Version May 2024
INTRODUCTION — Ankle injuries are among the most common problems presenting to primary care offices and emergency departments [1-3]. Patients with ankle sprains (stretching, partial rupture, or complete rupture of at least one ligament) constitute a large percentage of these injuries. Most ankle sprains involve the lateral ligament complex. The medial deltoid ligament complex is strong and rarely injured in isolation.
The management and prevention of common ankle sprains are reviewed here. The evaluation and diagnosis of common ankle sprains and the evaluation and management of high ankle sprains (syndesmosis injuries) are discussed separately. (See "Ankle sprain in adults: Evaluation and diagnosis" and "Syndesmotic ankle injury (high ankle sprain)".)
Other injuries of the lower leg, ankle, and foot are covered separately, including the following topics:
●Fractures of ankle and adjacent bones (see "Ankle fractures in adults" and "Talus fractures" and "Fibula fractures" and "Stress fractures of the tibia and fibula" and "Tibial shaft fractures in adults")
●Ankle tendon injuries (see "Achilles tendinopathy and tendon rupture" and "Non-Achilles ankle tendinopathy" and "Calf injuries not involving the Achilles tendon")
●Pediatric ankle injuries (see "Foot and ankle pain in the active child or skeletally immature adolescent: Evaluation" and "Ankle pain in the active child or skeletally immature adolescent: Overview of causes")
●Foot injuries (see "Overview of foot anatomy and biomechanics and assessment of foot pain in adults" and "Evaluation and diagnosis of common causes of hindfoot pain in adults" and "Evaluation, diagnosis, and select management of common causes of midfoot pain in adults")
TREATMENT
Immediate therapy — All ankle ligament sprains can be treated acutely in a similar fashion. Initial management goals are to limit pain and swelling and to maintain range of motion before gradually introducing exercise (table 1). Protection, rest, ice, compression, and elevation (PRICE) is a common-sense approach for the first two to three days, although formal study of its effectiveness is lacking.
●Protection is provided by applying an elastic bandage and, depending on the extent of injury, a splint, walking boot, or possibly a cast.
●Rest is achieved by limiting weightbearing; if needed, patients use crutches until they are able to walk with a normal gait.
●Cryotherapy applied as ice or cold water immersion is recommended for 15 to 20 minutes every two to three hours while awake for the first 48 hours or until swelling is improved, whichever comes first [4,5].
●Compression with an elastic bandage to provide support and minimize swelling should be applied early.
●The injured ankle should be kept elevated to further alleviate swelling. Ideally, the ankle should be kept above the level of the heart, but this may be difficult to achieve.
Acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) can be used for analgesia; no particular NSAID has been shown to be superior. Both oral and topical NSAIDs are more effective than placebo [6-9]. Of the topical NSAIDs, gel formulations of diclofenac, ibuprofen, ketoprofen, and some diclofenac patches provided the best effect, according to a systematic review of 61 studies [10]. There are no studies comparing topical NSAIDs and oral NSAIDs in the acute treatment of ankle sprain, nor are there studies comparing NSAIDs with non-NSAID analgesics (eg, acetaminophen), so it is not clear that an antiinflammatory effect is important. Care should be taken to avoid unnecessary or prolonged use as NSAIDs may be associated with complications and suppress the healing process. (See "Nonselective NSAIDs: Overview of adverse effects", section on 'Possible effect on tendon injury'.)
Physical therapy is the mainstay of recovery from an ankle sprain. Range of motion exercises, including plantarflexion, dorsiflexion, and foot circles (picture 1), should be started early, once acute pain and swelling subside, to maintain range of motion. The intensity of rehabilitation is increased gradually with the addition of strength and balance exercises. Ankle splints or braces can limit extremes of joint motion and allow early weightbearing while protecting against reinjury. (See 'Rehabilitation' below and 'Splints and braces' below.)
For isolated medial (deltoid) ankle sprains, which are uncommon, a brief period of immobilization and non-weightbearing (from three to seven days) should be followed by weightbearing in a stabilizing brace and initiation of range of motion exercises, as described above [11].
The treatment of severe (grade III) ankle sprains is controversial. A brief period of immobilization may be helpful in some instances. Grading of ankle sprains is reviewed separately; grade III injuries are discussed below. (See "Ankle sprain in adults: Evaluation and diagnosis", section on 'Classification of ankle sprains' and 'Immobilization and bracing' below.)
Immobilization and bracing
Mild (grade I) and moderate (grade II) sprains — Patients with mild (grade I) lateral or medial ankle sprains do not require immobilization [12]. Treatment with an elastic wrap (eg, ACE bandage) or compression sleeve (picture 2) for a few days following the injury is sufficient.
Patients with moderate (grade II) lateral sprains may need sustained support following their injury. The combination of an elastic wrap and an Aircast or similar splint (picture 3), or application of a functional splint (such as a figure-eight brace), for up to a few weeks is generally sufficient. Ankle support in patients with mild or moderate sprains should not interfere with early rehabilitation.
Patients with grade II medial (deltoid) ankle sprains (an uncommon injury) are treated with a brief period of immobilization and non-weightbearing, after which they can begin weightbearing in a solid, stand-alone brace (eg, controlled ankle movement [CAM] boot (picture 4)), external brace that fits over the shoe (eg, TayCo brace (picture 5)), or a soft functional brace (eg, Aircast (picture 3); figure-eight brace (picture 6)). Selection may be based on several factors including the patient's sense of comfort and stability [11].
Three systematic reviews have reported that functional rehabilitation (ie, early activity and minimization of brace use) for lateral ankle sprains yields superior results for a number of clinically important outcomes compared with immobilization [12-14]. However, the studies included in these reviews are limited by their low quality (problems include small numbers, incomplete descriptions of interventions, inconsistent outcome measures, and heterogeneity of functional treatments and immobilization techniques). The Cochrane systematic review on this subject has since been withdrawn [13]. In a separate analysis of higher-quality trials, the only statistically significant result was that patients treated with functional rehabilitation returned to work sooner than those treated with immobilization alone (average 12.9 days sooner, 95% CI 7.1-18.7). Although these systematic reviews must be interpreted cautiously, the results suggest improved outcomes using functional rehabilitation. It is notable that immobilization was not significantly favored in any of the analyses.
Severe (grade III) sprain — Given the inconclusive results of available evidence, it is difficult to determine the appropriate role and timing for immobilization and early functional rehabilitation in patients with severe lateral ankle sprains. It appears reasonable, particularly if mobilization is painful and compliance likely to be difficult, to offer a short period (10 days) of immobilization in a non-weightbearing cast. Alternatively, a comparable period of strict non-weightbearing and immobilization using a combination of an Aircast splint and an elastic wrap may be used. Early functional rehabilitation can be started once immobilization is discontinued. For patients treated without casting, the importance of compliance with the treatment plan (eg, maintaining non-weightbearing status and immobilization for the designated period) should be emphasized.
Patients who sustain a severe medial ankle sprain involving a full rupture of both the superficial and deep deltoid ligament (an uncommon injury) should be immobilized in a cast or CAM boot, avoid weightbearing by using crutches, and be referred to an orthopedic surgeon for shared decision-making about surgical versus conservative management [11,15]. (See 'Indications for referral' below.)
Data from the systematic reviews discussed above suggest that early mobilization and support using a stabilizing orthosis may result in earlier resumption of work and sports, compared with immobilization. However, a well-designed, multicenter, randomized trial of severe ankle sprains performed after the systematic reviews cited above reported a different conclusion [16]. In this study, 584 patients with severe ankle sprains were assigned to treatment using a below-knee cast for 10 days, Aircast brace, Bledsoe immobilization boot, or tubular compression bandage. Assessment at three months using a validated score for ankle function found the greatest improvements in the cast group. Few, if any, patients received functional rehabilitation. The authors noted that compliance with treatments other than casting could not be monitored. Follow-up at nine months revealed no significant differences in outcome or complications among the treatment groups. Of note, the most common reason for refusing to participate in the study was an unwillingness to be treated with a cast.
Rehabilitation
Approach and exercises — Functional rehabilitation is important in aiding the return to activity and preventing chronic instability and recurrent injury [17-19]. This should be started in the first few days for grade I and II lateral ankle sprains and between days 7 and 14 for grade I and II isolated medial ankle sprains (depending on the degree of pain with weightbearing) [11,15]. A sample rehabilitation program for uncomplicated, low-grade injuries is provided (table 2).
Early functional rehabilitation begins with exercises for mobility (foot circles (picture 1), alphabet exercises [have the patient trace letters in the air with his big toe], Achilles tendon stretch (picture 7)) and strength (isometric and isotonic plantarflexion, dorsiflexion, inversion, eversion, toe curls (picture 8) and marble pickups, heel walks and toe walks) and proceeds to exercises for proprioception (circular wobble board (picture 9) and walking on different and unstable surfaces) and activity-specific training (progressing from walk-jog, to jog-run, to run, to run with change of direction) [20-23].
In most patients with mild or moderate lateral ankle sprains, functional rehabilitation should begin as soon as the initial pain and swelling have subsided sufficiently to allow the patient to perform simple exercises. A randomized controlled study of patients with acute grade I and II ankle sprains showed that patients who started therapeutic exercises within the first week of injury were engaging in weightbearing activities earlier without differences in pain, swelling, or rate of reinjury compared with those who did not [18]. For isolated medial ankle sprains, we recommend starting functional rehabilitation after 7 to 14 days of ankle rest and protection. Patients may begin rehabilitation once they can ambulate without pain. Rehabilitation continues until the patient has returned to pain-free, full activity.
The rehabilitation program should take several weeks in order for the ankle to strengthen and to limit the chance of reinjury. In a study of active-duty marines with grade II ankle sprains, those undergoing a structured rehabilitation program returned to duty up to several months earlier than those without rehabilitation [19].
Whether regular, supervised physical therapy is beneficial for all patients is unclear. A systematic review of four studies comparing home exercise programs with supervised physical therapy found that supervised rehabilitation resulted in less pain and subjective instability at intermediate follow-up (eight weeks after injury) but no difference at longer follow-up [24]. A subsequent large and well-conducted randomized trial involving 503 participants with grade I and II acute ankle sprains compared usual care (written instructions about PRICE and graduated weightbearing activities) with usual care plus supervised physical therapy [25]. This study found no improved outcome, functional or subjective, with the addition of supervised physical therapy in the short term (one and three months) as well as at six months. Although the equivocal long-term benefits of supervised physical therapy reported in these studies raise questions about whether such treatment is needed for all patients, supervised rehabilitation may be advantageous for patients for whom a faster return to work or sport is especially important. If supervised rehabilitation is not feasible for a patient, a home exercise program is highly recommended.
According to a systematic overview of available systematic reviews and meta-analyses, there is strong evidence that exercise therapy (defined as supervised strengthening and mobility exercises) following an acute ankle sprain reduces the risk of recurrence [17]. All three systematic reviews assessed in the overview study that examined the relationship between rehabilitation using exercise therapy and ankle sprain recurrence as a primary outcome reported that exercise therapy reduced the rate of repeat ankle injury.
Manual joint therapy for ankle sprains involves distraction or mobilization of the talocrural joint in the anteroposterior (sagittal) plane. Such therapy is not appropriate for the early treatment of grade III sprains, for which a short period of immobilization is preferred, but may be useful during the rehabilitation of less severe sprains. A systematic review of small, heterogeneous studies reported that manual mobilization combined with exercise therapy decreases short-term pain in patients with acute lateral ankle sprain [26]. In patients with subacute or chronic ankle instability, similar manual joint mobilization reduced pain, increased the range of dorsiflexion, and improved overall ankle function at one month (no study extended follow-up beyond one month).
Splints and braces — During functional rehabilitation, it may be of benefit to use splints, braces, elastic bandages, or taping to try to reduce instability, protect the ankle from further injury, and limit swelling. For sport and other physically demanding activities that place stress on the ankle (eg, hiking), the authors favor using a soft lace-up or hook-and-loop-closure brace (picture 6) for 4 to 12 weeks following injury (4 weeks for in-line sport and activity, 12 or more weeks for field sports and other activities that involve lateral motion or uneven terrain).
A systematic review of studies looking at the treatment of acute ankle sprains reported the following results [12]:
●Lace-up ankle supports (picture 6) were superior to semi-rigid ankle supports, elastic bandages, and tape in preventing persistent swelling.
●Semi-rigid ankle supports (picture 3 and table 3) resulted in a quicker return to work and to sports, and less instability at short-term follow-up, than elastic bandages.
●Tape (picture 10 and picture 11 and picture 12) caused more skin irritation than elastic bandages.
●It remains unclear whether taping improves proprioception [27].
Regardless of whether patients used tape, a semi-rigid brace, or a lace-up brace, functional outcomes were the same after six months in one randomized trial [28].
The results of a small, limited randomized trial comparing rehabilitation of ankle sprain using a semi-rigid support brace, neuromuscular training, or a combination of bracing and neuromuscular training suggest that using an elastic semi-rigid support (picture 13) during sports activity decreases injury recurrence [29].
Indications for referral — Referral is typically unnecessary for ankle sprains of mild or moderate severity. However, severe sprains and other injuries identified during the workup of a suspected sprain may warrant referral. Indications for referral to an orthopedic surgeon include:
●Unstable fracture (See "Ankle fractures in adults".)
●Dislocation or subluxation
●Syndesmosis injury (See "Syndesmotic ankle injury (high ankle sprain)".)
●Tendon rupture
●Wound penetrating into the joint
●Uncertain diagnosis
●Chronic ankle instability unresponsive to appropriate physical therapy (including proprioceptive and strength training)
Patients with neurovascular compromise (distal findings of decreased sensation, motion, or circulation) require emergency evaluation.
Surgery — Based on the limited evidence discussed below, it is unclear whether patients with acute ankle sprains would benefit from surgery. Given functional outcomes for non-severe injuries, relative costs, and operative risks, it is unlikely that surgery is justified in most patients with mild or moderate ankle sprains. Surgery may be reasonable in select patients with severe (grade III) sprains who are engaged in professional sports or other activities that impose repeated large stresses on the ankle joint. Referral to an orthopedic surgeon is appropriate for such patients. (See 'Indications for referral' above.)
A meta-analysis from 2000 limited to controlled trials of surgery for acute ruptures of lateral ankle ligaments found that patients treated with surgery were significantly less likely to experience giving way of the ankle compared with those receiving functional, nonsurgical treatment (relative risk [RR] 0.23, 95% CI 0.17-0.31) [30]. However, a subsequent systematic review concluded that there were methodologic flaws in all trials, making it impossible to determine the relative effectiveness of surgical and conservative treatment for sprains of the lateral ankle [31].
A subsequent prospective trial of therapy for lateral ankle ligament rupture allocated 185 patients to surgery and 203 patients to functional treatment based upon the week in which they presented [32]. After a median follow-up of eight years, compared with those managed nonoperatively, fewer patients treated surgically reported residual pain (16 versus 25 percent), symptoms of giving way (20 versus 32 percent), and recurrent sprains (22 versus 34 percent). At follow-up, patients treated surgically were less likely to have a positive anterior drawer test (30 versus 54 percent); however, this was assessed by clinicians who knew how the patients had been treated. There was no difference in the percentage of patients with radiographic evidence of joint degeneration. Thus, there were no blinded, objective assessments in this trial that demonstrated superiority of surgery.
Although many experts conclude that delayed operative reconstruction of injured ligaments achieves results similar to that with acute repair [30], we are not aware of any head-to-head trials that examine this issue.
Ultrasound and other unproven therapies — According to a systematic review of six trials including 606 patients, ultrasound therapy is not an effective treatment for acute ankle sprain [33]. Other therapies that do not appear to be effective include low-level laser [34], hyperbaric oxygen therapy [35], and platelet-rich plasma therapies [36]. (See "Hyperbaric oxygen therapy" and "Biologic therapies for tendon and muscle injury".)
RETURN TO ACTIVITY — The extent of injury determines the time required for healing and the corresponding ability to return to physically demanding work and sport [37]. Appropriate rehabilitation (and immobilization for grade III injuries) can decrease this period. (See 'Treatment' above.)
Return to work — Depending upon pain and the severity of injury, most people with a lateral ankle sprain that does not involve complete disruption of ligaments can return to work within a few days with bracing and other needed accommodations, and to full office work by about two weeks, provided the work does not entail heavy labor. The patient may need to work primarily while sitting and avoid heavy lifting. Most are able to return to full work and activities by three to four weeks.
For more severe injuries involving total disruption of ligaments and for manual laborers, return to full work duties may not be possible for six to eight weeks. Reasonable precautions in this setting include working primarily while seated, avoiding any heavy lifting, and limiting standing or walking on uneven surfaces. Full return to work should not be expected until six to eight weeks post-injury, depending upon the nature of the work (heavy laborers will likely require a longer period of rest) and appropriate progress with physical therapy.
Return to sport — Ankle sprains limit the ability to participate in nearly any sport. Before returning to sport, the athlete recovering from a sprain should have sufficient ankle stability and function to compete safely and avoid reinjury (which can worsen underlying pathology). Multiple systematic reviews describe the lack of high-quality evidence to inform criteria for return, and thus, available guidelines are necessarily based on clinical experience and expert opinion [38-41].
Criteria for return to sport typically include a static balance test and assessment of sport-specific movement. (See 'Functional assessment' below.)
Athletes can reasonably return to play following an ankle sprain when they meet the following criteria:
●Pain and swelling have substantially improved or resolved.
●The athlete can complete in-office assessment tests (eg static balance, side hop test) without instability or significant pain.
●The athlete can perform sport-specific movements at full speed without instability, significant pain, or subsequent (eg, next-day) swelling. This determination may require feedback from a physical therapist, athletic trainer, or other knowledgeable source.
●The athlete feels they are physically and mentally ready to return to competition.
According to a retrospective review of 2429 lateral ankle sprains among United States college athletes, 44 percent of athletes who sustained mild injuries returned to play in less than 24 hours, presumably with proper ankle support, while 3.6 percent of athletes with severe injuries required more than 21 days before returning to play [42]. Interventions that appear to lead to a quicker return to play include functional rehabilitation, compression (eg, support with an elastic bandage during activity), and joint mobilization during early care when appropriate [43]. Most experts recommend using a functional brace during all sporting activity while recovering from a moderate or severe ankle sprain. In most cases, the brace is worn for the season (in seasonal sports). (See 'Splints and braces' above.)
Functional assessment — The performance on formal functional tests that mimic the physical demands of sport may be an important determinant of an athlete's readiness to return to play, especially if in-office testing is equivocal, or in the case of a high-level athlete. Several terms are used for such assessments, including functional testing, functional performance testing, and physical performance testing. Functional testing uses specific, measurable assessments to determine if an individual can safely withstand the demands specific to their sport.
Functional tests include assessments of both agility and balance. Commonly used tests include:
●Static balance test – The patient stands on the rehabilitated leg only for a minimum of ten seconds to determine whether they can maintain a stable position.
●Star excursion balance test (SEBT) – Standing on the rehabilitated leg, the patient extends the non-injured lower limb as far as possible to eight different points along an octagonal grid (picture 14), with measurement taken of the "reach distance" of the extended (non-weightbearing) limb at each point. A modified version, the "Y-balance test" (YBT), assesses anterior, posteromedial, and posterolateral reach distance [44,45]. The YBT requires a proprietary balance platform and measurement markers along the tested planes; the SEBT requires an eight-line grid drawn on the testing surface.
●Side-hop test – Standing on the rehabilitated leg, the patient performs 10 side-to-side (coronal plane) hops, medial then lateral (total of 20 hops), between markers 30 cm apart. The time needed to complete the hops is compared to a standardized norm or to the non-affected side. The mean time to completion for control subjects is nine seconds; an increase of 1.2 to 2 seconds or more for the limb with the injured ankle is considered diagnostic of functional instability. This test is easy to perform (especially when using the uninjured limb as the standard) and accurately detects ankle instability [46,47].
●Single-limb hop test – Standing on the rehabilitated leg, the patient performs a series of hops on a 120 cm by 60 cm (approximately) board that incorporates 15-degree slopes in four orientations relative to the ankle: upward, downward, lateral, and medial. Time to completion is compared with standardized norms or the time when performed on the patient's uninjured lower extremity [48]. This assessment requires construction or purchase of the assessment board.
Most research on functional testing of ankle injury involves patients with chronic lateral instability rather than acute ankle sprain. A systematic review of 169 studies of functional testing of the lower extremity found little evidence to support functional assessments for pre-season screening, injury prediction, or outcome following injury [49]. A subsequent systematic review found that certain functional tests do reliably distinguish between patients with and without chronic ankle instability [46]. These tests are commonly used by sports medicine clinicians and athletic training staff to assess patients recovering from an acute ankle sprain in addition to chronic instability. Although these assessments are based on research about and clinical observation of lateral ankle sprains, they are appropriate for medial or multi-ligamentous ankle injury.
Several studies of functional assessment indicate that a patient's subjective sense of instability is as predictive of low functional testing scores, if not more predictive, than a history of sprain or findings of laxity [48,50]. As part of the functional assessment, it is important to ask the athlete if their ankle feels stable and whether they feel ready to resume playing at full intensity. A simple way to learn a patient's sense of instability is to use a 0 to 100 visual analogue scale rating the instability of their injured ankle compared with their unaffected ankle; their injured ankle should score 80 or higher (assuming the unaffected side is 100) for the clinician to recommend return to sport (or the clinician can determine their own cutoff based on the specific demands of the sport/activity).
For overall return to sport decisions, an athlete's self-assessment of their readiness to return, emotionally, mentally, and physically, is an important factor. Scoring tools and standardized questionnaires are available for self-assessment [44,51].
Sideline assessment of acute injury — While high-quality evidence to guide return to play for an acute injury sustained during an athletic contest is lacking, experienced team physicians use functional tests like the ones described above to decide whether an athlete should return to competition. The side-hop test is useful and easy to administer. Other simple tests that may be used include:
●Forward and backward hops
●Repeated sprint starts
●Sprints with sudden change of direction (ie, cutting, zig-zag sprints)
●Side-to-side movements with change of direction
Athletes who cannot perform such tests without undue pain or instability should not return to competition. If an athlete successfully completes the side-hop and other tests, athletic trainers, team physicians, or other qualified clinicians will typically wrap, tape (picture 12 and picture 10 and picture 11), or brace (picture 6) the injured ankle prior to the athlete's return to the contest.
Post-surgery — Return to work or sport following surgery for an ankle sprain is at the discretion of the surgeon, but patients should expect to be on crutches for approximately two weeks or longer followed by a period of weightbearing as tolerated in a cast. Sedentary work may be permitted by two to six weeks. Twelve to 16 weeks following surgery may be required before it is possible to return to full activities and a physically demanding job.
OUTCOMES — Ankle ligaments provide mechanical stability, proprioceptive information, and directed motion for the joint. Acute ankle sprains can result in lost days of work and inability to participate in sports.
A meta-analysis of 31 studies that assessed the outcome of patients with acute ankle sprains noted the following [52]:
●Pain decreases rapidly during the first two weeks following injury
●Up to approximately 33 percent of patients report some pain after one year
●Healing rates vary widely among studies, with 36 to 85 percent of patients reporting full recovery over the first three years
Another systematic review noted that prior ankle sprain is associated with reinjury of either the ipsilateral or contralateral ankle [53].
Recurrent ankle sprains can lead to functional instability and loss of normal ankle kinematics and proprioception, which can result in recurrent injury, chronic instability and pain, and early degenerative bony changes [54]. Up to 70 percent of ankle osteoarthritis is associated with prior sprain [55]. According to a questionnaire study of 132 patients, risk factors for chronic ankle dysfunction at five years included ankle sprain sustained in dominant leg, pain present at 6 to 12 months after injury, and recurrent sprain [56].
CHRONIC ANKLE INSTABILITY — Most ankle sprains recover fully with nonoperative treatment, but a substantial minority of patients develop some chronic ankle instability, which can present as recurrent ankle sprain, giving way of the ankle without a new sprain, sensation that the ankle is unstable, avoiding or modifying usual daily or sporting activities, and recurrent ankle pain or swelling after six months [57,58]. Predicting which patients who sustain an ankle sprain will develop instability is difficult. A cohort study of patients with ankle injury found no correlation between the severity of the initial sprain and residual disability at seven-year follow-up [57].
Formal six-week rehabilitation programs with a focus on balance, proprioception, and strength exercises performed three times per week have been shown to help those with chronic ankle instability [59,60]. We think it is reasonable to recommend such training as part of the treatment for these patients. A systematic review of seven trials involving 3726 participants reported that proprioceptive training is effective at reducing the rate of ankle sprains in sporting participants, particularly those with a history of ankle sprain [61]. Other small randomized trials and observational evidence suggest that strength and balance exercises can improve ankle strength, range of motion, and perceived ankle stability compared with a "wait-and-see" approach or usual care [62-64]. Most studies have not included pain as an outcome, although one randomized trial reported no difference in pain scores between the intervention and control groups [65].
PREVENTION — Options for primary or secondary prevention of ankle injuries include external ankle supports and physical training. External supports include semi-rigid orthoses (table 3 and picture 13), lace-up supports (picture 6), high-top shoes, and taping (picture 10 and picture 11 and picture 12). Physical training interventions may include strengthening, proprioceptive ankle training using a wobble board (picture 9), stretching, and other techniques.
External supports and shoe modifications — Two systematic reviews published in 2010 evaluating trials that assessed the effectiveness of interventions to prevent ankle sprains concluded that commonly used external supports (eg, bracing, taping) all reduce the risk of injury to a comparable degree, but only among patients with a history of ankle sprain [66,67]. Risk is reduced by approximately 70 percent in this patient group (relative risk [RR] ranged from 0.15 to 0.5 among trials). Subsequently, two randomized, non-blinded trials reported that use of a lace-up ankle brace reduced the frequency, but not the severity, of ankle injuries in high school football and basketball players regardless of whether the athlete had sustained an ankle sprain previously [68,69].
Athletes may have concerns about decreased performance with external ankle supports. A study that looked at running and jumping performance found differing results depending on the specific brace or method (such as taping) used, but in no case did a support decrease performance by more than 5 percent [70].
A novel approach to the prevention of lateral ankle sprain involves attaching a patch to the outside lateral edge of the shoe that reduces friction at the interface between the shoe edge and playing surface, while desired friction at the plantar sole is maintained. High friction at this edge-sole interface may account for the higher rate of non-contact, lateral ankle sprains among athletes who play court sports. A pilot randomized trial involving 510 indoor-sport athletes with a history of lateral ankle sprain reported lower recurrence rates and shorter time lost to injury in the group wearing the shoe patch [71]. While this intervention holds promise, further study is needed to validate these results.
Physical training — A simple, easy-to-implement ankle prevention program for recreational athletes and active people of all ages could include the exercises below. This program would take approximately 15 minutes and would be performed two or three times per week:
●Single-leg barefoot balance for 30 seconds, performed with eyes closed on each leg, done for one or two sets
●Single-leg heel raises, one to three sets of 15 to 20 repetitions on each leg (picture 15)
●Single-leg strength training (weighted or unweighted) such as step-back (reverse) lunges (hip and knee both at 90 degrees at bottom position) or rear-leg-elevated squats (picture 16), one to three sets of 15 to 20 repetitions on each side
●Sport- or activity-specific warm-up drills incorporating agility movements (eg, side-to-side shuffles, shuttle runs, hill or stair runs) for five minutes
A number of physical training interventions to reduce the risk of ankle sprain in athletes have been studied. These include comprehensive neuromuscular training regimens (an approach similar to that used for anterior cruciate ligament injury prevention), strength training, and balance training. Studies vary in approach and quality, but results suggest that these approaches are beneficial [17,72-76].
●A systematic review of seven trials involving 3726 participants concluded that proprioceptive training programs are effective at reducing the rate of ankle sprains in sporting participants [61]. These results were statistically significant whether all participants were considered (RR 0.57, 95% CI 0.34-0.97) or only those with a history of ankle sprain (RR 0.64, 95% CI 0.51-0.81).
●A systematic review of 10 randomized trials involving over 4000 male and female soccer players concluded that injury prevention programs are safe and effective [77]. However, the studies included a wide range of interventions, and further research is needed to determine which exercises are most effective at reducing injury rates.
●A secondary analysis of five studies (including two randomized trials) reported a statistically significant reduction in the risk of such sprains among athletes who performed neuromuscular training (incidence rate ratio [IRR] 0.68, 95% CI 0.46-0.99) [75]. This pooled analysis involved 2265 male and female youth soccer and basketball players who sustained 188 ankle sprains. Regular neuromuscular training included dynamic stretching and exercises for strength, agility, and balance.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Ankle sprain".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Ankle sprain (The Basics)" and "Patient education: How to use crutches (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Initial care – Standard care immediately following injury consists of protection (eg, bandage, splint, boot), rest, ice, compression with an elastic bandage, non- or partial-weightbearing, and elevation (table 1). Range-of-motion exercises, including plantarflexion, dorsiflexion, and foot circles (picture 1), should be started early, once acute pain and swelling subside. (See 'Immediate therapy' above.)
●Immobilization and ankle support – Mild (grade I) sprains do not require immobilization; support with an elastic bandage is sufficient. Moderate (grade II) sprains may need support with an elastic wrap and an Aircast or similar splint (picture 3), a stabilizing soft splint (picture 6), or figure-eight brace for up to several weeks. Athletes or heavy laborers with grade I or II sprains typically continue to wear ankle support for several months (through the end of the sports season). We use a soft lace-up or hook-and-loop-closure brace (picture 6). (See 'Mild (grade I) and moderate (grade II) sprains' above.)
Management of severe (grade III) ankle sprains is controversial. Some may warrant surgery; others are managed with functional rehabilitation. We suggest a brief period (about 10 days) of non-weightbearing and immobilization, rather than early weightbearing, for patients with severe ankle sprains not being treated surgically (Grade 2C). Particularly if mobilization is painful and compliance likely to be difficult, we feel it is reasonable to initiate treatment with a brief period of non-weightbearing and immobilization in a cast or combination of rigid splint and elastic bandage. Afterwards, semi-rigid ankle supports are typically used for several weeks to months, followed by transition to a figure-eight brace. (See 'Severe (grade III) sprain' above.)
●Rehabilitation – Once symptoms and swelling subside, functional rehabilitation is introduced. Exercises to regain and improve balance, mobility, and strength are the focus. Intensity is increased gradually as function improves and the program continues over weeks to months depending primarily on the severity of injury. A sample program is provided (table 2). (See 'Rehabilitation' above.)
●Return to activity – Most patients recovering from a lateral ankle sprain that does not involve complete ligament disruption return to sedentary work within a few days. More severe injuries require three to six weeks. Up to eight weeks or longer may be needed before sports and heavy labor can be resumed safely, depending on the extent of injury and compliance with physical therapy. (See 'Return to activity' above.)
●Chronic instability – In patients with symptoms that persist for more than six to eight weeks, magnetic resonance imaging (MRI) may be obtained to rule out conditions such as talar dome fractures or syndesmosis injury. Rehabilitation programs with a focus on balance, proprioception, and strength exercises often help those with chronic ankle instability. Referral to an orthopedic surgeon may be useful for patients with chronic ankle instability, particularly those who fail to improve with appropriate rehabilitation. (See 'Chronic ankle instability' above.)
●Prevention – Lace-up supports can help prevent ankle reinjury during high-risk activities. Proprioception and strength training, possibly under the guidance of a physical therapist, can help reduce the risk of reinjury. (See 'Prevention' above.)
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