Conditions & Treatments - Ankle Sprain


The ankle, or talocrural, joint is an articulation of three bones: the talus, the fibula, and the tibia (1). Three ligaments provide lateral support to the ankle: the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament (1). The deltoid ligament (which consists of the anterior and posterior tibiotalar ligaments, the tibiocalcaneal ligament, and the tibionavicular ligaments) provides medial support to the ankle (1). Peroneus longus, peroneus brevis, and peroneus tertius evert and provide dynamic stability to the ankle (1).

Ankle Sprains
Approximately 30% of injuries suffered by collegiate and high school athletes are ankle sprains (1). In the U.S., ankle sprains occur with an estimated incidence of 2.15 sprains per 1,000 people per year (2). The anterior talofibular ligament and the calcaneofibular ligament are the first and second most commonly sprained ligaments, respectively (1). These ligaments are often sprained simultaneously via a forced plantarflexion and inversion mechanism (1). While less common than an inversion mechanism of injury, a forced eversion mechanism of injury may result in a deltoid ligament sprain (1).

Classification of Ankle Sprains
A sprain occurs when a ligament is stretched or torn (3). Sprains are classified by grades I (least severe) to III (most severe) (1).



Examination of Ankle Sprains
A physical therapy examination of a sprained ankle should subjectively include questions regarding "the onset of symptoms, the distribution of symptoms, aggravating and easing postures, mechanism of injury, prior treatments, and prior history of ankle pain" (4). Objectively, a clinician may choose to examine posture, single leg balance, gait, range of motion, joint mobility, muscle strength, and special tests when appropriate (i.e. figure-of-eight test, anterior drawer, inversion stress test, talar tilt, eversion stress test, external rotation stress test, squeeze test, Cotton test, fibular translation test) (4,5).

Treatment of Ankle Sprains
The healing process consists of three phases: acute, subacute, and maturation (1). Depending on the severity of the ankle sprain, the acute phase will last 3-5 days (1). During the acute phase, the patient should use cryotherapy (ice) to reduce pain and swelling (2). Most studies recommend icing for 20 minutes every two hours; however, some research shows that an intermittent protocol of 10 minutes icing, 10 minutes off, 10 minutes icing every two hours results in greater short-term pain relief (2). Patients should start bearing weight and exercise as soon as the pain allows (2).

During the subacute phase, which begins around three days after the original injury and lasts up to six weeks, tissue repair begins and collagen fibers start forming scar tissue on the injured ligament (1). Gentle stress to the repairing tissue is necessary to ensure that the collagen fibers are aligning and developing properly (1).

The maturation phase may start as early as one week post injury (grade I sprains) or as late as three weeks post injury (grade III sprains) (1). During the maturation phase, it is important to continue stressing the repairing ligaments to ensure that the collagen scar tissue fibers align and develop appropriately (1). While the maturation phase may last up to a year, return to normal activities may occur as early as one to two weeks post injury (grade I sprains) or as late as 12-16 weeks post injury (grade III sprains) (1).

Physical Therapy and Ankle Sprains - What the Evidence Shows
Earlier Cochrane reviews (2011 and 2005) have shown that therapeutic ultrasound and hyperbaric oxygen are not effective treatments for acute ankle sprains (2).

Evidence shows that initiating range of motion exercises and mobilizing the ankle joint within one week post injury results in better outcomes (return to work or sport)(2). Incorporating strengthening and proprioceptive training into the rehabilitation process has been shown to not only reduce subsequent ankle injuries, but also reduce future hamstring, knee, and other lower extremity injuries (2).

A systematic review of 8 studies published in 2014 demonstrated that joint mobilization and manipulation techniques improve pain and range of motion in patients suffering from acute ankle sprains and improve function in patients suffering from subacute/chronic ankle sprains (6).

A study published by Cleland et al. in 2013 compared outcomes between a group receiving manual therapy in addition to an exercise program to a group completing only a home exercise program (4). Manual therapy techniques utilized included proximal tibiofibular joint thrust manipulations, distal tibiofibular joint mobilizations, talocrural manipulations, talocrural mobilizations, and subtalar joint mobilizations (4). Both groups completed the same exercise program, consisting of stretching, strengthening, balance, and dynamic activities (4). Researchers concluded that in this study, combining manual therapy with exercise resulted in greater improvements in short-term and long-term pain and function than exercise alone (4).

Having had a previous ankle sprain is the greatest risk factor for having a future ankle sprain (2). Therefore, proper treatment and rehabilitation is of utmost importance when treating an ankle sprain to prevent a future reoccurrence.


Last Revised: March 24, 2014
By: Michelle Kornder, SPT


1) Brotzman, SB. Chapter 5: Foot and Ankle Injuries. In Brotzman, SB, Manske RC. Clinical Orthopaedic Rehabilitation: An Evidence-Based Approach. 3rd ed. Philadelphia, PA: Mosby, Inc.;2011.
2) Tiemstra JD. Update on Acute Ankle Sprains. American Family Physician. 2012;85(12):1170- 1176. Available from: University of Wisconsin Madison, Madison, WI. Accessed March 11, 2014.
3) Mayo Clinic. Diseases and Conditions: Sprains and strains. Available at: 20020958. Accessibility verified March 11, 2014.
4) Cleland JA, Mintken P, McDevitt, A, et al. Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial. Journal of Orthopaedic and Sports Physical Therapy. 2013;43(7):443-455. Available from: University of Wisconsin Madison, Madison, WI. Accessed March 11, 2014.
5) Hallisy, Thein-Nissenbaum. PT 677 -MS Dysfunction: Examination, Diagnosis, & Management II. Madison, WI: Department of Physical Therapy; 2013.
6) Loudon JK, Reiman MP, Sylvain J. The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review. Br J Sports Med. 2014;48:365-370. Available from: University of Wisconsin Madison, Madison, WI. Accessed March 11, 2014.
7) Kerkhoffs GM, van den Bekerom M, Elders LAM, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012;46:854-860. Available from: University of Wisconsin Madison, Madison, WI. Accessed March 11, 2014.




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