|Year : 2014 | Volume
| Issue : 1 | Page : 14-20
Lateral ankle sprain: A review
Shibili Nuhmani1, Moazzam Hussain Khan2
1 Department of Rehabilitation Sciences, Jamia Hamdard University, New Delhi, India
2 Department of Physiotherapy Centre for Physiotherapy and Rehabilitation, Jamia Millia Islamia, New Delhi, India
|Date of Web Publication||29-Apr-2014|
Moazzam Hussain Khan
Centre for Physiotherapy and Rehabilitation, Jamia Miallia Islamia, New Delhi
Source of Support: None, Conflict of Interest: None
Ankle sprain injuries are the most common injury sustained during sporting activities. One-sixth of all sports injury loss time is from ankle sprains. Each year, an estimated 1 million persons, present to physicians with acute ankle injuries. Three-quarters of ankle injuries involve the lateral ligamentous complex, comprised of the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament. Lateral ankle sprains typically occur when the rearfoot undergoes excessive supination on an externally rotated lower leg. The diagnosis of a sprain relies on the medical history including symptoms, as well as making a differential diagnosis mainly in distinguishing it from strains or bone fractures. Despite their prevalence in society, ankle sprains still remain a difficult diagnostic and therapeutic challenge in the athlete, as well as in society in general. The high incidence of ligamentous ankle injuries requires clearly defined acute care and a broad knowledge of new methods in rehabilitation. In addition to rapid pain relief, the main objective of treatment is to quickly restore the range of motion of the ankle without any major loss of proprioception, thereby restoring full activity as soon as possible. The purpose of this article is to review the anatomy, pathomechanics, investigation, diagnosis, management of lateral ankle sprains.
إن إصابات وثي الكاحل هي الأكثر شيوعاً خلال النشاطات الرياضية خيث يراجع حوالي مليون شخص سنوياً الأطباء بسبب إصابات الكاحل الحادة. ثلاثة أرباع إصابات الكاحل تشمل مركب الأربطة الوحشي الذي يتألف من الرباط الكعبي الشظوي الأمامي، والرباط الشظوي البقي والرباط ألكعبي الشظوي الخلفي. تحدث إصابات وثي الكاحل عادة عندما يتعرض مؤخر القدم إلى استلقاء مفرط على طرف سفلي دائر للخارج.
يعتمد تشخيص الوثي على القصة المرضية بما يشمل الأعراض مع إجراء تشخيص تفريقي للتميز بين الوثي والكسر العظمي. ورغم شيوع هذه الإصابة في المجتمع فإنها تظل تحديا من ناحية التشخيص والعلاج عند الرياضيين كما هو الحال فى كل المجتمع. إن اارتفاع فى حدوث إصابات أربطة الكاحل يتطلب وجود خطة عناية حادة مع الإلمام بطرق التأهيل الحديثة. فبالإضافة إلى تخفيف الألم السريع فإن هدف العلاج الرئيسي هو إعادة مدى حركة الكامل إلى الطبيعي وبسرعة، دون حدوث خسارة كبيرة لاستقبال الحس العميق وبذلك إعادة النشاط الكاحل في أسرع وقت. إن هدف هذا المقال هو مراجعة الجوانب التشريحية والآليات المرضية والاستقصاءات والتشخيص والمعالجة لحالات وثي الكاحل الوحشي .
Keywords: Functional rehabilitation, lateral ankle sprain, lateral collateral ligaments
|How to cite this article:|
Nuhmani S, Khan MH. Lateral ankle sprain: A review. Saudi J Sports Med 2014;14:14-20
| Introduction|| |
Injuries to the lateral ligaments of the ankle complex are the most common musculoskeletal injuries seen among the recreational and competitive athletes. , It creates long-term disabilities. It has significant impact on cost, athletic participation, and activities of daily life. 
Since most sports activities involve running, jumping, and turning, high stresses are often put on the joints of the lower limbs, including the ankle. Hansen et al., reported that 67.3% of their football players had sprained their ankles during sports. Smith and Reisch  reported that 70% of their basketball players had a history of ankle sprain and 80% of them had multiple sprains. Chronic ankle problems such as chronic pain, muscular weaknesses, and ease of giving way were not uncommon for those athletes with a history of ankle sprain. ,
Traditionally, the diagnosis of ankle sprain is based on history and delayed physical examination, 5-7 days after initial trauma.  The most common injury mechanism is supination and adduction (called inversion) with the foot plantar flexed. Any additional X-rays are used only to exclude other diagnoses, such as a fracture or disturbance of the joint congruency, based on the Ottawa ankle rules.  Generally, the prognosis of ankle injuries is good, whatever treatment is followed.  Pijnenburg  has showed that at least 80% of patients in all compared treatment groups were free of complaints after 1 year. However, there is still potential for improvement in 20% of these patients.
| Anatomy and Pathomechanics|| |
The ankle joint comprises of three major articulations: The talocrural joint, the subtalar joint, and the distal tibiofibular syndesmosis.  The talocrural joint is also termed the tibiotalar joint or the mortise joint, and is formed by the articulation of the dome of talus, the tibial plafond, the medial malleolus and the lateral malleolus. This joint, in isolation, behaves rather like a hinge joint that allows mainly plantarflexion and dorsiflexion. The fibula extends further to the lateral malleolus than the tibia does to the medial malleolus, thus creating a block to eversion.  Such body feature mainly allows larger range of inversion than eversion, thus, inversion sprains are more common than eversion ones. 
The ligaments that surround the ankle joint consist of the lateral collateral ligaments, syndesmotic ligaments, and the medial collateral ligaments (MCLs). The lateral collateral ligaments consist of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL) , Generally, the lateral collateral ligaments are weaker and more prone to injury than MCL. The ATFL is the most frequently damaged lateral collateral ligament followed by CFL and then PTFL which is rarely injured. The ATFL extend from the anterior portion of the distal fibula stretching forward to insert on the talus. Its role in the ankle mechanics is checking plantar flexion and inversion of the ankle. Thus, it is these movements that stress the ligaments most and cause it to be damaged. ,,,
The higher incidence of inversion trauma over eversion sprain injuries can be partially explained by two anatomical considerations. First is medial malleolus is shorter than lateral malleolus which allow the talus to invert than evert. Second the ligament structures on the lateral side of the joint occur as a discrete fascicular bundle and therefore are not strong as the broader, expansive deltoid ligament on the medial side and hence rupture.
| Mechanism of Injury|| |
Lateral ankle sprains most commonly occur due to excessive supination of the rear foot about an externally rotated lower leg soon after initial contact of the rear foot during gait or landing from a jump. , The ATFL is the first to rupture with such forced inversion of the ankle. Rupture of the ATFL is always associated with rupture of the joint capsule because the ligament is incorporated into capsule.
Rupture of ATFL because of forced inversion allows the anterior subluxation of the talus out of the ankle mortise. Forced plantar flexion in combination with adduction causes rupture of the ATFL, followed by partial rupture of CFL. If the continued force is applied, then CFL ruptures completely followed by the rupture of PTFL.
Lateral ankle sprains are based on a grade 1-3 classification. A grade 1 ankle sprain usually entails microscopic tearing of the ATFL. Symptoms may include minimal swelling and point tenderness directly over the ATFL; however, there is no instability and the athlete can ambulate with little or no pain. A grade 2 ankle sprain involves microscopic tearing of a larger cross-sectional portion of the ATFL. Symptoms may include a broader region of point tenderness over the lateral aspect of the ankle, a painful limp if able to ambulate, and bruising and localized swelling due to tearing of the anterior joint capsule, ATFL, and surrounding soft tissue structures. A grade 3 ankle sprain entails a complete rupture of the ATFL and may also involve microscopic or complete failure of the CFL. The PTFL is rarely injured during inversion ankle sprains. Symptoms may include diffuse swelling that obliterates the margins of the Achilles tendon, inability to ambulate, and tenderness on the lateral and medial aspects of the ankle joint. ,,
The following orthopaedic tests may prove useful in aiding diagnosis. ,,,,,,,
Anterior drawer test
Stabilizing the tibia and fibula, the foot is held in 20° of plantar flexion, while the talus is drawn forward in the ankle mortise. This tests the integrity of the ATFL and anterior joint capsule. A positive test result would be greater than 5 mm of anterior motion of the STJ as compared with the noninjured ankle, and an audible clunk may be elicited. If the ankle is inverted while conducting the anterior drawer test, it also evaluates the integrity of the CFL.
Talar tilt test
The ankle is held in anatomical position, and the talus is tilted into adduction and abduction. This primarily tests the integrity of the CFL when the foot is in a neutral position; when the test is performed with plantar flexion, it also evaluates the integrity of the ATFL. A positive test result would be 5°-10° of increased inversion as compared with the noninjured ankle and would be indicative of a tear of the CFL.
External rotation test
Manual passive external rotation of the foot and ankle in a neutral or slightly dorsiflexed position would widen the ankle mortise. Pain over the distal syndesmosis is positive for a syndesmotic injury.
Tibia/fibula squeeze test
Result is positive for a syndesmotic sprain if compression of the tibia and fibula in the midcalf region produces pain over the distal syndesmosis.
Tape is applied around the distal syndesmotic region for support. A positive test result for syndesmotic injury would be reduced pain over the distal syndesmosis during ambulation or when performing a heel raise.
| Investigation|| |
Radiographs are taken to rule out fracture of the medial and lateral malleoli, the talus and the fifth metatarsal layer.
It is helpful in determining completeness of the ligamentous tear or determining the presence of avulsed fragments of the bone. Traction forces are applied to the ankle to promote tilt or drawer effect and comparison are made between injured and uninjured side.
It is performed within 48 h of the injury to evaluate multiple ligament injury.
For detecting multiple ligament rupture but an isolated ATFL injury cannot be detected by this technique.
Magnetic resonance imaging (MRI)
It is the highly reliable and accurate imaging modality for evaluation of precise location and extends of partial to complete tear of collateral ligaments.
- Medial ligament sprain
- Syndesmosis sprain
- Bifurcate ligament injury
- Achillus tendon rupture
- Peroneal tendon suluxation or dislocation
- Flexor hallucis longus injury
- Lateral periostitis
- Ostrigonum injury
- Anterior tibial tendon injury
| Management|| |
Acute phase: Early management includes RICE (rest, ice, compression, and elevation). Cryotherapy should be used immediately after the injury. Heat should not be applied to an acutely injured ankle joint, because it encourages swelling and inflammation through hyperaemia.  Crushed ice in a plastic bag may be applied to the medial and lateral ankle over a thin layer of cloth. Alternatively, the foot and ankle may be cooled by immersion in water at a temperature of approximately 12.7°C (55°F). The foot and ankle should be cooled for approximately 20 min every 2-3 h for the first 48 h or until edema and inflammation have stabilized. Benefits of cryotherapy include a decrease in metabolism that limits secondary hypoxic injury.  In subacute phase goal include continued reduction of swelling, inflammation, and pain, while some motion strengthening and appropriate controlled weight bearing are started. The rehabilitative phase focuses on improving strength, endurance, tolerance, and weight-bearing proprioception.
Treatment modalities during functional rehabilitation focus upon improving ankle mobilization and proprioception. The stationary bicycle and swimming can be useful to improve ankle range of motion. Strengthening is begun only after normal weight bearing and pain-free range of motion. Therapy focused on improving proprioception can utilize the tilt board and trampoline as a means to increasing balance and neuromuscular control. Boyce et al.,  reported that the use of an Aircast ankle brace produced significant improvement in ankle joint function in 10 days and 1 month compared with an elastic support bandage. Madras and Barr  reported that ankle disk training on wobble board were effective in enhancing single leg balance and reducing recurrent sprain injury, while Osborne et al.,  and Sheth et al.,  reported the effect of ankle disk training in enhancing peroneal muscle reaction time. De Simoni et al.,  suggested that a 12-week prescription of orthosis was effective in improving functional stability at the ankle joint. Recently, Christakou et al.,  suggested that imagery may be effective in improving muscle endurance in the rehabilitation of grade II ankle sprain.
| Treatment of Grade 1 and 2 Ankle Sprains: For Which Types/Severity of Injuries?|| |
The goals of therapy are to accentuate the normal healing process and protect the ligament from further injury. The acronym PRICESMMS stands for proprioception training, rest/modified activity, ice, compression, elevation, stabilization, medications (nonsteroidal anti-inflammatory drugs), mobilization, and strength training.  These rehabilitation techniques should be applied appropriately during each phase of treatment. Progression of the treatment plan depends on the severity of injury, the patient's response to therapy, and the achievement of goals during each treatment phase. ,
Acute inflammatory phase (24-72 hours)
- Ice therapy should be applied for 20 minutes on/1 hour off throughout the day, with a compression bandage and the leg elevated above the heart. Cryotherapy reduces pain, edema, and secondary hypoxic damage to injured tissues ,,,
- NSAIDs, electric muscle stimulation, pulsed ultrasound, antiedema massage, and low-level laser therapy may help in reducing inflammation ,,
- Ankle pumps, 10 to 20 pumps per hour, should be conducted in a pain-free range to decrease edema and increase circulation 
- Ambulate weight bearing as tolerated with axillary crutches if necessary. A semirigid orthosis, laceup style brace, or tape provides mechanical joint stability in the frontal plane. ,
- Depending on the severity of injury, pain-free modified activity can be used to maintain cardiovascular fitness. Examples of modified activity may include deep-water pool running, swimming with a pool buoy between the legs, or stationary cycling ,,
- Several studies were conducted on grade 1 and grade 2 ankle inversion injuries using manipulation of the TCJ. Two studies showed manipulation of the talus in an anterior to posterior vector improved range of motion in dorsiflexion at the ankle mortise. , Another study showed that manipulation of the joints and soft tissue improved dorsiflexion as well as reduced pain and edema 
- Active or passive soft tissue techniques such as Active Release Technique, Graston Technique, muscle energy technique, and transverse friction massage can be applied directly to the ligament and surrounding soft tissue structures to facilitate early ligament healing.
Numerous clinical studies support the use of transverse friction massage in the treatment of ligament sprains.  Recently, Loghmani and Warden  conducted a study on instrument-assisted crossfiber massage (IACFM) and its effect on ligament healing. Bilateral MCL injuries were induced on the knees of 51 rodents. The IACFM was commenced with a Graston handheld tool on one of the rodent's MCLs 1 week post injury, at a frequency of 3 sessions per week and for duration of a minute. The contra lateral MCL was used as the non treated control. Histological sections were obtained 4 weeks post injury. The scar region of the IACFM-treated ligaments, as compared with the contra-lateral non-treated ligaments, appeared to have greater cellularity; and the collagen fibers appeared to be aligned more longitudinally. This study suggests that IACFM may accelerate early tissue-level healing. 
A more cautious approach to treatment may be necessary if there is suspicion of a grade 3 lateral ankle sprain.  In the opinion of one of the authors, if the initial examination reveals severe swelling, pain, and inability to bear weight, the athlete should be placed in a functional walking orthosis and instructed to ambulate with crutches in a non weight bearing gait. Nonsteroidal anti-inflammatory drugs (NSAIDs), ice, compression, and elevation should be used to attempt to reduce swelling and pain. A reexamination should be conducted 3 days later. If there is no observable improvement, an MRI study should be used to assess the severity of injury. If the MRI indicates a completely torn ligament, the athlete should continue to follow the above regimen for approximately 4 more days, thereby allowing the retracted ligament ends to heal appropriately before progressing to the next stage of treatment.
Reparative phase (3-5 days, collagen production intensifies 10-14 days)
Goals include reducing inflammation, facilitating the ligament healing process, restoring active and passive ranges of motion, minimizing loss of strength, maintaining cardiovascular fitness, and starting propioceptive rehabilitation. ,,
- Joint mobilization and soft tissue techniques of the TCJ and the STJ to free up joint restrictions and aid in improving range of motion ,,,,
- Passive stretch of the gastrocnemius and soleus musculature with a towel, three sets of 30-s holds. Stretching on a slant board or with a prostretch can be incorporated when the patient can at least partially bear weight with minimal pain
- Isometric exercise should be conducted as soon as the patient can tolerate it to prevent muscle atrophy.  Active and passive range of motion can be conducted with minimal pain in dorsiflexion, plantar flexion, eversion, and the pain-free range of inversion. The therapist may conduct three sets of 10 with a 3- to 5-s hold at the passive end range. The patient can conduct isometric exercises at home
- Strengthen the peroneii, tibialis anterior and extensors, and the triceps surae with thera-Band, 3 sets of 10 - 15 repetitions for each muscle group  also strengthen the gluteus medius musculature to prevent lateral sway,  once the patient can fully weight bear without pain, he can add resistance greater than body weight as tolerated. This may include standing and seated calf raises. If no weights are available, teach the patient to go up on the toes on both feet and then shift all the weight to the injured side and lower down on that leg
- Standing proprioception training can be conducted on the floor, a wobble board, or an air-filled cushion. Start with single-leg standing on a flat surface, 3 times with 30-s holds; use upper extremity support from a counter if necessary. Progress to eyes closed. Progress to exercises on an air-filled cushion. Have patient balance on a wobble board for 30 - 60 s conducting various drills. ,, Proprioception training has been shown to reduce the occurrence and reoccurrence of ankle sprains ,
- Proprioception training in the seated position with the Biomechanical Ankle Platform System board.
- Shoe gear modification depending on the athlete's foot structure and the playing surface 
- At the end of each treatment session, apply ice therapy and other modalities to control inflammation. 
The above exercises should be conducted relatively pain-free and progressed based on the patient's response to therapy and based on the principles of ligament healing. After demonstrating proficiency in conducting the exercises under the supervision of a therapist, the patient can be given a home exercise routine. If there is an excessive increase in swelling or pain, temporarily reduce the intensity or duration of the exercises followed by inflammation control.
Remodelling phase (15 - 28 days, 3 weeks regain 60% strength, 3 months regain 100% strength)
Goals include restoration of tensile strength, proprioception, and return to sport. ,
- Modified training may progress and include activities such as jumping rope, higher-intensity training runs, or sprints
- Incorporation of multidirectional agility drills can begin at this stage. Start with controlled exercises that are on both legs; then progress to single leg. Progress to jumping over a height, such as a low cone. Progress to increasing in speed. It is important to vary the speed and intensity of sport-specific exercises to continually challenge the proprioceptive system.  All progressions should be performed only as pain, comfort, and stability allow.
- Begin jumping forward and backward over a line
- Progress to jumping laterally over a line
- Progress to box drills
- Incorporate multidirectional sport-specific proprioceptive exercises
After being discharged from care, the athlete should be encouraged to continue a home exercise program to ensure full restoration of impairments and to prevent reinjury. McHugh et al., had football players with a history of ankle sprains perform single-leg stance on a foam stability pad for 5 min each leg. This was done 5 days a week for 4 weeks of preseason and 2 days a week for 9 weeks during the season. This was the only preventative exercise used and was done on their own. The study showed a 77% decrease in injury incidence. A study by Hupperts et al., showed a similar decrease in injury risk with unsupervised exercises, demonstrating that a home program can be an effective tool in rehabilitation.
Although the overall quality of studies on functional treatment is somewhat limited, a systematic review of 21 trials (2,184 total participants) showed that functional treatment is superior to immobilization for treatment of ankle sprains.  Five of the trials showed that, compared with immobilization, more patients undergoing functional treatment returned to sports during the study period, and two trials showed that these patients returned to sports 4.6 days sooner [95% confidence interval (CI), 1.5 to 7.6]. Seven of the trials showed that patients undergoing functional treatment returned to work 7.1 days sooner than those treated with immobilization (95% CI, 5.6-8.7). Although the extent and type of benefit associated with functional treatment varied among individual studies, no benefits were seen with immobilization.
Functional treatment usually consists of three phases: (1) the PRICE protocol is initiated within 24 h of injury to minimize pain and swelling and limit the spread of injury; (2) exercises to restore motion and strength usually begin within 48-72 h of injury (see accompanying patient handout for exercise descriptions); and (3) endurance training, sport-specific drills, and training to improve balance begin when the second phase is well underway.
| Conclusion|| |
This paper summarizes the current knowledge on lateral ankle sprain which is the one of the most common sports-related injury. An accurate diagnosis and prompt treatment can minimize an athlete's time lost from sport and prevent future re injury. Key points of rehabilitation are control of pain and swelling acutely with nonsteroidal anti-inflammatories and RICE, then restoring normal range of motion, strengthening muscle groups, and retraining proprioception of the ankle joint.
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