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Ankle Sprain Cheat Sheet by

Presentation , Management etc

Ankle anatomy

Deltoid ligament limits eversion, dorsif­lexion and planta­rfl­exion - rarely injured (strongest ligament), isolated sprains are rare
Most commonly sprained = Anterior talofi­bular ligament (ATFL) - due to it being the weakest ligament
and Calcan­eof­ibular ligament (CFL)


- Chronic pain/d­isa­bility
- Recurrent Ankle instab­ility
- Osteoc­hro­ndral defects of the talus
- Peroneal tendon injuries
- Neurov­ascular injuries
- Tibiotalar OA
- Pantalar OA


- Grade I: Stretch with no macros­copic fibre disruption
- Grade II: Partial Fibre disruption
- Grade III: Rupture (Usually associated with another injury, usually f#) + syndes­motic structures + tendon rupture


- Physically active people (baske­tball, footba­ll,­soccer, soldiers)- most common
- Males and females affected equally
- Highest in 15-19 yo
- Limited ankle dorsif­lexion
- Previous Hx of ankle sprain
- Lateral ankle = inversion sprain
- Medial ankle = eversion sprain (rare due to limited eversion of the ankle)
Usually occurs due to eversi­on/­pro­nation and abduct­ion­/ex­ternal rotation
Foot planted in pronation, upper body falls laterally -unexp­ected misste­p/l­anding on uneven surface


- Sudden onset of pain from "­rolling the ankle"/­landing from a jump/s­tepping into a hole
- Pts may recall a pop at the time
- Pain from mild aching to intense (worse at the end of the day
- Aggravated by weight bearing
- Swelling (worse at the end of the day)
- Rapid bruising and swelling could indicate rupture
- Bruising and discol­our­ation gradually gravitates towards foot
- Cold foot and or paraes­thesia = neurov­ascular compro­mis­e/c­omp­artment syndrome
- Tenderness over affected ligament
- ROM may be painful on passive invers­ion­/do­rsi­flexion (lateral) or passive eversion (medial)
- +ve Talar tilt, +ve Anterior draw test, +ve ankle eversion stress test +ve external rot test
- Syndes­motic sprains can be differ­ent­iated with the fibular squeeze test (rare in the general popula­tion, ankle in high forced ext rot and/ankle dorsif­lexion)
- Palpation dorsalis pedis and posterior tibia pulses + sensation over foot for neurov­ascular compromise
- Suspect instab­ility = recurrent sprains, difficulty running on uneven surfaces, cutting and jumping, giving way
- Palpation of ATFL, CFL and PTFL and medial ankle and entire fibula to assess for f# (pain and crepitus)
- Assess foot : especially navicular, midfoot and 5th metatarsal
- FADI, FAAM, LEFS and sports ankle rating system

Red Flags

- Signif­icant Instab­ility
- Signif­icant Crepitus
- Catching
- No response to conser­vative care after 4-6 weeks
- MRI/US considered


- Ottawa Ankle rules:
- Ankle X-ray = bone tenderness at A
- Bone Tenderness at B
- Inability to weight bear both immedi­ately and on physical exam
- AP, Lat, Mortise views

- Foot X-ray = Bony tenderness at C and D
- Inability to weight bear both immedi­ately and on physical exam
- AP, lateral, oblique

- Moderate spec, high sens
- Should not be used:
- A distra­cting injury
- Intoxi­cation
- Diminished lower extremity sensation
- Head injury­/co­ope­ration disorders


- Syndes­motic sprain
- F# (Lisfranc)
- Disloc­ation
- Intraa­rit­cular meniscoid
- Subtalar sprain
- Achilles tendin­opathy
- Inflam­matory Arthro­pathy


- Usually heal quickly, but some report pain, instab­ility, crepitus, weakness, stiffness, swelling
- PRICE for 72 hours after injury
- Ice/ice massage for 15 minutes each hour
- NSAID advice
- All sprains may require complete immobi­lis­ation
- Prevention = taping­/using devices (air splint­/velcro brace)
- Then manual therapy
- Joint mobili­sation
- Transverse friction massage of affected ligament
- Myofascial release and stretching of gastro­soleus
- Ankle Alphabet
- When ROM, pain and swelling improves, move onto streng­thening
- Streng­thening includes isometric contra­ctions against immobile object then to dynamic resistance with weights, tubing, bands
- Streng­htening of dorsif­lexion, plantar flexion, inversion and eversion
- Streng­thening of Peroneals (resisted eversion)
- If ankle is instable = hip abductor streng­thening
-Wobbl­eboard to gain propri­oce­ption
- Return to activity starts with straight line then progress to forwar­ds/­bac­kwards, side to side,p­ivoting cutting motions
- Return to play = full pain free ROM and ankle strength >80-90%
- Grade III/ syndes­mosis involv­ement = surgical consult (younger patients with occupa­tio­n/a­cti­vities that places them at higher risk of re-injury)
- If ligame­ntous laxity - immobilise and crutches should be given, refer to orthop­aedic surgeon (could be osteoc­hondral defects of the talus, peroneal tendon, intra-­art­icular loose bodies and fractures)

Whitman's CPR

- Symptom's worse when standing
- Symptoms worse in the evening
- Navicular drop >5mm
- Distal tibiof­ibular joint hypomo­bility
- Predicts the sucess of manipu­lation and exercise
- 3 out of the 4 variables above = >95% sucess rate


- Mild- Moderate sprains usually recover within 7-15 days
- Instab­ility and defects occur in 25-40% of patients


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