Lateral Ankle Sprain
- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications
- 12 See Also
- 13 References
- Ankle sprain
- Rolled ankle
- Inversion Ankle Injury
- Lateral Ankle Sprains (LALS or LAS)
- Low Ankle Sprain
- This page refers to acute sprains of the lateral Ankle Joint
- Described by Garrick in 1977
- LAS represents most common lower limb musculoskeletal injury in physically active persons
- Ankle ligament sprains are the most common injury in NCAA sports, accounting for 15% of all reported injuries 
- Overall, ankle injuries represent up to 30% of all injuries in sports
- Lateral ankle sprains represent 70-90% of all ankle sprains
- 18% of all sports injuries in the Netherlands were ankle injuries between 2000-2004
- Location/ Surface/ Sport
- Indoor /court sports had the highest incidence rates estimated as 7 ankle sprains per 1000 exposures
- Injury mechanism is characterized by a high velocity inversion and internal rotation of the ankle/foot complex
- Particularly prevalent in field and court sports
- Vast majority will self resolve in 4-6 weeks, although some may persist for years
- Occurs due exaggerated, high force inversion and plantarflexion
- Leads to stretching, tearing or rupture of the lateral ankle ligaments
- Typically in a sequential pattern depending on severity
- Starts with anterior talofibular ligament (ATFL) followed by calaneofibular ligament (CFL) followed by posterior talofibular ligament (PTFL)
- First contact mechanism
- Due to player-to-player contact with impact by an opponent on the medial aspect of the leg
- Occurs just before or at foot strike, resulting in a laterally directed force across the ankle
- This causes the player to land with the ankle in a vulnerable, inverted position
- Second contact mechanism
- Forced plantar flexion where the injured player hit the opponent’s foot when attempting to shoot or clear the ball.
- Chronic Ankle Instability
- Ankle Osteoarthritis
- Syndesmotic Sprain
- Maisonneuve Fracture
- Osteochondral Defect
- Medial Ankle Sprain
- Ankle Joint
- Lateral Ligaments
- Type of foot wear
- Type of supportive device
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Nerve Injuries
- Athletes typically report a sudden twisting of the ankle joint
- They may have an inability to bear weight
- They usually can identify the palpatory painful spot
- Also endorse swelling, bruising (may be subacute)
- Inability to return to sport
- Sometimes endorse a snap or crack
- Physical Exam: Physical Exam Ankle
- Palpate all bony and soft tissue structures (see: Ottawa Ankle Rules)
- If no pain along ATFL distribution, likely not a standard LAS
- Special Tests
- Standard Radiographs Ankle
- Typically normal
- Ottawa Ankle Rules
- Decision making rule can help determine if xray is necessary
- They are close to 100% sensitive (need citation)
- Van Dijk et al
- Early on they found sensitivity 92%, specificity 64%
- Inconclusive physical exam they found sensitivity 100%, specificity 72%
- Among ED physicians, accuracy was similar to MRI
- Useful when other soft tissue injuries are suspected
- Tendinous and syndesmotic trauma
- Osteochondral lesions
- Occult fractures
- Joshy et al: sensitivity 92-100%, specificity 100%
- In comparison with arthroscopy, MRI (93%) was superior to US (63%) in correctly locating the injured portion of the ATFL
- Grade I (mild)
- Injury: ligament fiber stretch without macroscopic rupture
- Clinically minor swelling, palpatory tenderness
- Hardly any functional loss
- No increased instability
- Grade II (moderate)
- Injury: partial ligament tear
- Moderate pain, swelling and palpatory tenderness
- Mild to moderate instability
- Moderate functional disability
- Grade III (severe)
- Injury: complete tear of the ligament and joint capsule rupture
- Severe bruising, swelling, and pain
- Significant loss of function and an increased instability
- Unable to bear weight and walk normal
- Nonoperative vs Operative
- Surgical intervention associated with increased cost, risk of complications (wound infection, nerve injury, dystrophy, poor wound healing)
- Nonoperative vs operative management of grade III have failed to demonstrate a superior modality, thus nonoperative management is often the preferred approach
- Prevention of recurrence
- PT helps with prevention of recurrence
- Missed time
- Return to play
- The vast majority of athletes will return to full pre-injury level of play
- Important to distinguish the complex injuries from the simple single ligament injuries
- Vast majority of cases
- PRICE Therapy
- Typically for the first 3-5 days
- Oral or topical appear to help
- External Support
- Doherty et al: MA, SR found external support (taping, bracing and orthoses) is effective for improving function
- Duration of total immobilization should be brief and early mobilization should be encouraged
- By 1-2 weeks transition to External Ankle Brace
- No difference between tape, semi rigid brace or lace up brace at 6 months
- Physical Therapy
- Manual Therapy
- Unclear whether manual therapy helps with function
- Ice Therapy
- May have some benefit in SR/MA but overall evidence is lacking due to low methodological quality
- Unknown benefit
- Primary reconstruction
Rehab and Return to Play
- Progressive weight bearing
- Early active range of motion (ROM) exercises
- Followed by strengthening exercises, proprioceptive training, and functional exercises
- Final phase of rehab
- Progressively simulate the physical demands of the respective sport modality
- Often includes jumping, turning, and twisting
- Several rehab programs have been suggested
- 1-2 weeks: lower leg cast
- 2-4 weeks: walking boot, active rehab
Return to Play
- Performance based
- Athlete should be able to progress from simple tasks to complex tasks
- Perform 90% of of function compared to unaffected ankle
- Progress through sport specific tasks
- Balance (wobble board)
- Persistent ankle laxity, pain, weakness
- Re-injury/ sprain
- If untreated, patients can develop
- Chronic disability
- Decreased physical activity
- Increased Fall Risk in geriatric patients
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
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