Lateral Ankle Sprain
1. Introduction
There are many muscles and ligaments in the ankle joint that work together to provide stability, strength, flexibility and movement. The ligaments of the ankle joint are categorised as either medial (inside) collateral ligaments or lateral (outside) collateral ligaments.
Although the ligaments of the ankle are strong fibrous bands, the lateral ankle ligaments are more susceptible to injury due to the movement available at the ankle joint during activity. The specific ligaments that might be affected are the anterior talofibular ligament, calcaneofibular ligament and the posterior talofibular ligament. The anterior talofibular ligament is reported to be the weakest of the three ligaments so is most often the ligament that is injured .
Ankle sprains are graded depending on how much damage has occurred to the ligaments.
Frequently Asked Questions
- Lateral ankle sprains describe pain and loss of function following an injury to the ligaments on the outside of the ankle.
- They are very common and account for 80% of soft tissue injuries to the ankle (1,2).
- No.
- Whilst uncomfortable, lateral ankle sprains heal and improve very well with appropriate conservative management.
- People who participate in sports that require jumping and landing, or activities requiring rapid changes in direction, especially on uneven surfaces, e.g. football, rugby.
- Research also shows that 70% of the general population will report having incurred an ankle injury during their lifetime (3).
- Pain on the outer side of the ankle.
- Instability of the foot and ankle.
- Swelling.
- Bruising around the outside of the ankle.
- Tenderness with direct pressure over the outside of the ankle.
- Difficulty walking.
- Difficulty standing on that foot.
- Early management centres around the PEACE & LOVE protocol which is explained in detail below.
- An assessment with a musculoskeletal physiotherapist can help provide you with the right exercises, advice and guidance to ensure a full recovery.
- With minor to moderate sprains (grades I and II), return to sport or normal activity can usually occur within 2-10 weeks with appropriate management and rehabilitation.
- For patients with more severe injuries (e.g. a complete rupture – grade III) recovery can take up to 16 weeks.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- A history of having “rolled” the ankle inwards, e.g. missing a step or landing awkwardly.
- Pain and the feeling of instability of the foot and ankle.
- Swelling and/or bruising around the outside of the ankle.
- Tenderness around the outside of the ankle.
- Difficulty walking.
- Difficulty standing on the affected foot.
3. Causes
Lateral ankle sprains commonly occur during activities involving jumping and landing, or activities requiring rapid changes in direction, especially on uneven surfaces. The usual mechanism of injury is a combination of turning the foot inwards, and pointing the foot and ankle downwards during weight-bearing activities, i.e. rolling the ankle inwards (4).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone sustaining a lateral ankle sprain. It does not mean everyone with these risk factors will develop symptoms.
- Previous ankle injury – if previous sprains are not well managed, they may lead to the development of chronic ankle instability which can make you prone to subsequent sprains.
- Poor proprioception (perception or awareness of the position or movement of a joint) and balance.
- Training surface – uneven ground challenges the foot and ankle to provide balance and support.
- Decreased fitness or sport-specific conditioning – impairments in strength, endurance and proprioception make joints more susceptible to injury.
- Inappropriate footwear – poor support might increase the likelihood of sustaining a lateral ankle sprain.
5. Prevalence
Acute ankle sprains are one of the most common musculoskeletal injuries and have a particularly high incidence among physically active individuals (5). More specifically, lateral ankle sprains are the most common lower limb musculoskeletal injury in people who participate in sports and recreational physical activities (6). It is estimated that 5000 new cases occur each day in the UK with about 302,000 annual visits to A&E (7).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like X-ray, MRI (magnetic resonance imaging) or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
Self-management directly after a lateral ankle sprain is vital. In the early stage of management, good practice now involves the use of the peace-and-love (9).
Protect: the injury the first few days, avoid activities that increase pain.
Elevate: the leg higher than the heart as often as possible.
Avoid anti-inflammatories: they may reduce tissue healing in the early stage.
Compression: can help reduce swelling.
Education: your body knows best, avoid unnecessary treatments.
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Load: let pain guide your return to normal activities.
Optimism: remain confident and positive.
Vascularisation: choose a pain-free exercise that elevates your heart rate.
Exercise: restore strength by adopting an active approach to recovery.
8. Rehabilitation
In this instance, the purpose of rehabilitation is to improve muscle strength, range of movement, balance and control which is commonly impaired following an ankle sprain (7). Below are three rehabilitation programmes created by our specialist musculoskeletal physiotherapists targeted at addressing physical issues following an ankle sprain. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Lateral Ankle Sprain
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
During the early stage of rehabilitation, we recommend you implement the peace-and-love protocol detailed above. Alongside this, early range of motion exercises should be completed as soon as possible within an individual’s limitations. A combination of a range of motion exercises and progressive loading will begin to work on improving the strength and stability of the ankle. Pain should not exceed 4/10 on your self-perceived pain scale whilst completing this exercise programme.
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Once the range of movement has been restored and pain and swelling have reduced, you can begin to restore strength and proprioception. Dependent upon the level of injury, guidelines suggest that a normal range of movement should be achieved within 2 weeks after the injury (7). This should not exceed 4/10 on your perceived pain scale.
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This programme is a further progression with challenging progressive loading of the ankle complex. This should not exceed 4/10 on your perceived pain scale.
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10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a musculoskeletal physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to the sport, a rehabilitation programme should incorporate plyometric based exercises; this might include things like bounding, cutting, and sprinting exercises.
11. Other Treatment Options
Very rarely is surgery needed for an ankle joint sprain as the anatomy of the ligaments allow for successful healing with conservative (non-surgical) management. In the presence of more complex injuries that are occasionally associated with lateral ankle injuries, a further scan may be required. This may be used to evaluate for the presence of damage to the cartilage (protective substance) which lines the ankle joint. However, this is extremely rare (8).
12. Links for Further Reading
References
- Kobayashi, T. and Gamada, K. (2014). Lateral ankle sprain and chronic ankle instability: a critical review. Foot & ankle specialist, 7(4), 298-326.
- Woods, C., Hawkins, R., Hulse, M. and Hodson, A. (2003). The Football Association Medical Research Programme: an audit of injuries in professional football: an analysis of ankle sprains. British journal of sports medicine, 37(3), 233-238.
- Hiller, C.E., Nightingale, E.J., Raymond, J., Kilbreath, S.L., Burns, J., Black, D.A. and Refshauge, K.M. (2012). Prevalence and impact of chronic musculoskeletal ankle disorders in the community. Archives of physical medicine and rehabilitation, 93(10).
- Wikstrom, E.A. and Hubbard, T.J., 2010. Talar positional fault in persons with chronic ankle instability. Archives of physical medicine and rehabilitation, 91(8).
- Waterman, B.R., Owens, B.D., Davey, S., Zacchilli, M.A. and Belmont Jr, P.J. (2010). The epidemiology of ankle sprains in the United States. JBJS, 92(13).
- Delahunt, E., Bleakley, C.M., Bossard, D.S., Caulfield, B.M., Docherty, C.L., Doherty, C…. Kaminski, T.W. (2018). Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. British journal of sports medicine, 52(20), 1304-1310.
- Bleakley, C.M., O’Connor, S.R., Tully, M.A., Rocke, L.G., MacAuley, D.C…. Bradbury, I. (2010). Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. Bmj, 340.
- Brukner, P. (2012). Brukner & Khan’s clinical sports medicine. North Ryde: McGraw-Hill.
- Dubois, B. & Esculier, J. (2020). “Soft-tissue injuries simply need PEACE and LOVE”, British journal of sports medicine, (54)2,72-73.
Other Conditions in
Ankles
Tibialis Posterior Tendinopathy
A condition involving injury to the tendon found around the bone at the inner side of the ankle leading to pain and weakness.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Ankle Fractures
When a bone, or bones, that make up the ankle joint are stressed beyond their capability resulting in a fracture.
Achilles Tendinopathy
Pain, swelling and stiffness of the achilles tendon that joins the heel bone to the calf muscles.