Ankle Sprain

Ligaments at the ankle joint:

1. Lateral
 ATFL: Plantar flexion, Inversion, internal rotation and adduction of talus;
anterior displacement of talus
 PTFL: Dorsiflexion, inversion, adduction, medial rotation of talus
 Calcaneofibular: Inversion and DF
ATFL is most commonly injured followed by Calcaneofibular
D/D: Sinus Tarsi Syndrome Chronic condition- result of repetitive ankle sprain; pain more severe on
standing, walking on uneven surfaces, supination and adduction of foot;
localization of pain at sinus tarsi and ankle instability are good indicators. Pain
over the sinus tarsi at end range PF + supination: typical sign
2. Medial
 Anterior talotibial: Abduction of talus when in PF and eversion (Deep
ligament of the medial complex: Joint is more unstable during PF)
 Posterior talotibial: DF, lateral translation, and External rotation of talus
(abduction of talus)
 Tibionavicular: external rotation of talus and lateral translation
 Tibiocalcaneal: Abduction of talus, Eversion
Grades of ankle sprain: west point sprain grading system

Criteria Grade 1 Grade 2 Grade 3

ATFL + ATFL + PTFL +

Location of
ATFL Calcaneofibular Calcaneofibular
tenderness
ligament ligament

Severe and diffuse

Edema and
Slight and local Moderate and local Medial & lateral
ecchymosis
swelling

-Difficult without -Impossible without

crutches significant pain
Weight-bearing Full or partial
-Limp with walking -Initially almost
ability Pain with running
-Unable to toe raise complete loss of
-Unable to hop ROM

Ligament damage Stretched Partial tear Complete tear

Instability none None or Slight Definite

Intervention: Non-surgical grade 1 and 2 ankle sprain
A. Phase 1: maximum protection phase
 Control pain, inflammation, and swelling: PRICE protocol
 Protect the healing area from re-injury: ankle should be positioned in
maximum amount of DF (close-pack position & maximum congruency) as
permitted by joint effusion and pain.
o Provide external support: elastic bandage, thermoplastic stirrup like an
AirCast, semi-rigid ankle orthotic or walking boot)
 Re-establish Pain-free ROM and prevent muscle atrophy:
o muscle setting exercises
o gentle capsular stretches: grade 1 and 2 mobilizations
o Exercises: towel stretches, ankle toe pumps, ankle circles, low-level
biomechanical ankle platform system exercises (wobble board in
sitting), active or AAROM exercises in PF, DF, Inversion, and Eversion,
Toe curls, etc. for foot intrinsics
o Mild manual isometrics in pain free range
o Concentric exercises can be started once the isometric exercises are
pain-free
o Seated lower extremity CKC’s can be initiated (seated heel raises)
o Unilateral Weight bearing on affected leg with appropriate support
or assistive device is encouraged

B. Phase 2: Controlled motion phase

 Criteria for progression:
o Pain free weight bearing and uncompensated gait pattern must be present
o Minimal pain and tenderness: pain might still be felt with activities more
vigorous than walking
o Full PROM and MMT at least 4/5

 Restore normal joint kinematics:

o Manually resisted exercises, concentric TheraBand exercises in DF, PF,
Inv, and Eversion. Avoid end-range inversion
o CKC’s: Seated marching on the floor or pillow
o Weight-bearing exs: unilateral stance on the floor, weight-shifting exs

 Protection of healing ligaments: have the patient wear a range-limiting brace

or orthosis to prevent excessive stress
  Stretch gastrocnemius and soleus muscle group to restore full DF motion.
Very important to prevent recurrent ankle sprains
 Grade 2 posterior glide of talus to increase DF
 Cross friction massage to ligaments as tolerated
 Gait training for walking and stair climbing: up with the good leg and down
with the bad leg
 Proprioceptive training and multidirectional balance activities (WBAT/PWB)

C. Phase 3: Return to function phase

 Strengthening exercises: TheraBand open-chain exercises
 Dynamic lower extremity stabilizers: perturbations and surface instability
 Forward-backward walking, crossover side-stepping with elastic resistance
 Wall slides, toe walking, heel walking, supine leg press
 Ankle destabilization exercises using BOSU/ BAPS board
 Multidirectional balance activities should progress from NWB to CKS’s and full
weight bearing once the ROM is full and pain-free
 Eccentric loading exercises
 Plyometric training: 2-foot ankle hopping etc.
 When the patient is involved in sports activities, the ankle should be splinted
or taped and appropriate shoes should be worn to protect the ligament from
re-injury
Criteria for return to sports:
 Full pain-free active and passive ROM
 No complaints of pain or tenderness
 75–80% strength o the plantar flexors, dorsi flexors, invertors, and evertors
compared to the uninvolved side
 Adequate unilateral stance balance (30 seconds with eyes closed)

Additional points:
If adhesions are developing in a healing ligament, then patient should actively move the
foot in a direction opposite to the line of pull of injured ligament. For example: for ATFL,
move the foot in PF and Inversion.
 Post-Surgical Ankle Rehab
Surgical intervention required for grade 3 ankle sprain: ATFL + PTFL + Calcaneofibular
ligaments are injured, instability of both tibiotalar and subtalar joints, increased talar tilt,
ankle mobility beyond physiologic ROM. Patient has a sensation of ankle giving away.
Indications for surgery:
o Chronic mechanical and functional instability of the ankle during activity that is not
resolved with several months of conservative management.
o Acute, radiographically, or arthroscopically confirmed third-degree lateral ankle
sprain resulting in a complete tear of the ATF and/or CF ligaments.
Immobilization Phase:
 Immediately after the surgery: Compression dressing, non-walking bi-valve dressing
with ankle in 0° dorsiflexion and slight eversion and leg elevated for 3-5 days as the
swelling subsides
 After 3-5 days a short leg cast is applied. This cast is removed at 2-6 weeks and
replaced by a removable cast boot or a CAM walking brace. Patient is instructed to
perform ankle DF/PF and inversion/eversion within 10-15 degrees arc of motion.
 At 6-12 weeks patient can discontinue the immobilizer during ambulation
 Weight bearing: full weight bearing without immobiliser recommended at 6-12
weeks usually
Phase 1: maximum protection phase (4-6 weeks)
 NWB ambulation with crutches is typical
 Elevation of operated leg for edema management
 Submaximal muscle setting exercises with ankle in neutral including fibularis muscles
 AROM for ankle DF/PF in pain-free range and inversion/eversion within 10-15
degrees pain-free arc of motion.
 Gait and transfer training with assistive device
 Active and resistive exercises for hip and knee and UE
 Mini squats in B/L stance with appropriate weight bearing
Phase 2 and 3: moderate and Minimum protection phase
Moderate protection phase begins at 4-6 weeks post op and minimum protection phase
begins at 8-12 weeks post op
 Restore full pain-free ROM: full ROM by 8 weeks
o Active multiplanar movements like figure of 8 or alphabets, etc.
 o Grade 2 or 3 mobilizations to tibiotalar or tibiofibular to increase DF or PF
o Self-stretching gastrocnemius and soleus complex stretching: begin with towel
stretching and progress to standing on a wedge for extended duration
 Muscle strengthening: Eversion strengthening and DF range particularly very
important to prevent recurrent injuries
o Unilateral calf raises with support to prevent loss of balance
o Hip and knee strengthening in WB
o Progress to plyometric training once weight bearing is pain-free, ankle is stable
with stress testing, 25 unilateral heel raises can be performed: Begin with B/L
jumping>>unilateral hopping forward, backward, side to side. Plyometrics should
initially be performed with ankle support
 Improve muscular endurance: pool walking/running, swimming, static bicycle, etc.
Land-based activities should initially be performed with ankle support
 Improve neuromuscular control and balance:
o Ankle proprioception may also be targeted on specific destabilization tools (ankle
destabilization boot, ankle destabilization sandal, air bladder) with moderate
inversion ROM (10°-15°) localized only under the rearfoot
o Grapevine walking, lateral shuffles, using sliding board, cutting activities etc.
 Re-establish pain-free symmetrical weight bearing:
o Begin gait training in a pool or land-based training on level surfaces as soon as
ambulation in a controlled ankle motion brace (which allows dorsi- and
plantarflexion) is permitted.
o Emphasize symmetrical weight bearing during sit-to stand movements and
eventually ascending and descending stairs
o Progress to ambulation and functional activities without the brace

For return to functional activity, patient should:

 Demonstrate normal uncompensated gait on even and uneven grounds
 Ankle musculature strength should be equal to or more than 90% of the contralateral
side
 Functional Hop test performance at 90% as compared to other side
For return to sports:
 Single-leg hop tests (for horizontal distance; for vertical distance; triple hop test;
figure-of-8 hop test; and 6-meter timed hop test
 Star Excursion Balance test
 Foot and Ankle Ability Measure functional questionnaire
 A brace to provide medial-lateral stability can be used while engaging in sports