#14 – Ankle Sprains


  • 25,000 ankle sprains each day in United States
  • Up to 30% of outpatient sports medicine clinics
  • Ankle injuries are the most common type of injury in high school athletes


  • Lateral
    • Lateral Collateral Complex
      • Anterior talofibular ligament (most common)
      • Calcaneofibular ligament (2nd most common)
      • Posterior talofibular ligament
    • Mechanism of Injury
      • Inversions with either dorsiflexion or plantarflexion


  • Medial
    • Deltoid Complex
      • Posterior tibiotalar ligament
      • Tibiocalcaneal ligament
      • Tibionavicular ligament
      • Anterior tibiotalar ligament
    • Mechanism of Injury
      • Forced eversion


  • Syndesmotic (high ankle sprain)
    • Distal Tibiofibular Syndesmosis
      • Anterior-inferior tibiofibular ligament
      • Posterior-inferior tibiofibular ligament
      • Transverse tibiofibular ligament
      • Interosseous membrane
      • Interosseous ligament
      • Inferior transverse ligament
    • Mechanism of Injury
      • External rotation with dorsiflexion


Important History Questions

  • What was the mechanism of injury?
  • Could you walk immediately after the injury?
  • Can you walk now?
  • Any previous history of ankle injuries?

Physical Exam

  • Observation
    • Swelling or ecchymosis
    • Ambulation to exam room
  • Palpation
    • Bony
      • Entire fibula (from lateral malleolus to fibular head)
      • Lateral malleolus
      • 5th metatarsal
      • Navicular
    • Soft Tissue
      • Palpate each ligament based on mechanism
    • Special Maneuvers
      • Lateral Injuries
        • Anterior drawer
          • Stabilize proximal leg to the ankle and grasp calcaneous and apply anterior force
        • Talar tilt
          • Stabilize proximal leg to ankle and grasp calcaneous and apply inversion force
      • Syndesmotic Injuries
        • Squeeze test (Hopkin’s test)
          • Compression of tibia and fibula at mid calf
        • External rotation stress test (Kleiger’s test)
          • Stabilize proximal leg to the ankle and applying external rotation force to the forefoot

Grading and Classifications

Screen Shot 2016-05-24 at 1.23.12 PM

Indications for Radiography

  • Ottawa Rules of Foot and Ankle
    • Published in 1996 and showed reduction of ankle x-rays by 28% if none of the following are present:
      • Posterior lateral malleolar tenderness
      • Posterior medial malleolar tenderness
      • Base of 5th metatarsal tenderness
      • Navicular tenderness
      • Inability to ambulate both immediately and in the ED


  • Views
    • Standard three views (AP, Lateral, Mortise)


  • Varus stress view


  • MRI
    • Used for clinically suspicious of syndesmotic injury with normal radiographs



  • Orthopaedic Referral
    • Fracture
    • Dislocation/Subluxation
    • Syndesmotic injury
    • Tendon rupture
    • Uncertain diagnosis
  • Non-operative
    • Low ankle
      • RICE
        • Cryotherapy 20 min every 2 hours for 48 hours
      • May use crutches and NWB up to 10 days (Grade II and III)
        • Early immobilization = better recovery
        • Cast vs CAM Boot vs Aircast
      • NSAIDs for pain control
      • Refer to physical therapy for grade II and III for rehabilitation exercises
    • Syndesmotic
      • CAM Boot vs short leg cast for 2-3 weeks
  • Operative
    • Indications
      • Low Ankle
        • Any grade with continued pain and instability despite extensive non-operative management
        • Any grade with bony avulsion
      • Syndesmotic
        • Instability on radiographs
        • Continued pain despite conservative pain
        • Associated ankle fracture
    • Procedures
      • Low Ankle
        • Modified Brostrum
          • Anatomic shortening and reinsertion of the ATFL and CFL
        • Tendon transfer and tenodesis
      • Syndesmotic
        • Screw fixation
        • Suture button

Athlete Return to Play

Screen Shot 2016-05-24 at 1.32.40 PM

Cottage Physician



  1. American College of Sports Medicine. Fact Sheets: Ankle Sprains. http://www.acsm.org/public-information/brochures-fact-sheets/fact-sheets.  Accessed May 23, 2016.
  2. Wheeless’ Textbook of Orthopaedics. Ankle Sprain. http://www.wheelessonline.com/ortho/ankle_sprain.  Accessed May 23, 2016.
  3. Low Ankle Sprain.  http://www.orthobullets.com/foot-and-ankle/7028/low-ankle-sprain.  Accessed May 23, 2016.
  4. High Ankle Sprain.  http://www.orthobullets.com/foot-and-ankle/7029/high-ankle-sprain.  Accessed May 23, 2016.
  5. Stiell I. Ottawa ankle rules. Can Fam Physician. 1996;42:478-80.
  6. Tiemstra JD. Update on Acute Ankle Sprains.  Am Fam Physician.  2012;85(12):1170-1176.
  7. De Brucker Y, Jager T, Devos H, Boulet CG, Kichouh M, De Maeseneer M, Shahabpour M, de May J. Trauma mechanism in ankle fracture: Let’s do the twisthttp://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&pi=121495&ti=402298&searchkey=.  Accessed May 24, 2016.
  8. Stress view of ankle – with deltoid ligament tearhttp://radiopaedia.org/cases/stress-view-of-ankle-with-deltoid-ligament-tear.  Accessed May 24, 2016.
  9. Hocutt JE, Jaffe R, Rylander CR, Beebe JK. Cryotherapy in ankle sprains. Am J Sports Med. 1982;10(5):316-9.
  10. Seah R, Mani-babu S. Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-35.
  11. Bleakley CM, O’connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964.
  12. Tsao LY.  Radsource.  High Ankle Sprain. http://radsource.us/high-ankle-sprains/.  Accessed May 24, 2016.

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