Lateral ankle sprains (LAS) are one of the most commonly treated injuries in Physiotherapy. The lateral ligament complex is comprised of the Anterior Talofibular Ligament (ATFL), the Calcaneofibular Ligament (CFL) and the Posterior Talofibular Ligament (PTFL).
LAS involves injury to one, two or all of these ligaments, with the anterior talofibular almost always being the first or only ligament to sustain an injury due to its anatomy and its inability to withstand force. LAS are classified as grade I, grade II and grade III, with grade I representing a stretch, grade II a partial tear and grade III a complete tear. Lateral ankle sprains: injury mechanism The mechanism of injury of LAS is inversion and plantarflexion, coupled with internal rotation (rolling ankle outwards). In this position, the ATFL is taut, while the CFL is relatively loose. In sport, LAS commonly occurs when accidentally stepping on another player’s foot, coming down from a jump or cutting/changing directions.
Lateral ankle sprains: prevention strategies Prevention strategies may include: external ankle bracing semi-rigid orthosis taping ankle disc training for balance and postural control identification of risk factors wearing the correct shoes. Lateral ankle sprains: treatment Initial treatment for LAS includes Rest, Ice, Compress and Elevation (RICER). The injured athlete must avoid factors that promote blood flow and swelling, such as hot showers, heat rubs, alcohol, or excessive weight-bearing.
Pain-killers may be required. 48 hours and beyond: early mobilisation – in a pain-free range muscle strengthening – especially evertor muscles proprioception and balance – wobble board and mini-trampoline functional exercises – running, cutting, lay-up and side-step. Return to sport is permitted when functional exercises can be performed without pain during and after activity. Long-term management Long-term management is critical in athletes who have sustained a lateral ankle sprain, as the re-injury rate for athletes is as high as 70 to 80%, with 10 to 20% of those going on to suffer chronic ankle instability.
Long-term management should begin with a trial of 2 to 3 months of conservative treatment and preventive measures as described above. However, if conservative treatment fails, surgical interventions may be an option. Treatment protocol Conservative treatment for lateral ankle sprains (Grades I, II and III) Phases and Goals of Phases Physiotherapy Treatment and Exercises Acute Limit extension of the injury Minimise pain Minimise swelling Rest Rest joint for 48 hours Ice Apply ice for 20 minutes: every 2 hours in the first 72 hours Compression Apply compression garment (e.g. elastic bandage) Elevation Elevate joint above heart while resting and applying ice Temporary immobilisation Apply brace to immobilise joint in the first 48 hours Potential non-weight bearing for first 48 hours Use of crutches to ambulate Educate patient on type/grade of sprain, and the rehabilitation necessary to recover. Include re-injury rates.
Activity modification No sport until pain subsides Sub-acute – begins 24–48 hours after injury Restore motion Regain strength and balance Ambulate partial weight bearing/full weight bearing without pain Use of crutches as pain permits External ankle support Semi-rigid orthosis or brace or tape Accessory mobilisation by the Physiotherapist Encourage mobility of ankle in pain-free motion Stretching Strength Balance Educate patient on importance of rehabilitation and external ankle supports, and activity modification Advanced – begins when patient is pain-free, has full range of motion, and adequate strength and proprioception Re-establishing motor coordination Functional exercises Strength Balance External ankle support Activity modification Return to sport – begins when the athlete can complete full training session with no pain during or after Return to sport pain-free at pre-injury level Sports-specific drills External ankle support Activity modification Education on prevention strategies, importance of maintaining strength and proprioception, and reminder of re-injury rates Progression to the next stage is dependent on pain and function Grade of injury will determine the length in each stage.