What is an Ankle Sprain?

An ankle sprain is one of the most common musculoskeletal injuries. It occurs when the ligaments that support the ankle joint are stretched or torn due to excessive twisting or rolling of the foot. Ligaments are strong bands of connective tissue that stabilize joints and prevent excessive movement.

Ankle sprains account for more than 90% of all ankle injuries, with the majority involving the lateral (outside) ligaments.

Epidemiology

• One of the most common sports injuries.
• Frequently affects athletes and physically active individuals.
• Approximately 1–10% of all sports injuries are ankle sprains.
• Anterior Talofibular Ligament (ATFL) injuries account for over 90% of lateral ankle sprains.
• Recurrent ankle sprains may result in chronic ankle instability.

Anatomy of the Ankle Ligaments

The lateral ankle is stabilized by three major ligaments:

1. Anterior Talofibular Ligament (ATFL)

• Most commonly injured ligament.
• Connects the fibula to the talus.
• Injured during inversion with plantar flexion.
• Weakest lateral ligament.

2. Calcaneofibular Ligament (CFL)

• Second most commonly injured.
• Connects the fibula to the calcaneus.
• Usually injured with more severe inversion injuries.

3. Posterior Talofibular Ligament (PTFL)

• Strongest lateral ligament.
• Least commonly injured.
• Usually damaged only in severe ankle trauma or dislocations.

Mechanism of Injury

Most ankle sprains occur when:

• The foot twists inward (inversion injury).
• The ankle is plantar-flexed during landing.
• Walking on uneven surfaces.
• Sports involving jumping and sudden direction changes.
• Falls or stepping awkwardly.

Risk Factors

• Previous ankle sprain
• Weak ankle muscles
• Poor balance
• Improper footwear
• High impact sports
• Running on uneven ground
• Obesity

Classification of Ankle Sprains

Grade I (Mild)

Ligament Injury

• Stretching without tearing

Symptoms

• Mild pain
• Minimal swelling
• No joint instability
• Able to bear weight

Recovery

1–3 weeks

Grade II (Moderate)

Ligament Injury

• Partial ligament tear

Symptoms

• Moderate swelling
• Bruising
• Pain while walking
• Mild instability

Recovery

3–6 weeks

Grade III (Severe)

Ligament Injury

• Complete ligament rupture

Symptoms

• Severe pain
• Marked swelling
• Significant bruising
• Unable to bear weight
• Gross ankle instability

Recovery

8–12 weeks or longer

Clinical Features

Patients may present with:

• Sudden ankle pain
• Swelling around the ankle
• Bruising
• Tenderness over injured ligament
• Difficulty walking
• Feeling of instability
• Limited ankle movement
• Popping sensation during injury

Associated Conditions

An ankle sprain may be associated with:

• Peroneal tendon injuries
• Osteochondral lesions of the talus
• Intra articular pathology
• Anterolateral ankle impingement
• Chronic ankle instability
• Sinus tarsi syndrome
• Base of fifth metatarsal fracture
• Anterior process of calcaneus fracture
• Lateral process of talus fracture
• Syndesmotic (high ankle) sprain
• Deltoid ligament injury (less common)

Diagnosis

Diagnosis is mainly clinical and supported by imaging when indicated.

Physical Examination

• Inspection for swelling and bruising
• Palpation of ATFL, CFL, and PTFL
• Range of motion assessment
• Anterior drawer test
• Talar tilt test
• Weight-bearing assessment

Imaging

X ray

Indicated if fracture is suspected (using Ottawa Ankle Rules).

Ultrasound

Useful for ligament evaluation.

MRI

Best for:

• Severe sprains
• Persistent pain
• Cartilage injuries
• Tendon injuries
• Chronic instability

Treatment

Immediate Management (RICE Protocol)

Rest

Avoid activities that worsen pain.

Ice

Apply for 15–20 minutes every 2–3 hours during the first 48 hours.

Compression

Use an elastic compression bandage or ankle brace.

Elevation

Keep the ankle elevated above heart level.

Pain Management

Common medications include:

• Paracetamol (Acetaminophen)
• Ibuprofen
• Naproxen

Use NSAIDs cautiously in patients with kidney disease, gastric ulcers, or bleeding disorders.

Immobilization

Depending on injury severity:

• Elastic bandage
• Lace up ankle brace
• Walking boot
• Short leg cast (rarely)

Rehabilitation

Early rehabilitation helps prevent chronic instability.

Phase 1

• Pain control
• Swelling reduction
• Gentle ankle movements

Phase 2

• Stretching exercises
• Range of motion exercises

Phase 3

• Strengthening with resistance bands
• Calf strengthening

Phase 4

• Balance and proprioception training
• Single leg standing
• Wobble board exercises

Phase 5

• Running
• Jumping
• Sport specific drills

Surgical Management

Surgery is rarely required but may be indicated for:

• Chronic ankle instability
• Recurrent ankle sprains
• Complete ligament rupture with persistent instability
• Failed conservative treatment
• Associated fractures requiring fixation

Possible Complications

• Chronic ankle instability
• Recurrent sprains
• Persistent pain
• Joint stiffness
• Post-traumatic arthritis
• Tendon injuries
• Chronic swelling

Prevention

• Perform ankle strengthening exercises.
• Improve balance and proprioception.
• Warm up before sports.
• Wear supportive footwear.
• Use ankle braces during high-risk activities.
• Avoid uneven surfaces when possible.

Prognosis

Most Grade I and Grade II sprains heal completely with conservative treatment and rehabilitation. Grade III injuries require a longer recovery period and, in some cases, surgical intervention. Proper rehabilitation significantly reduces the risk of recurrence.

Key Points

• ATFL is the most commonly injured ligament.
• CFL is the second most commonly injured ligament.
• PTFL is rarely injured.
• Over 90% of ankle sprains involve the lateral ligaments.
• Early rehabilitation is essential to restore strength, balance, and prevent chronic ankle instability.

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