SUMMARY
Low ankle sprains are common twisting injuries, particularly in athletes, and represent the most frequent cause of missed athletic participation.
They most commonly involve the anterior talofibular ligament (ATFL), the weakest component of the lateral ligament complex.
Diagnosis is primarily clinical, with radiographs indicated only when Ottawa Ankle Rules criteria are met.
Treatment is usually nonoperative, emphasizing early functional rehabilitation, while surgery is reserved for chronic instability or associated pathology.
EPIDEMIOLOGY
Incidence
• Most common sports-related injury
• >90% of all ankle sprains
Demographics
• Common in all athletic populations
• Most frequent injury in dancers
• High incidence in indoor court sports (basketball, volleyball)
Risk Factors
Patient-related
• Limited ankle dorsiflexion
• Decreased proprioception
• Balance deficits
• Prior ankle sprain
Environmental
• Indoor court surfaces
• Jumping and cutting sports
ETIOLOGY & PATHOPHYSIOLOGY
Mechanism of Injury
• Inversion injury, typically on a plantarflexed foot
Ligament Involvement
• (Anterior talofibular ligament) ATFL – most commonly injured
• (Calcaneofibular ligament) CFL – second most common
• (Posterior talofibular ligament) PTFL – rarely involved
Pathophysiology
• Recurrent sprains may lead to functional or mechanical instability
• Loss of ligamentous restraint alters ankle biomechanics
• Associated neuromuscular deficits contribute to chronic instability
ANATOMY
Lateral Ligament Complex
• ATFL
Primary restraint to anterior talar translation
Tight in plantarflexion
Most vulnerable to injury
• CFL
Stabilizes ankle and subtalar joints
Tight in dorsiflexion
Injury contributes to subtalar instability
• PTFL
Strongest lateral ligament
Rarely injured except in severe trauma
CLASSIFICATION
Clinical Grading of Low Ankle Sprains
Grade | Ligament Injury | Swelling/Ecchymosis | Weight Bearing |
I | No tear | Minimal | Normal |
II | Stretch/partial tear | Moderate | Mild pain |
III | Complete tear | Severe | Severe pain |
PRESENTATION
Symptoms
• Pain with weight bearing
• Swelling and ecchymosis
• Recurrent instability
• Catching or popping sensation (suggests intra-articular pathology)
Physical Examination
• Focal tenderness over involved ligaments
• Anterior drawer test
Assesses ATFL
Best performed in plantarflexion
• Talar tilt test
Excessive inversion (>15°) compared with contralateral side indicates ATFL and CFL injury
IMAGING
Radiographs
Indications (Ottawa Ankle Rules):
• Inability to bear weight
• Medial or lateral malleolar tenderness
• 5th metatarsal base tenderness
• Navicular tenderness
Views
• AP, lateral, and mortise ankle views (weight-bearing preferred)
MRI
Indications
• Persistent pain after 6–8 weeks
• Suspected osteochondral injury
• Peroneal tendon pathology
Findings
• Lateral ligament attenuation or tear
• Bone bruising in severe sprains
TREATMENT
Nonoperative (First-Line)
Initial Management
• The traditional RICE protocol has largely been replaced by the PEACE & LOVE (Protect, Elevate, Avoid anti-inflammatories, Compress, Educate and Load, Optimism, Vascularization, Exercise)
• PEACE & LOVE protocol for acute injury management, emphasizing protection, patient education, and early functional recovery
• Short-term immobilization using a walking boot or brace, as needed for pain control and protection
• Early protected weight bearing, progressed as symptoms allow
• Physical therapy, focusing on:
· Peroneal muscle strengthening
· Proprioception and balance training
Immobilization
• Short period (≈1 week) in walking boot or brace
• Grade III injuries may require up to 10 days of casting
Rehabilitation
• Early range-of-motion exercises
• Progressive strengthening
• Proprioceptive and balance training
• Peroneal muscle strengthening
Outcomes
• Early functional rehab allows fastest return to activity
• Supervised PT improves early outcomes
• No reliable predictors of chronic instability
Operative
Indications
• Chronic pain and instability despite extensive nonoperative treatment
• Symptomatic osteochondral lesions
• Bony avulsion fractures
Procedures
• Modified Broström–Gould
Anatomic repair of ATFL ± CFL
Reinforced with extensor retinaculum
• Nonanatomic reconstructions
Tendon transfers (Evans, Chrisman–Snook)
Reserved for failed prior repairs
COMPLICATIONS
• Chronic ankle instability
• Osteochondral lesions of the talus
• Peroneal tendon pathology
• Missed fractures (5th metatarsal, talus, calcaneus)
• Neuropathic pain due to stretch neurapraxia
PROGNOSIS
• Pain decreases rapidly within first 2 weeks
• 5–33% report residual symptoms at 1 year
• Increased risk of recurrent sprains in both ankles