand patients will do well with a basic home exercise program.[49]  A randomized controlled trial of 503 participants found no significant difference between those patients who participated in a formal physical therapy program and those who did not.[50]

The National Athletic Trainers’ Association (NATA) issued guidelines for treating and preventing ankle sprains in athletes, including recommendations for the early use of nonsteroidal anti-inflammatory drugs (NSAIDS) post injury, functional rehabilitation rather than immobilization for grade I and II ankle sprains, and prophylactic ankle supports for athletes with a history of previous ankle sprains.[40, 41] Immobilization with a rigid stirrup brace or below-knee cast is recommended for grade III sprains for at least 10 days, followed by controlled therapeutic exercise. Other recommendations include the following[40, 41] :

  • To prevent injury, institute a 3-month or longer balance and neuromuscular control program for athletes, especially for those at higher risk

  • To reduce reinjury rates, institute balance training throughout rehabilitation and follow-up management of ankle sprains[86]

  • During rehabilitation, include comprehensive range-of-motion, flexibility, and strengthening exercises of the surrounding musculature

  • Before returning the patient to sport-specific tasks, ensure the injured limb's functional performance measures at least 80% of the uninjured limb

  • Note that the diagnostic accuracy of special tests (eg, anterior drawer test, inversion talar tilt test) is greater 5 days after injury than 2 days after injury

 

Conservative Therapy for Acute Sprain

The acute phase of treatment should last for 1-3 days after the injury. The goals of acute treatment are to control pain, minimize swelling, and maintain or regain ROM.

RICE/PRICES

Rest, ice, compression, and elevation (ie, RICE) are the mainstays of acute treatment; more comprehensively, the combination of protection, relative rest, ice, compression, elevation, and support (PRICES) is used.[1]

Protective devices include air splints or plastic and Velcro braces. Most sprains can be treated without casting. Depending on the severity of the sprain, protective devices are used for 4-21 days. Criteria for discontinuing use of a device include minimal swelling and pain at the site of injury. The ROM should be smooth, particularly with dorsiflexion and plantar flexion.

Relative rest is advocated, because it promotes tissue healing. Advise the patient to avoid activities that cause increased pain or swelling. Advocate early, pain-free movements during this time. Encourage patients to take their ankle out of their brace and move it through a pain-free ROM. Aggressive pain-free ROM is recommended. Having patients spell the letters of the alphabet with their foot and ankle several times per day is one simple activity to recommend even in an acute care setting.

Use ice to control swelling, pain, and muscle spasm. As a rule, do not apply ice or cold packs directly to the skin; wrap the pack in a towel before use. Recommend that the patient apply ice for 15-20 minutes, 3 times daily. Contrast baths can be used 24-48 hours after injury.

Recommend the use of compression with an ACE wrap, an elastic ankle sleeve, or a lace-up ankle support. Advise the patient that further support of the ankle can be facilitated by wearing high-top, lace-up shoes. This can help to minimize edema.[3]

Encourage elevation of the injured ankle to facilitate the reduction of swelling. Advise the patient to keep the ankle above the level of the heart.

Support can include taping or the use of lace-up ankle supports with combination hook-eye (ie, Velcro) straps.[3]

Ankle braces

Immobilization can aid healing but can hinder it as well. Acutely protecting the weakened, painful area is appropriate, but prolonged immobilization leads to muscle atrophy and loss of motion. Limited stress creates a stronger scar formation, because the collagen fibers line up parallel to the stress instead of at random. For these reasons, limited immobilization with a stirrup or lace-up ankle brace is usually used, whereas casting is avoided. (See the images below.)

Ankle brace Ankle brace
Example of a lace-up ankle support. Courtesy of Sw Example of a lace-up ankle support. Courtesy of Swede-O, Inc.
Example of a brace for immobilization or functiona Example of a brace for immobilization or functional purposes. Courtesy of Swede-O, Inc.
Example of a brace that can be used for functional Example of a brace that can be used for functional purposes. Courtesy of Swede-O, Inc.
Example of a brace secured with Velcro straps. Cou Example of a brace secured with Velcro straps. Courtesy of Swede-O, Inc.
Example of a lace-up ankle support brace with figu Example of a lace-up ankle support brace with figure-8 straps. Courtesy of Swede-O, Inc.

However, results from the Collaborative Ankle Support Trial (CAST) indicated that there are benefits to the use of a below-knee cast for 10 days. CAST was a randomized, controlled trial designed to estimate the clinical effectiveness and cost-effectiveness of 3 methods of ankle support compared with double-layer, tubular compression bandage. The below-knee cast and the Aircast brace (applied 2-3 days after injury, to allow time for swelling to resolve) offered cost-effective alternatives to tubular bandages for acute, severe ankle sprains, with the below-knee cast having the advantage in terms of overall recovery at 3 months. Because no differences in long-term outcome were noted, the investigators suggested that practitioners should consider likely compliance and acceptability to patients when choosing a brace.[51]

Occasionally, the use of posterior splinting and crutches with non–weight-bearing ambulation is helpful for more severe ankle sprains (ie, when foot motion and weight bearing are extremely painful). Usually, the use of a posterior splint is limited to a few days, and weight bearing as tolerated is encouraged.

In general, ankle splints are applied to minimize movement and provide support and comfort by stabilizing an injury at that joint. Splints are primarily used to stabilize injuries to bones until the patient can be evaluated by a consultant, such as an orthopedic surgeon. Splints are also used to achieve immobilization for primary healing or in the presurgical period. All patients with injuries that are splinted should be referred for evaluation by a consultant in a timely fashion (usually within 2-3 d).

To see complete information on Splinting, Ankle, please go to the main article by clicking here.

Ankle braces have been shown to be effective in preventing some types of ankle sprains.[52, 53, 54, 55, 56, 57, 58] The use of high-top shoes has been proposed to prevent ankle injuries, but study results have been mixed.[57, 58, 59, 60]

Janssen et al evaluated the effectiveness of combined bracing and neuromuscular training, or bracing alone, against the use of neuromuscular training on recurrences of ankle sprain after usual care. The study included 384 athletes, aged 18-70, who had sustained a lateral ankle sprain. The training group received an 8-week home-based neuromuscular training program, the brace group received an ankle brace to be worn for 12 months, and the third group received both the training program, as well as the ankle brace, to be worn for 8 weeks. The main outcome measure was self-reported recurrence of the ankle sprain. During the 1-year follow-up, 69 participants (20%) reported a recurrent ankle sprain: 29 (27%) in the training group, 17 (15%) in the brace group and 23 (19%) in the group that combined both. The authors concluded that bracing was superior to neuromuscular training in reducing the incidence but not the severity of self-reported recurrent ankle sprains after usual care.[61, 62]

Ankle taping

Ankle taping can increase ankle stability by at least 2 mechanisms: limitation of motion and proprioception.[63] For a single treatment, ankle taping is less expensive than either a brace or an athletic shoe. Initially, the effectiveness of ankle taping is similar to bracing.[64, 65] However, studies have demonstrated a significant loss of effectiveness after 24 minutes of activity[66] ; moreover, ankle taping becomes virtually ineffective after periods as short as 40 minutes.[67] The effect of taping on individuals with chronic ankle instability is relatively small.[68]

The effectiveness of ankle taping is highly dependent on the expertise of the individual who performs the taping. Although the primary effect is improved proprioceptive function, taping may also cause variable effects on motor performance. Ankle taping has the potential to either enhance or hinder the function of the peroneal muscles, depending on the location and technique with which the ankle was taped. Thus, having an experienced, certified athletic trainer (ATC) or physical therapist do the taping usually produces optimal results. In general, athletes without easy access to an ATC or physical therapist may find an ankle brace easier to use and more effective. A meta-analysis by Wang et al reported Kinesio taping as superior to other athletic taping methods.[87]

 

To see complete information on Ankle Taping and Bracing, please go to the main article by clicking here.

Pain Control for Acute Sprain

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in treating sprains is somewhat controversial.[69] Some physicians argue that the anti-inflammatory effects of NSAIDs are helpful in decreasing swelling, which ultimately increases the speed of recovery. Others believe that acutely used NSAIDs can lead to increased swelling if, owing to platelet inhibition, bleeding occurs.[69, 70]  However, a recent meta-analysis of 46 papers found that there was strong evidence that use of non-steroidal anti-inflammatory drugs resulted in better control of pain, reduction of swelling and improved function after an acute sprain.[71]

If NSAIDs are not used, acetaminophen (Tylenol, Panadol, Anacin Aspirin Free) or other pain medicines may be required for pain control in some athletes with moderate to severe ankle sprains.[72]

Acupressure Therapy

A small, randomized controlled trial of 62 patients showed significant shortening of recovery time in function, swelling and pain with acupressure.[73]

Conservative Therapy for Chronic Sprain

For recurrent lateral ankle sprains, treatment should begin with a trial of conservative therapy for approximately 2-3 months. The treatment goals include the patient regaining full strength in the affected ankle, being provided protective support as needed, and returning to activity participation. These goals are accomplished through ROM and strength exercises, sports-specific functional progression, protective support as needed, and weight-bearing, multidirectional balance exercises.[74]

Other therapeutic strategies include the use of lateral heel wedges, peroneal muscle strengthening, proprioceptive/coordination exercise, taping, and ankle-foot orthoses with ankle and subtalar support.[75] However, these options are seldom accepted on a long-term basis (especially in athletes), and surgical stabilization is, in many cases, the treatment of choice.

For recurrent sprains that involve the medial ligaments, slight modifications to the conservative treatment of lateral sprains are used. These include ankle stirrup bracing, casting, and orthoses (in addition to physical therapy). Once again, if these measures are unsuccessful, surgical intervention is necessary.

In syndesmotic injuries, when a diastasis has been present for longer than 3 months, significant arthritic changes have probably begun. Diastasis refers to any loosening in the attachment of the fibula to the tibia at the inferior tibiofibular joint. In most cases, arthroscopic evaluation of the ankle joint is helpful in determining the best course of management. Surgical options are discussed below.

Chronic instability of the subtalar joint frequently requires surgical intervention. Despite this, the treatment is initially nonsurgical and is similar to the conservative management of recurrent or chronic lateral ankle instability. This includes peroneal strengthening, proprioceptive training, Achilles tendon stretching, and the use of a brace. Taping of the ankle by an athletic trainer can be of benefit, especially when a subtalar sling modification is incorporated.

Indications for Surgical Intervention

In most patients, operative repair of third-degree ATFL tears and medial ankle ligament tears does not contribute to an improved outcome. One of the few absolute indications for surgery in patients with a sprained ankle is a distal talofibular ligament third-degree sprain that causes widening of the ankle mortise. A second indication for surgical treatment of acute ankle sprains is a deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise. In selected young patients with high athletic demands who have both anterior talofibular and calcaneofibular complete ruptures, surgical repair may be the treatment of choice. Further research is needed to determine the best treatment for complete double-ligament lateral ankle sprains.

Surgical procedures for chronic ankle instability and sprains vary greatly in their ability to correct subtalar instability. A review of the literature showed the Watson-Jones procedure to be associated with subjective instability 20-90% of the time, and the Evans procedure, 20-33%. In addition, with the Evans procedure, a persistent anterior drawer sign was found in 45-60% of patients. In the Chrisman-Snook procedure, 13-30% of patients had subjective persistent instability. Decreased inversion is common with all these procedures.

For more information, see Surgical Interventions in Ankle Sprain.

When to Return to Normal Activity

Athletes with ankle sprains may return to activities as permitted by their symptoms. The physician may have to design a strict regimen of activities, because many athletes have a tendency to ignore pain during activities. In general, individuals should start with in-line activities (eg, jogging) and then progress to forward-backward and side-to-side activities. Pivoting and cutting activities are added only when the athlete is minimally symptomatic with the previous activities.

Return-to-play criteria during the recovery phase (3 d to 2 wk post injury) include the following:

  • Full, pain-free active and passive ROM

  • No pain or tenderness

  • Strength of ankle muscles 70-80% of that on the uninvolved side

  • Ability to balance on 1 leg for 30 seconds with eyes closed

Return-to-play criteria during the functional phase (2-6 weeks postinjury) include the following:

  • Normal ROM of the ankle joint

  • No pain or tenderness

  • Satisfactory clinical examination

  • Strength of ankle muscles 90% of the uninvolved side

  • Ability to complete functional examination

Physical Therapy

The treatment plan during the recovery phase is aimed at the patient regaining full ROM, strength, and proprioceptive abilities. Strengthening is started with isometric exercises and advanced to the use of elastic bands or surgical tubing, as shown below.

strengthening using an elastic band. strengthening using an elastic band.

Strengthening is performed in the following 4 cardinal ankle motions: dorsiflexion, plantar flexion, eversion, and inversion. Strengthening of the peroneals, which act as dynamic stabilizers of the ankle, is critical.

Proprioception rehabilitation begins with single-leg-stance exercises in a single plane and progresses to multiplanar exercises. The patient stands on the injured side with the foot and arch in a neutral position and holds the foot of the uninjured side off the ground. For safety, this exercise should be completed near a wall. Initially, the patient looks at the feet and attempts to hold the position. When the patient can comfortably and easily hold the position for 3 minutes, he/she changes the focus of the eyes to a location in front of the body. When the patient can comfortably and easily hold the position with the eyes looking forward for 3 minutes, the position is then held with the eyes closed. A modified Romberg test may be useful in evaluating the progression of proprioceptive rehabilitation.

Other useful exercises include the use of a balance or tilt board, as shown below; these can be made by attaching a dowel or half of a croquet ball to the bottom of a piece of plywood. The athlete stands on the board and attempts to control balance while touching the board to the floor in a controlled manner to complete various patterns (eg, 4 points of the compass). Finally, the athlete advances to functional drills, jogging, sprinting, and cutting, and then progresses to figure-of-eight and carioca drills.[7]

Tilt board. Tilt board.

Long-Term Complications

Studies have shown that at least 40% of acute ankle sprains result in residual ankle symptoms at 6 months.[76, 77] At least 10-20% of acute ankle sprains result in residual ankle instability, pain, or other chronic symptoms.[78, 16, 79]

If pain persists despite rehabilitation, further workup is indicated. Diagnoses to consider include the following:

  • Chronic lateral ankle instability typically is accompanied by a feeling of instability by the patient. Swelling is noted with activity, and recovery is prolonged.

  • Intra-articular meniscoid lesions represent localized fibrotic synovitis in the lateral ankle following inversion sprains. The condition also is known as impingement syndrome.

  • Peroneal tendon subluxation is due to detachment of the peroneal retinaculum from its normal insertion on the posterior border of the fibula to the lateral surface of the fibula.

  • Talar dome fracture occurs with inversion and eversion injuries, but it may not be readily seen on radiographs.

  • Anterior process fracture of the calcaneus occurs with inversion injuries. Patients commonly display bony tenderness rather than ligamentous point tenderness.

  • Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy, can develop after ankle sprains. The reason for this is unknown; however, the condition may arise from an abnormal response to disuse and/or splinting of the foot and ankle. Early, controlled activity and rehabilitation may prevent the development of CRPS.

Prevention

The prevention of future ankle sprains depends on the type of activity in which the patient is engaged. Certain sports (eg, soccer, basketball, volleyball) have a high incidence of ankle sprains.[1, 3, 80, 81, 82]

Athletes must understand the importance of adequate training and conditioning to prevent future injury or to minimize injury severity. An adequate warm-up period and a gradual transition into activity are general principles that also can be applied to prevent future injury. The athlete should wear shoes with good stability and, if possible, should exercise on even surfaces.[81] High-top shoes, lace-up ankle braces, Velcro ankle braces, and/or ankle taping may add stability during activities and prevent further injury.[83] Evidence suggests that muscle imbalance and increased body mass may place athletes at risk for ankle sprains; thus, it is important for an athlete to have good muscle strength and endurance and maintain good overall conditioning.[84]

Consultations

Consultations are seldom indicated unless the physician suspects that the ankle or a fracture is unstable. Most ligamentous injuries and fractures heal well after 4-6 weeks of guarded weight-bearing and guarded motion, along with a progressive rehabilitation program (as previously outlined). Surgical intervention by an orthopedic or podiatric surgeon may be warranted in these situations. The clinician simply has to determine a comfort level in treating a particular condition. Once that level has been exceeded, consultation with the appropriate specialist is indicated.

 

Medication

Medication Summary

Analgesics and NSAIDs frequently are used to control pain and inflammation. Ultimately, the clinician has the prerogative to determine the most appropriate medication. Pain control is the initial treatment goal for ankle sprains.

As previously stated, the use of NSAIDs is somewhat controversial.[57] Some physicians argue that the anti-inflammatory effects of NSAIDs help to decrease swelling, which ultimately increases the speed of recovery. Others believe that acutely used NSAIDs, by inhibiting platelets, increase the likelihood of additional swelling by increasing the potential for bleeding.[69, 70, 72]

If NSAIDs are not used, acetaminophen or other analgesics may be required for pain control in some patients with moderate to severe ankle sprains.[72]

Analgesics

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.

Acetaminophen (Tylenol, Aspirin-Free Anacin, Cetafen,)

Used for mild pain or if patient cannot tolerate NSAIDs.

Nonsteroidal anti-inflammatory drugs

Class Summary

If significant ecchymosis is observed at the presentation of acute injury, consider not prescribing for 24-48 h, which may prevent further hemorrhage into the injury site. The NSAIDs listed here are considered first-line drugs on most formularies, but several other agents in this category are available.

Ibuprofen (Motrin, Advil, Nuprin)

Used for analgesia and anti-inflammatory effect; take with food. Member of the propionic acid group of NSAIDs. Available in low-dose form as an over-the-counter medication. Highly protein bound, metabolized in liver, and eliminated primarily in urine. May reversibly inhibit platelet function.

Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)

Used as an analgesic and anti-inflammatory medication; take with food.

 

Questions & Answers

Overview

What are the signs and symptoms of an ankle sprain?

What is an ankle sprain?

What is included in the physical exam of an ankle sprain?

Which imaging studies are performed in the evaluation of an ankle sprain?

What is included in conservative therapy for an ankle sprains?

What is included in physical therapy for ankle sprains?

Which medications are used in the management of an ankle sprain?

What is the role of surgery in the management of ankle sprains?

What is an ankle sprain?

What are the classifications of ankle sprains?

How is instability of ankle sprains assessed?

What are the treatment options for ankle sprains?

What is the role of surgery in the treatment of ankle sprain?

What is the anatomy relevant to ankle sprains?

What is the pathophysiology of ankle sprain?

What causes ankle sprains?

What causes recurrent ankle sprains?

What is the prevalence of ankle sprains?

What is the prognosis of ankle sprains?

What is the prognosis of recurrent ankle sprains?

What is the prognosis of subtalar and ankle instability resulting from ankle sprains?

What information about ankle sprains should patients receive?

Presentation

Which clinical history is characteristic of ankle sprains?

Which physical findings are characteristic for ankle sprains?

What is the role of anterior drawer test in the evaluation of ankle sprains?

What is the role of talar tilt test in the evaluation of ankle sprains?

What is the role of external rotation test in the evaluation of ankle sprains?

What is the role of squeeze test in the evaluation of ankle sprains?

What is the role of neurovascular assessment in the evaluation of ankle sprains?

How are ankle sprains graded?

What is the evaluation for functional instability in patients with ankle sprains?

DDX

How is ankle fracture differentiated from ankle sprain?

How is neurovascular compromise differentiated from an ankle sprain?

What conditions should be considered if pain continues after rehabilitation of an ankle sprain?

Which conditions should be included in the differential diagnoses of ankle sprains?

What are the differential diagnoses for Ankle Sprain?

Workup

What is the role of imaging in the workup of ankle sprains?

What are the National Athletic Trainers’ Association (NATA) guidelines for the workup of ankle sprains?

What are the Ottawa Ankle Rules and how are they used to diagnose ankle sprain?

What are views that should be included in the radiographic studies of ankle sprains?

What is the role of stress radiographic films in the diagnosis of ankle sprains?

What is the role of CT scanning in the diagnosis of ankle sprains?

What is the role of MRI in the diagnosis of ankle sprains?

What is the role of arthrographic imaging in the diagnosis of ankle sprains?

What is the role of a bone scan in the diagnosis of ankle sprains?

Treatment

What are the treatment options for ankle sprains?

What are National Athletic Trainers’ Association (NATA) guidelines for treating and preventing ankle sprains in athletes?

What is the goal of acute treatment for ankle sprains?

What is included in the conservative treatment of ankle sprains?

What is the role of braces in the acute treatment of ankle sprains?

What is the role of casts and splints in the acute treatment of ankle sprains?

What is the efficacy of bracing in the treatment of ankle sprains?

What is the role of ankle taping in the management of ankle sprains?

What is the role of NSAIDs in the treatment of ankle sprains?

What is the role of acupressure in the treatment of ankle sprains?

What are the treatment options for chronic recurrent ankle sprains?

What are the indications surgical intervention to treat ankle sprains?

What activity regimen is used following an ankle sprain to prepare athletes to return to play?

What are the return-to-play criteria for an ankle sprain during recovery phase?

What are the return-to-play criteria for an ankle sprain during the functional phase?

What is included in physical therapy for ankle sprains?

What are the long-term complications of ankle sprain?

How are recurrent ankle sprains prevented?

Which specialist consultations are helpful in the management of ankle sprain?

Medications

Which medications are used in the treatment of ankle sprains?

Which medications in the drug class Nonsteroidal anti-inflammatory drugs are used in the treatment of Ankle Sprain?

Which medications in the drug class Analgesics are used in the treatment of Ankle Sprain?