Lateral ankle sprains (LAS) are the most common musculoskeletal injuries in athletes and are highly prevalent in the general population. Children aged 12 or younger exhibit the highest incidence rates (2.85 per 1,000 exposures), while among adults, females are reported to have nearly double the incidence rate of males. Approximately 40% of traumatic ankle injuries occur during sports, with indoor and court sports like basketball and volleyball posing the highest risk, reaching an incidence of 7 per 1,000 exposures. Despite this high prevalence, only about 50% of individuals seek medical attention.
Typical Patient Presentation and History¶
Patients typically present following a sudden onset inversion-related injury. History taking should include the trauma mechanism, ability to bear weight immediately after injury, and any history of previous ankle instability or sprains. Presentation often includes acute pain, swelling, and impaired function, such as a limited ability to walk or bear weight. Injuries are clinically graded to indicate severity:
Grade I:¶
Ligaments are stretched without macroscopic tearing; the ankle remains stable.
Grade II:¶
Partial ligament tearing, typically involving a complete tear of the anterior talofibular ligament (ATFL) and a partial tear of the calcaneofibular ligament (CFL); results in some instability and positive special tests.
Grade III:¶
Complete rupture of all three lateral ligaments, associated with significant instability and haematoma.
Knowledge Check
The Ottawa Ankle Rules have a very high sensitivity (92%-100%) for identifying fractures of the malleoli, midfoot, and base of the fifth metatarsal. They are used to prioritize excluding fractures before assessing ligamentous damage.
Diagnosis¶
The diagnostic process prioritises excluding fractures using the Ottawa Ankle Rules (OAR), which have a very high sensitivity (92%--100%) for identifying fractures of the malleoli, midfoot, and base of the fifth metatarsal. To assess ligamentous damage, physical examination is most reliable when delayed 4--5 days post-trauma, as the sensitivity and specificity of tests like the anterior drawer test are optimised during this window. Specific clinical tests include:
Anterior Drawer Test: Primarily assesses the ATFL.
Talar Tilt Test: Evaluates the CFL.
Reverse Anterolateral Drawer Test: Found to be more sensitive and accurate than the traditional anterior drawer for ATFL injuries.
Ultrasound offers high sensitivity (99% for ATFL) and is a cost-effective adjunct for real-time visualization of laxity. MRI is reserved for suspected high-grade injuries, occult fractures, or persistent symptoms where underlying joint damage is suspected.
Management¶
Management is divided into acute treatment and long-term prevention.
Acute Phase:¶
There is strong evidence for the use of functional support (bracing or taping) over rigid immobilization. Immobilization (casts) should be restricted to a maximum of 10 days for severe Grade III sprains to reduce pain and oedema before starting functional treatment.
Knowledge Check
Immobilization in casts should be restricted to a maximum of 10 days for severe Grade III sprains to reduce pain and oedema before starting functional treatment. There is strong evidence for the use of functional support (bracing or taping) over rigid immobilization.
Pharmacology:¶
Strong evidence supports short-term use of NSAIDs (oral or topical) to reduce pain and swelling, though paracetamol and opioids are effective alternatives.
RICE Therapy:¶
While widely practiced, there is insufficient evidence to support the effectiveness of RICE alone. However, cryotherapy combined with exercise therapy can significantly improve short-term function and loading.
Exercise and Manual Therapy:¶
Supervised exercise-based programmes focusing on neuromuscular and proprioceptive training are strongly supported for stimulating functional joint stability. Manual therapy (joint mobilisations) provides a short-term increase in range of motion and pain reduction when combined with exercise.
Surgery:¶
This is controversial for acute sprains and should be reserved for cases that fail to respond to thorough conservative management or for professional athletes requiring quick recovery.
Prevention:¶
There is strong evidence for bracing and moderate to strong evidence for neuromuscular/proprioceptive training in preventing recurrent ankle sprains. Prophylactic bracing is also recommended for high-risk activities to prevent first-time sprains
Evidence-Based Rehabilitation and Management of Lateral Ankle Sprains¶
A comprehensive evidence-based rehabilitation programme for lateral ankle sprain (LAS) prioritises early functional treatment and progressive loading over rigid immobilisation. For first-time sprains, the programme should begin with the use of functional supports, such as braces or tape, which allow for protected movement while avoiding the loss of muscle strength and proprioceptive impairment associated with casts. Progressive weight-bearing should be initiated as soon as pain allows to facilitate a faster return to work and sport. In instances of severe Grade III injuries, a short period of immobilisation in a below-knee cast may be used to manage acute pain and oedema, but this must be restricted to a maximum of 10 days.
Exercise therapy is the fundamental component for both acute and recurrent sprains and should be commenced as early as possible after the injury. A structured programme must include neuromuscular training, balance re-education, and proprioceptive exercises to restore functional joint stability. Evidence indicates that the effectiveness of these programmes in preventing recurrence is significantly enhanced when administered in high doses (exceeding 900 minutes total). For patients with Chronic Ankle Instability (CAI) or recurrent sprains, the programme should adopt a more holistic approach, incorporating proximal strengthening of the gluteal and core musculature to improve dynamic control of the lower kinetic chain.
Manual therapy, including lymphatic drainage and joint mobilisations (specifically anterior-to-posterior talar glides), should be integrated to reduce pain and provide a short-term increase in dorsiflexion range of motion. These techniques are most effective when combined with active exercise rather than used as stand-alone passive modalities. Pharmacological support with oral or topical NSAIDs is recommended in the acute phase (\<14 days) to reduce pain and swelling, although paracetamol and opioids are effective alternatives. While RICE therapy (rest, ice, compression, elevation) is standard practice, it lacks strong evidence as an isolated treatment; however, cryotherapy used alongside exercise can significantly improve short-term loading capacity.
For long-term management and secondary prevention, the use of a prophylactic brace for 6 to 12 months is strongly advised, particularly during high-risk sports activities. The progression toward return to sport should be criteria-based, focusing on objective measures of static balance, sport-specific movement patterns, and the mitigation of psychological factors such as kinesiophobia. Surgery is not recommended as a primary treatment for acute sprains and should only be considered for professional athletes requiring rapid recovery or for cases of chronic instability that have failed to respond to a comprehensive, supervised exercise programme
Knowledge Check
Evidence indicates that the effectiveness of neuromuscular and proprioceptive training programmes in preventing ankle sprain recurrence is significantly enhanced when administered in high doses exceeding 900 minutes total. This emphasizes the importance of sufficient volume in rehabilitation programmes.