Ankle sprain (twisted ankle)


An ankle sprain also known as a twisted ankle, rolled ankle, floppy ankle, ankle injury or ankle ligament injury, is a common medical condition where one or more of the ligaments of the ankle is torn or partially torn.
There are three types of ankle sprain:

  1. Inversion: the most common type of ankle strain (70-85% of ankle sprains). It affects the lateral side of the foot leading to a stretch or damage of the lateral collateral ligaments such as the anterior talofibular, posterior talofibular and calcaneofibular ligament. Peroneal muscle&tendons may be strained leading to lateral leg pain and dynamic instability. In the worse scenario injury to the superficial peroneal nerve may occur causing weakness in eversion.
  2. Eversion: less common than inversion sprain. It affects the medial side of the foot leading to a stretch or damage of the deltoid ligament.Often is quiet severe and fractures are common. May require surgery.
  3. High ankle sprain: rare. It affects the ligaments above the ankle that join together the two long bones of the lower leg, called the tibia and fibula. It is usually happens if the foot is forced up, or if the leg is forcefully twisted while the foot is planted. This injury can occur either by itself or with an inversion or eversion sprain.

The amount of force determines the grade of the sprain (amount of damage or the number of ligaments that are damaged). A mild sprain is a Grade 1. A moderate sprain is a Grade 2. A severe strain is a Grade 3. (See Table below).

Improper landing on foot due to:

  • Uneven surface
  • Genu varum or valgus, tibia varum, etc.
  • Body weight too lateral on foot during stance.
  • Improper position of foot prior to heel strike.

Muscle imbalance: weak evertors (peronei/fibularis muscles), tight invertors (tibialis anterior & posterior)
Proprioceptive deficit which could be due to pre/existing injury. As a matter of fact proprioception is important in protecting ankle from sprains by proper position of foot before the foot strikes the ground.

History: a carefully taken history will elicit the mechanism of injury and provide valuable clues as to the ligamentous structures that may be injured. For example, an athlete who steps in a hole while running on uneven terrain will most likely suffer a plantarflexion/inversion injury and damage the anterior talofibular ligament. On the other hand, an anterior lineman who has a teammate land on the back of his ankle while his foot is externally rotated will suffer a dorsiflexion/external rotation injury with suspected damage to the syndesmosis. Other important historical features to obtain from the athlete include whether there was a perception of a “pop” at the time of injury; whether the athlete was able to continue to play after the injury; whether the athlete was able to bear weight on the ankle after the injury; and the time elapsed before swelling ensued. A history of ankle injury or an inadequately rehabilitated ankle that has been previously injured are other features that should be important to note.
Observe gait: Can the patient support his full body weight? does he limp? An inability to bear weight suggests severe injury or fracture (see guideline). Download guidelines for acute injury of the ankle —> click here
Observe carefully the ankle for swelling, deformity, and ecchymosis. Note amount of bruising and location (often takes 24-72 hours), however more the ankle is bruised and greater is the injury.

  1. tenderness is anterior to lateral malleolus, if the anterior talofibular ligament is injured.
  2. tenderness is inferior to lateral malleolus, if the calcaneofibular ligament is injured.
  3. when tenderness is superior or posterior to lateral malleolus, consider X-Ray..
  4. tenderness is in the medial ankle, if the deltoid ligament is injured, however eversion sprain may require x-ray to rule out avulsion fracture of the medial malleolus/ fibula fracture.
  5. Palpate the base of the fifth metatarsal, the anterior process of the calcaneus, the lateral and posterior processes of the talus, and the peroneal tendons should be palpated since injuries to these structures may mimic an ankle sprain.

Provocative test (proceed carefully and only if you believe it is safe):

  1. Anterior drawer test to evaluate the anterior talofibular ligament.
  2. Inversion talar tilt test to evaluate the calcaneofibular ligament .
  3.  Eversion talar tilt & rotation stress test to evaluate the deltoid ligament. (Kleiger test).
  4. Thompson’s test to evaluate Achilles tendon rupture which may mimic ankle sprain (Thompson’s test)
  5. Finally, the integrity of the peroneal tendons can be tested. The peroneus brevis and peroneus longus travel behind the posterior aspect of the lateral malleolus. They are kept in place by a fibrous retinaculum that can be torn or injured. If this occurs, the tendons can sublux from the groove in which they sit in the posterior aspect of the lateral malleolus. This can be assessed by stabilizing the lower extremity with one hand with the other hand placed behind the heel. The foot is placed into dorsiflexion and eversion. An anterior force is then applied, which may reveal the subluxation of the tendons over the lateral malleolus. The physical examination should be completed by performing a careful neurovascular assessment of the distal foot.

Accurate diagnosis should be made and more serious injury excluded before starting any treatment.
A physiotherapist may help more than a chiropractor or osteopath in the early phase stage
Early phase: initially ankle sprain should be treated using the abbreviation PRICE.

  1. Protect: Open Basket Weave Tape for sever edema, closed Basket Weave with minor swelling.
  2. Rest by reducing weight bearing (crutches as needed)
  3. Ice should be immediately applied. It keeps the swelling down. It can be used for 20 minutes to 30 minutes, three or four times daily. Combine ice with wrapping to decrease swelling, pain and dysfunction (important during first 24hrs).
  4. Compression with tape or wrap to control edema, however should not be too tight up to 72hrs
  5. Elevation to control edema up to 72hrs

Early mobilization following ligamentous injury stimulates collagen orientation and promotes healing, even though full strength of the injured ligamentous structure may not be achieved for several months.
Consider pulsed US, Electrotherapy, manipulation of foot, ankle, knee, back, etc. (ankle manipulation opposite direction of mechanism of injury), isometric contraction.

Late phase (usually 72hrs post injury):

  • Alternate hot and cold, however control swelling with cold and do no apply heat until edema or bruise subside.
  • Manipulate joints as needed
  • Wean from crutches
  • US and switch to closed basket weave or lace-up splint (which may be cheaper for the patient in the long-term)
  • Treat trigger point.
  • Stretch muscles but avoid muscles that have been stretched during the injury.

Rehabilitation has variable timing depending on the severity of the injury. However the following points should be followed under a physiotherapist supervision:
1. Restore strength, starting with isometric exercises.
2. Partial weight bearing to full weight bearing, resisted plantar flexion and dorsiflexion. Walking in the pool or in advanced stage running with a jacket in deep end of pool.
3. Movements that are similar to the mechanism of injury should be avoided.
4. if pain or swelling increase then treatment may be too aggressive. However remember to ice the area after exercising.
5. After 10-14 days post injury, increase walking distance and speed, otherwise cycling or rowing.
6. Elastic bands can be used and start jogging if pain free and full ROM.
7. Strength plantar flexors muscles (toe raises).
8. Balance drills to improve proprioception (easy task)
9. When patient is able to perform the points above then more challenging tasks can be given, such as tilt board and wobble board to improve balance and proprioception. Ex. while patient is standing on the wobble board the therapist could pass him a ball. Patients should be taped when participating in high risk activities.
10. Improve coordination and strength, forward run, backward run, figure 8, zigzags 45°, stops and go, etc.
11. Make sure flexibility is 100% and strength is almost 100% before returning to high risk activities.

Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for persistent instability after months of rehabilitation and non-surgical treatment. Surgical options include:
• Arthroscopy: A surgeon looks inside the joint to see if there are any loose fragments of bone or cartilage, or part of the ligament caught in the joint.
• Reconstruction: A surgeon repairs the torn ligament with stitches or suture, or uses other ligaments and/or tendons found in the foot and around the ankle to repair the damaged ligaments.
Possible complications of ankle sprains and treatment include abnormal proprioception. There may be imbalance and muscle weakness that causes a re-injury. If this happens over and over again, a chronic situation may persist with instability, a sense of the ankle giving way (gross laxity) and chronic pain. This can also happen if you return to work, sports or other activities without letting the ankle heal and become rehabilitated.
Read ankle injury guidelines  before referring patient for X-ray, however X-ray is also suggested when patient does not respond to treatment or there is a worsening or persistent signs&symptoms.
Refer in case of: failure to respond to conservative treatment, vascular insufficiency, significant neurologic deficit, fracture, ankle instability.
If the injury happen on field, return to play if: minimal pain, normal ROM, minimal edema, normal vascular and neurological function, able to perform one leg stand, heel walk, toe walk, walk and other functional tests related to the sport. Apply Gibney tape
Recurrent sprains may be due to poor proprioception.
Warm-up before doing exercises and vigorous activities
Pay attention to walking, running or working surfaces
Wear good shoes

Dott. Emanuele Luciani
Osteopathphysiotherapist, hatha yoga teacher
Osteopath registered with the General Osteopathic Council (GOsC)
(number 8232
 "Centro Studi Tre Fontane"
Via Luigi Perna 51, Rome
Lateral epicondylitis (tennis elbow)


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