Definition:

Partial or complete tearing of the lateral ligaments of the ankle following forced inversion.

Pathophysiology:

Typically occurs when the ankle is suddenly “twisted” in a sports activity or by stepping off an uneven surface (usually involves inversion, plantar flexion & internal rotation forces at the ankle). Inversion sprains may also strain the fibularis (peronei) muscles as they try to resist the forces of the injury.

See grading scale on table below:

Grade

Description & Healing

Grade I

• Mild swelling & point tenderness over ligament, no bruising
• Single ligament (anterior talofibular ligament), mild stretch, no instability
• No or mild limp/loss of function, mild difficulty hopping on one leg
• Functional recovery in 2-14 days

Grade II

• Bruising visible on one side of ankle, mild to moderate swelling
• Large spectrum of injury that can include complete tear of anterior talofibular

ligament & partial tears of calcaneofibular & posterior talofibular ligaments

• Mild to moderate instability demonstrated
• Obvious limp, unable to hop or run
• Functional recovery in 14-40 days (up to 2 months)

Grade III

• Severe bruising & swelling on both sides of ankle
• Difficult to visualize achilles tendon due to swelling, tenderness on both sides

• Complete tearing of multiple ligament & joint capsule; may also involve a ‘high’

(syndesmotic) ankle sprain where tibiofibular ligaments are involved
• Marked instability

• Unable to bear weight, almost complete loss of ROM
• Functional recovery time 1-3 months (possibly up to 6 months)

Demographics

Incidence: very common ~45% of all sports injuries

Age: 10-30 yrs. peak (can occur at any age)

Gender: male = female
Risk factors:

  • Prior ankle sprain (50% reoccurrence rate)
  • Athletic activities involving running & cutting movements on high grip surfaces (soccer, basketball football)
  • High foot arch (pes cavus)
  • Poor landing technique
  • Proprioceptive deficit (prior injury) or Joint Position Sense (JPS) decreases with fatigue
  • Muscle imbalance (weak peronei muscles)

 History

  • Forceful trauma – twisting or ‘rolling’ of ankle, patient may hear a ‘popping’ sound or have sensation of tearing
  • History of prior ankle sprains
  • Limp after injury, with localized swelling

 Physical

Inspection:
  • Limp with swelling over lateral ankle
  • Swelling bilateral (grade 2 or 3 – intracapsular) or one side (grade 1 – extracapsular)
  • Possible bruising & ecchymosis

Palpation:

  • Tenderness over anterior talofibular ligament
  • If compression of distal tibia & fibula is painful may indicate distal interosseous ligament injury
  • Difficult to palpate if substantial swelling

Motion:

  • More limited ROM as severity increases
  • Pain with Passive ROM into inversion
  • Possible weakness/pain with peroneus (eversion) muscle contraction on RROM
  • Peronei & retinaculae are often involved which can lead to decreased proprioception

 Treatment

  • Protect, rest, compress, cold-therapy and elevate the area
  • Consider compressive wrap
  • Consider crutches in more severe injuries
  • Consider short-term use of lace-up brace; note that long term bracing does NOT show increased success & may even slow normal recovery
  • Start Passive ROM ASAP!
  • Reduce swelling & increase local fluid movement
  • In chronic sprains with external scar tissue consider cross friction massage
  • Short-term NSAID use

Rehabilitation Program

  • Week 1: Passive ROM, ice after activity
  • Week 2: Increase ROM, consider rocker board & theraband strengthening exercises
  • Week 3: Continue exercises, consider adding inversion-eversion & limited side to side rocking
  • Week 4+: as patient ability dictates progress to proprioceptive wobble board & sport activities

Prevention/Patient Education

  • Avoid activities that cause pain or swelling
  • Consider orthotic evaluation & use
  • Address biomechanical technique issues

Prognosis

  • Excellent for mild cases, early rehab. is key!!!
  • Moderate to severe injuries may have residual lifestyle limiting symptoms for 6 – 18 months
  • Early treatment minimizes chronic issues
  • Chronic cases may be predisposed to degenerative joint disease