How to Effectively Treat Lateral Ankle Sprains
Written by: Vinh Vuong, PT, DPT
Ankle sprains…we’ve all encountered them whether it’s occurred to ourselves or to someone we know. There are many different types, but the focus for this post will be lateral ankle sprains. In general, the frequency for lateral ankle sprains can range from 7 out of every 1000 individuals or over 30,000 a day as stated in the literature. It occurs regularly in the athletic population and is a problem that will often be encountered in the clinic. The big issue with this injury, left untreated, is the development of chronic ankle instability. Risk factors include previous ankle sprain, no supportive bracing, lack of warm-up prior to activity, and no balance/proprioceptive program for a previous ankle sprain injury. So, with this condition being so prevalent, what is the best way to treat it?
Typically, the injury occurs with the ankle in a plantarflexed and inverted position. This could result from landing inappropriately after a jump, walking on uneven surfaces and slipping, or maybe horribly attempting to ice skate for the first time (true story).
In order to treat a lateral ankle sprain, understanding the basic anatomy involved is important. There are three main ligaments that are involved in maintaining the lateral ankle stability:
The anterior talofibular ligament (ATFL)
The calcaneal fibular ligament (CFL)
The posterior talofibular ligament (PTFL)
The strength integrity of these three ligaments is rated PTFL > CFL > ATFL. This means that the ATFL and CFL are the most commonly injured ligaments for someone with a lateral ankle sprain. These ligaments (mainly the CFL and ATFL) play a role as the static stabilizers along with the bony congruity of the ankle joint, syndesmotic ligaments, retinacular and capsular system. There’s also the musculotendinous structures that act as the dynamic stabilizers. Though the ATFL is the most commonly injured ligament, it acts as the primary restraint to anterior ankle subluxation with inversion stresses in plantarflexion. When any of these ligaments become compromised, they are classified into grades based on severity:
Grade 1 (Mild)
Slight stretching and microscopic tearing of the ligament fibers but not macroscopic tearing
Mild tenderness and swelling around the ankle
Little to no functional loss or joint instability
Recovery can take about 7-10 days
Grade 2 (Moderate)
Partial tearing of the ligament
Moderate tenderness and swelling around the ankle
Moderate functional loss with mild-to-moderate joint instability
Recovery can take about 2-4 weeks
Grade 3 (Severe)
Complete tear of the ligament
Significant tenderness and swelling around the ankle
Moderate-to-severe instability of the joint
Recovery can take 5-10 weeks
** While understanding the differences between the grades of an ankle sprain is important, it is also essential to know how tissues heal over time. Check out this short post on tissue healing and adaption for more information.**
It is important to note that, regardless of which nonoperative treatment performed, there is still about a 10-40% chance of developing chronic ankle instability along with symptoms of pain. In those cases, surgical interventions may be warranted. There are many proposed conservative ways for treating a lateral ankle sprain (R.I.C.E. being a popular one) but what seems to be most consistent in the literature is a combination of manual therapy interventions and exercise. Early mobilization and progressive weight bearing also decreases the time for returning to prior level of function as well as minimizing the risk of chronic instability. This affects the neuromuscular structures, mechanoreceptors, muscle spindles, cutaneous nerves, and central pathways.
The ankle complex has many bony articulations that need to be considered when performing manual therapy. Understanding the arthokinematics of each is also key when determining which direction to perform the mobilization/manipulation techniques for improving mobility. Research has shown that these techniques below are helpful to individuals who have sustained an acute or developed into a chronic lateral ankle sprain:
Talocrural manipulation or distraction
Anterior to posterior talus glide
Medial or lateral glide of subtalar joint
Distal tibiofibular joint anterior/posterior mobilization
Proximal tibiofibular joint mobilization
The following are a few recommended exercises that can be performed for those with a lateral ankle sprain. However, keep in mind the severity and irritability of the ankle when deciding which exercise is appropriate. For example, if someone sustained an ankle sprain yesterday, you wouldn’t want to be doing any plyometric exercises the next day. Also, some of these exercises may only be appropriate for return-to-sport athletes rather than less active individuals. Use your judgement at your discretion or ask an expert for an appropriate progression program.
Forward lunge with theraband around ankle joint or with therapist assist
Plyometric / Agility
With lateral ankle sprains being so prevalent, it’s important to address the dysfunctions appropriately to prevent future occurrences or chronic ankle instability. Have you ever sprained your ankle before? If so, what was the treatment intervention that worked for you? I would love to see the ideas and recommendations that worked for your experiences.
Thanks for reading and we’ll see you next time!
- Cleland JA, Mintken PE, Mcdevitt A, et al. Manual physical therapy and exercise versus supervised home exercise in the management of patients with inversion ankle sprain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2013;43(7):443-55.
- Digiovanni CW, Brodsky A. Current concepts: lateral ankle instability. Foot Ankle Int. 2006;27(10):854-66.
- Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002 Dec; 37(4):364-375.
- Loudon JK, Reiman MP, Sylvain J. The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review. Br J Sports Med. 2014;48(5):365-70.
- Polzer H, Kanz KG, Prall WC, et al. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev (Pavia). 2012;4(1):e5.
- Truyols-domí nguez S, Salom-moreno J, Abian-vicen J, Cleland JA, Fernández-de-las-peñas C. Efficacy of thrust and nonthrust manipulation and exercise with or without the addition of myofascial therapy for the management of acute inversion ankle sprain: a randomized clinical trial. J Orthop Sports Phys Ther. 2013;43(5):300-9.