Thursday, March 30, 2023

Ankle Sprain

Practice Essentials

An ankle sprain is usually that of an inversion-type twist of the foot, followed by pain and swelling. The most commonly injured site is the lateral ankle complex, which is composed of the anterior talofibular, calcaneofibular, and posterior talofibular ligaments.

Signs and symptoms

Signs and symptoms of an ankle sprain include the following:


Swelling and/or bruising

Cold foot or paresthesia (possible neurovascular compromise)

Muscle spasm

See Clinical Presentation for more detail.


The physical examination confirms a diagnosis made on the basis of patient history and differentiates an ankle sprain from a fracture. Examination in patients may include the following tests:

Anterior drawer test: To assess for ankle instability (see the image below)

Anterior drawer test.

Anterior drawer test.

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Prone anterior drawer test: Also tests for ligamentous instability

Talar tilt test (or inversion stress maneuver): To assess integrity of the calcaneofibular ligament (see the image below)

Talar tilt test.

Talar tilt test.

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External rotation test: To evaluate the integrity of the syndesmotic ligaments

Kleiger test: Variation of the external rotation test; to assess the integrity of the deltoid ligament

Squeeze test (or fibular compression test): To evaluate for syndesmotic or fibular injury

Neurovascular evaluation: To assess neurovascular status of the affected limb

Imaging studies

The following radiologic studies may be used to evaluate ankle sprains:

Plain radiography: Guided by the Ottawa Ankle Rules to diagnose ankle or foot fractures

Stress-view radiography: May provide further assessment for ankle stability; accuracy of study increases with use of local anesthesia

Computed tomography scanning: May be indicated for imaging of soft tissues or for bone imaging beyond radiography; useful for evaluating osteochondritis dissecans and stress fractures

Magnetic resonance imaging: May be useful to assess a suspected syndesmotic or high ankle sprain or if osteochondrosis or meniscoid injury is suspected in patients with a history of recurrent ankle sprains and chronic pain

Ankle arthrography: May be useful for determining capsular damage and the number of ankle ligaments damaged

Bone scanning: To detect subtle bone abnormalities (eg, stress fracture, osteochondral defects) and syndesmotic disruptions

See Workup for more detail.


Conservative therapy

Conservative therapy for acute ankle sprains may be described by the acronyms RICE (rest, ice, compression, and elevation) and PRICES (combination of protection, relative rest, ice, compression, elevation, and support). Protective devices include air splints or plastic and Velcro braces. Ankle taping can also increase ankle stability, but its effectiveness is highly dependent on the expertise of the individual who performs the taping.

Physical therapy during the recovery phase is aimed at the patient regaining full range of motion, strength, and proprioceptive abilities, and may include the following:

Strengthening exercises: Starts with isometric exercises, then advances to use of elastic bands or surgical tubing

Proprioception rehabilitation: Starts with single-leg-stance exercise in a single plane, then progresses to multiplanar exercises

Other exercises: Uses a balance or tilt board, then advances to functional drills, jogging, sprinting, and cutting, and then progresses to figure-of-eight and carioca drills


The following medications are used in the management of ankle sprain:

Analgesics (eg, acetaminophen)

Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen)


In most patients, there is no improved outcome with operative repair of third-degree anterior talofibular ligament tears and medial ankle ligament tears.

Indications for operative intervention in patients with an ankle sprain include the following:

Distal talofibular ligament third-degree sprain that causes widening of the ankle mortise

Deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise

In selected young patients with high athletic demands who have both anterior talofibular and calcaneofibular complete ruptures

Surgical procedures for chronic ankle instability and sprains include the Watson-Jones procedure, the Evans procedure, and the Chrisman-Snook procedure.

See Treatment and Medication for more detail.

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