what is ankle sprain?

Ankle Sprain

Introduction

An ankle sprain is one of the most frequent musculoskeletal injuries seen in both the athletic and general population. It occurs when the ligaments that support the ankle are stretched or torn, usually due to a sudden twist or roll of the foot. Although often considered a minor injury, ankle sprains can lead to chronic pain, joint instability, and long-term complications if not managed appropriately. Prompt treatment and rehabilitation are essential for optimal recovery.

Anatomy

The ankle joint, or talocrural joint, is composed of the tibia, fibula, and talus bones. This joint allows dorsiflexion and plantarflexion of the foot. It is supported by multiple ligaments, which maintain joint stability.

The primary ligaments involved in ankle sprains are:

  • Anterior talofibular ligament (ATFL)

  • Calcaneofibular ligament (CFL)

  • Posterior talofibular ligament (PTFL)

  • Deltoid ligament (on the medial side)

  • Syndesmotic ligaments (interosseous membrane, anterior and posterior tibiofibular ligaments)

The lateral ligaments, especially the ATFL, are most commonly affected in inversion injuries.

Epidemiology

Ankle sprains account for a significant percentage of sports-related injuries, representing up to 25% of all musculoskeletal injuries. They are particularly prevalent in sports that require running, jumping, or sudden directional changes, such as basketball, football, volleyball, and tennis. Adolescents and young adults are at higher risk due to increased activity levels. Lateral ankle sprains are the most common type, representing approximately 85% of cases.

Etiology / Causes

An ankle sprain typically occurs when the foot is forced into an unnatural position, such as rolling inward (inversion) or outward (eversion). Common causes include:

  • Stepping on an uneven surface

  • Improper landing after a jump

  • Sudden twisting motions

  • Weak or imbalanced ankle musculature

  • Inadequate footwear

  • Previous ankle injuries leading to instability

Pathophysiology

An ankle sprain results in damage to one or more of the ligaments surrounding the joint. Depending on the force and direction of injury, the ligament may be stretched, partially torn, or completely ruptured. This triggers an inflammatory response, resulting in pain, swelling, and decreased joint function. The most commonly injured ligament is the anterior talofibular ligament (ATFL), particularly in inversion-type sprains.

Classification

Ankle sprains are classified into three grades:

  • Grade I: Mild stretching of the ligament fibers with minimal swelling and tenderness. No joint instability.

  • Grade II: Partial tear of the ligament with moderate pain, swelling, and some loss of function. Mild to moderate instability may be present.

  • Grade III: Complete tear of the ligament with severe pain, significant swelling, bruising, and joint instability. Weight-bearing is often very difficult or impossible.

Clinical Presentation

Patients with an ankle sprain often report a sudden onset of pain during activity, followed by:

  • Swelling around the ankle

  • Bruising or discoloration

  • Difficulty walking or bearing weight

  • Tenderness over the affected ligaments

  • A feeling of the ankle "giving way"

  • Reduced range of motion

Diagnosis

Diagnosis is primarily clinical but may be supported by imaging.

Clinical evaluation includes:

  • Observation for swelling, bruising, and deformity

  • Palpation for tenderness over the ligaments

  • Range of motion assessment

  • Special tests such as the anterior drawer test (for ATFL) and talar tilt test (for CFL)

Imaging options:

  • X-rays to rule out fractures (guided by the Ottawa Ankle Rules)

  • MRI to assess ligament damage in severe or chronic cases

  • Ultrasound for dynamic soft tissue evaluation

Differential Diagnosis

  • Fracture (e.g., distal fibula, talus)

  • High ankle sprain (syndesmotic injury)

  • Achilles tendon rupture

  • Peroneal tendon injury

  • Osteochondral lesion

  • Subtalar joint sprain

Management / Treatment

Acute Phase (first 48–72 hours):

  • Rest: Avoid activities that cause pain

  • Ice: Apply cold packs for 15–20 minutes every few hours

  • Compression: Use an elastic wrap or brace to control swelling

  • Elevation: Keep the ankle elevated above heart level

  • NSAIDs for pain and inflammation

  • Avoid HARM (Heat, Alcohol, Running, Massage) during the first 48 hours

Subacute Phase:

  • Begin range of motion exercises

  • Initiate gentle strengthening exercises for surrounding musculature

  • Balance and proprioception training

  • Soft tissue mobilization and manual therapy as needed

  • Gradual return to activity with sport-specific rehabilitation

Return to Sport Criteria:

  • Full, pain-free range of motion

  • Strength equal to the uninjured side

  • No swelling or tenderness

  • Ability to perform functional and sport-specific tasks without instability

Prognosis

Recovery time depends on the severity of the sprain:

  • Grade I: 1 to 2 weeks

  • Grade II: 3 to 6 weeks

  • Grade III: 6 to 12 weeks or longer, with some cases requiring bracing or surgical intervention

With appropriate treatment and rehabilitation, most patients return to pre-injury activity levels. However, inadequate management can result in chronic instability or repeated injuries.

Complications

  • Chronic ankle instability

  • Recurrent sprains

  • Tendinopathy or peroneal weakness

  • Osteoarthritis

  • Delayed healing or prolonged pain

  • Proprioceptive deficits

Prevention

  • Strengthening exercises for ankle and foot muscles

  • Proprioceptive and balance training

  • Wearing proper, activity-specific footwear

  • Taping or bracing in high-risk individuals

  • Warm-up routines before exercise or sport

  • Gradual return to activity after injury

Clinical Bottom Line

An ankle sprain, while often considered minor, requires a structured and individualized approach for full recovery. Physiotherapists play a key role in assessment, education, rehabilitation, and prevention. A comprehensive rehab program focusing on restoring mobility, strength, and proprioception can minimize the risk of long-term complications and recurrent injury.

References

  1. Brukner, P., & Khan, K. (2017). Brukner & Khan's Clinical Sports Medicine. 5th Edition. McGraw-Hill Education.

  2. Fong, D.T.P., Hong, Y., Chan, L.K., Yung, P.S.H., & Chan, K.M. (2007). A systematic review on ankle injury and ankle sprain in sports. Sports Medicine, 37(1), 73–94.

  3. Hertel, J. (2002). Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training, 37(4), 364–375.

  4. American Academy of Orthopaedic Surgeons. OrthoInfo: Ankle Sprains. https://orthoinfo.aaos.org


Location: Pakistan

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