This document discusses the case of a 35-year-old man who sustained a Grade 2 sprain of the anterior talofibular ligament in his right ankle while playing basketball. On examination, swelling and discoloration were observed over the anterior and lateral ankle, with increased pain on inversion and plantarflexion tests. Radiographs did not reveal any fractures. The document then provides background information on ankle anatomy, the classification of ankle sprains, signs and symptoms, epidemiology, diagnostic tests, differential diagnoses, conservative and surgical management options, and the evidence for rehabilitation techniques.

3.  Introduction
 Ligamentous Anatomy of Ankle
 Classification
 Mechanism of Injury
 Signs and Symptoms
 Epidemiology
 Diagnostic Tools
 Differential Diagnosis
 Management
 Evidence Based Rehabilitation.
 Recommendations.

4. Mr. Nasir is a 35-year-old computer programmer who
plays Basketball at the local recreation center. He
sustained a massive inversion sprain of his right ankle
when landing on foot of an opponent after jumping
to rebound the basketball. He wrapped the ankle
and iced it for 2 days. On the 3rd day he went for a
radiograph. No fracture was detected, But he does
have a Grade 2 Instability of the Anterior talofibular
ligament. Observation revealed swelling and
discoloration in the anterior and lateral ankle region.
He experienced a marked increase in pain wit
inversion and Planterflexion tests, with anterior gliding
of the talus, and with palpation over the involved
ligament. Because of muscle guarding strength was
not tested.

5.  Ankle injuries are among the most
common injuries presenting to primary
care offices and emergency
departments.
 Also known as twist ankle, rolled ankle
or ankle ligament injury.
 Recurrent ankle sprains can lead to
functional instability and loss of normal
ankle kinematics and proprioception,
which can result in recurrent injury,
chronic instability, and early
degenerative bony changes.
That
has to
hurt!!!
Boruta PM, Bishop JO, Braly WG, Tullos HS. Acute lateral ankle
ligament injuries: a literature review. Foot Ankle 1990; 11:107.

6. Three ligaments make up the lateral
ankle ligament complex.
 Anterior talofibular ligament (ATFL)
 Calcaneofibular ligament (CFL)
 Posterior talofibular ligament (PTFL)
Usually anterior Talofibular
Ligament (ATFL) is affected
Function of Ligaments
Ankle ligaments provide
mechanical stability,
Proprioceptive information, and
directed motion for the joint.
Attarian DE, McCrackin HJ, DeVito DP, McElhaney JH, Garrett
WE Jr. Biomechanical characteristics of human ankle
ligaments. Foot Ankle. Oct 1985;6(2):54-8

7. Grade I (First Degree)
 The ligament damage has occurred without
any significant instability developing.
Grade II (Second Degree)
 The ligament has been more significantly
damaged, but there is no significant instability.
Grade III (Third Degree)
 The ligaments have been torn and instability
has resulted.
Moreira V, Antunes F (2008). "[Ankle sprains: from diagnosis to
management. the physiatric view]". Acta Med Port (in
Portuguese) 21 (3): 285–92

8. Types of Ankle Sprain
Lateral (Inversion) Sprains
 Approximately 70-85% of ankle
sprains are inversion injuries.
High (Syndesmotic) Sprain
 A high ankle sprain is an injury to
the large ligaments above the
ankle that join together the
bones of the lower leg.
Medial (Eversion) Sprains
 This affect the medial side of the
foot and deltoid ligament is
stretched

9.  The foot is placed in forced inversion
and plantar flexion
 It can be from an unstable/irregular surface
 Also caused by forced trauma

10. Swelling*
Pain*
Discoloration*
Redness
Warmth
Inability to walk
Ankle Instability
*The most common symptoms
Sprained ankle. American Academy of Orthopaedic Surgeons.
http://www.orthoinfo.org/topic.cfm?topic=a00150. Accessed June 9,
2014

11.  Sprained ankles have been estimated to
constitute up to 30% of injuries seen in
sports medicine clinics. More than 23,000
people per day in the United States,
including athletes and non-athletes,
require medical care for ankle sprains.
Stated another way, incident cases have
been estimated at 1 case per 10,000
persons per day.
Mahaffey D, Hilts M, Fields KB. Ankle and foot injuries in sports. Clin
Fam Pract; 1999:1(1):233-50

13.  The Ottawa ankle
rules are a set of
guidelines for
clinicians to help
decide if a patient
with foot or ankle pain
should be offered X-
rays to diagnose a
possible bone
fracture.
 Sensitivity: 98.5%
Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle
rules to exclude fractures of the ankle and mid-foot: systematic
review. BMJ 2003; 326:417.

14.  The rules are as follows :
An ankle series (Ankle Radiograph) is only indicated for
patients who have pain in the malleolar zone AND
i. Have bone tenderness at the posterior edge or tip of
the lateral or medial malleolus OR
ii. Are unable to bear weight both immediately after
the injury and for four steps in the emergency
department or doctor's office.
A foot series (Foot Radiograph) is only indicated for
patients who have pain in the midfoot zone AND
i. Have bone tenderness at the base of the fifth
metatarsal or at the navicular OR
ii. Are unable to bear weight both immediately after
the injury and for four steps in the emergency
department or doctor's office.

15. Anterior Draw Test
Purpose:
To test for ligamentous
laxity or instability in the
ankle. This test primarily
assesses the strength of
the Anterior Talofibular
Ligament.
Diagnostic Accuracy:
Sensitivity: .71
Specificity: .33
Docherty, Carrie. "Reliability of the Anterior Drawer and Anterior
Tilt Tests using the Ligmaster Joint Arthometer." 2009

16. External Rotation Test
Purpose:
To help identify a
tibiofibular Syndesmotic
injury (high ankle sprain).
The term "high ankle
sprain" refers to an isolated
injury to the tibiofibular
syndesmosis
Diagnostic Accuracy:
Sensitivity: 20
Specificity: 84.5
Cesar, Paulo. "Comparison of Magnetic Resonance Imaging
to Physical Examination for Syndesmotic Injury After Lateral
Ankle Sprain ." American Orthopaedic Foot and Ankle
Society. 32.2 (2011): n. page. Web. 23 Sep. 2012

17. Talar Tilt test
Purpose:
The talar tilt test detects
excessive ankle
inversion. If the
ligamentous tear
extends posteriorly into
the calcaneofibular
portion of the lateral
ligament, the lateral
ankle is unstable and
talar tilt occurs.
Diagnostic Accuracy:
Sensitivity: 67
Specificity: 75
Extracted from Orthopedic Physical Examination Tests:
An Evidence-Based Approach: "Medial Talar Tilt Stress Test": Hertel
et al. Sensitivity 67, Specificity 75, LR+ 2.7, LR- 0.44

18.  Lateral malleolus fracture
 Osteochondral injury to talus
 Posterior-lateral talar process fracture
 Anterior process of calcaneus (beak) fracture
 Achilles tendon injury
 Fifth metatarsal fracture (styloid process or base)
 Subtalar joint injury
 Calcaneo-fibular Ligament sprain
 Posterior talo-fibular ligament sprain
 Calcaneo-cuboid ligament sprain
Young CC et al, Ankle sprain, Medscape, Sep 2011

19. surgical
Conservative

20. Max. protection
phase
Mod. Protection
phase
Min. protection
phase
Return to activity
1-3 Days 4-10 Days 11-21 Days 3-8 weeks
• PRICE formula
• Protection with a
splint
• Icing every
2hours during 1st
48hours
• Elevation to
reduce swelling
• Gentle
mobilization to
inhibit pain
• Partial WB with
crutches
• Muscle-setting
Techniques
• Non weight
bearing AROM
• Cross-fiber
massage
• Grade 2 joint
mobilization
• Toa curls
• Seated calf
stretches
• Endurance
training
• strengthening
exercises of
intrinsic foot
muscles
• Weight bearing as
tolerated
• Initiate Eccentric
ex.
• Toe walks
• Subtalar
mobilization
• Tape or Brace for
sports or other
strenuous
activities
• Proprioception/
balance board ex
• ↑ Weight bearing as
tolerated
• Agility drills.
• Adv. Exercises
Static→dynamic
• Isokinetic resistance
training
• Specific sport training
• Protective bracing for
participation into a
sports
Caroline, Kysner, and Colby Lyn Allen. "Therapeutic Exercise Foundation and
Techniques." FA. Davis, Philadelphia (1988).

21.  Surgical repair of ruptured ankle ligaments is
sometimes considered in patients with ankle
sprains.
 It is Usually indicated for Grade III ankle sprain
 A meta-analysis that looked at controlled trials
of surgery for acute ruptures of lateral ankle
ligaments found that compared with functional
treatment, patients treated with surgery were
significantly less likely to experience giving-way
of the ankle (relative risk 0.23, 95% CI 0.17-0.31).
Pijnenburg AC, Van Dijk CN, Bossuyt PM, Marti RK. Treatment of
ruptures of the lateral ankle ligaments: a meta-analysis. J Bone
Joint Surg Am 2000; 82:761

23. Reference Study Design Study method Results
Bleakley, C. M.
McDonough, S.
M. et al. Aug
2006.
Cryotherapy for
acute ankle sprains:
a randomised
controlled study of
two different icing
protocols
Randomized
controlled trial
Group 1
n = 46 standard
ice application
Group 2
n = 43 intermittent
ice application.
Function, pain,
and swelling were
recorded at
baseline and
one, two, three,
four, and six
weeks after injury.
It was Assessed
from the study
that Intermittent
applications may
enhance the
therapeutic effect
of ice in pain
relief after acute
soft tissue injury

24. Reference Study Design Study method Results
Michel P.J. van den
Bekerom, et al,
July/Aug. 2012,
What Is the
Evidence for Rest,
Ice, Compression,
and Elevation
Therapy in the
Treatment of Ankle
Sprains in Adults?
Randomized
controlled trial
After deduction of
the overlaps among
the different
databases,
evaluation of the
abstracts, and
contact with some
authors, 24
potentially eligible
trials remained. The
full texts of these
articles were
retrieved and
thoroughly assessed
as described. This
resulted in the
inclusion of 11 trials
involving 868
patients.
It was concluded
that Insufficient
evidence is
available from
randomized
controlled trials to
determine the
relative
effectiveness of
RICE therapy for
acute ankle
sprains in adults.

25. Reference Study Design Study method Results
Axelsen, S. M.
Bjerno, T. 1993,
effect of Laser
therapy in
management of
ankle sprain
Randomized
controlled trial
40 patients were
randomly
selected from the
casualty ward
All pts. Received
the low-level
Laser treatment
unless ankle
sprain was
painless
After assessment
pain was
significantly
reduced. There
was no significant
effect on swelling
and
discoloration.

26. Reference Study Design Study method Results
Green, T. et al. April
2001, Effectiveness
of passive
accessory joint
mobilization on
acute ankle
inversion sprains
Randomized
controlled trial
N=41 subjects with
acute ankle
inversion sprains
(<72 hours) & no
other injury in L.L
were Randomly
Assigned to 1 of 2
treatment groups
1. Control group
Received only
RICE protocol
2. Treatment Group
received
Antero-posterior
gliding of Talus
in addition to
RICE protocol
Study Revealed
that addition of a
talocrural
mobilization to
the RICE protocol
in the
management of
ankle inversion
injuries
necessitated
fewer treatments
to achieve pain-
free dorsiflexion
and to improve
stride speed

27. Reference Study Design Study method Results
Vicenzino, B.
Branjerdporn, M.
et al. july 2006,
Initial changes in
posterior talar
glide and
dorsiflexion of the
ankle after
mobilization with
movement in
individuals with
recurrent ankle
sprain
A double-blind
randomized
crossover
experimental
study
N=16
subjects with
(mean +/- SD age,
19.8 +/- 2.3 years)
with a history of
recurrent lateral
ankle sprain and
deficits in posterior
talar glide (71%)
and weight-bearing
dorsiflexion (34%)
were studie
Treatment group:
weight-bearing
MWM, non-weight-
bearing MWM
Control group:
No treatment
It was found that
Both the weight-
bearing and non-
weight-bearing
MWM treatment
techniques
significantly
improved
posterior talar
glide by 55% and
50% Respectively.

28. Reference Study Design Study method Results
Verhagen, E. A.
van Tulder, M. et
al. Sep. 2005,
Effect of
Proprioceptive
balance board
training
programme for
the prevention of
ankle sprains in
volleyball Players
Prospective
Randomized
controlled trial
n=116 male &
female Volleyball
teams followed
prospectively during
the 2001-2002
season.
Teams were
Randomized into
Control and
Intervention Group
This study
highlights that
Significantly fewer
ankle sprains in
the intervention
group were found
compared to the
control group.

29. Reference Study Design Study method Results
Refshauge, K. M.
Raymond, J. et al.
Feb. 2009,
The effect of ankle
taping on detection
of inversion-eversion
movements in
participants with
recurrent ankle
sprain.
Controlled
laboratory study
16 participants with
recurrent ankle
sprain under 2
conditions: with the
ankle taped or
untaped were
selected. The
threshold for
movement
detection was
examined at 3
velocities (0.1
deg/s, 0.5 deg/s,
and 2.5 deg/s) and
in 2 directions
(inversion and
eversion).
It was found that
Taping the ankle
decreased the
ability to detect
movement in the
inversion-eversion
plane in
participants with
recurrent ankle
sprain.

30. Patient-reported comfort
and satisfaction during
treatment with a semi-rigid
brace was significantly
increased. The rate of skin
complication in this group
was significantly lower
compared to the tape
group (14.6% versus 59.1%,
P < 0.0001).
Lardenoye S, Theunissen E, Cleffken B, Brink PR, de Bie RA,
Poeze M. The effect of taping versus semi-rigid bracing on
patient outcome and satisfaction in ankle sprains: a
prospective, randomized controlled trial. BMC musculoskeletal
disorders. 2012; 13: 81

31. Reference Study Design Study method Results
Boyce, S. H.
Quigley, M. A.
Campbell, S. Jan.
2005,
Management of
ankle sprains: a
randomized
controlled trial of
the treatment of
inversion injuries
using an elastic
support bandage
or an Aircast
ankle brace
Prospective
Randomized
controlled trial
N=50 pts.
Randomized into 2
Groups
Group 1:
Elastic support
bandage +
standard RICE
Group 2:
Air cast brace +
standard RICE
It was analyzed that
the use of an
Aircast ankle brace
produces a
significant
improvement in
ankle joint function
compared with
standard
management with
an elastic support
bandage.

32. Reference Study Design Study method Results
Ismail, M. M.
Ibrahim, M. M.
et al. June, 2010,
Plyometric training
versus resistive
exercises after
acute lateral ankle
sprain
Randomized
controlled trial
N=22 athletes
(aged from 20 to 35
years) of both sexes
with grade I or II
unilateral inversion
ankle sprain (at
least 3 weeks after
acute injury) were
randomly allocated
Group 1:
Pylometric training
Group 2:
Resistive training for
6 weeks
Isokinetic peak
torque/body weight
for invertors and
evertors at 30 & 120
degree/s
This study reports
that Plyometrics
were more effective
than resistive
exercises in
improving
functional
performance of
athletes after lateral
ankle sprain.

33. A Metaanalysis suggests that
Subjects who were Braced
with Ankle-Stirrup has
significantly Reduced
Inversion Stress at ankle than
those who were not braced.
Kimura IF, Nawoczenski DA, Epler M, Owen MG. Effect of the AirStirrup
in Controlling Ankle Inversion Stress. The Journal of orthopedic and
sports physical therapy. 1987; 9(5): 190-3

34. There is a strong evidence that
Star Excursion Balance training is
more effective than the
conventional therapy program in
improving functional stability of
the sprained ankle.
Chaiwanichsiri D, Lorprayoon E, Noomanoch L. Star excursion balance
training: effects on ankle functional stability after ankle sprain. Journal of
the Medical Association of Thailand = Chotmaihet thangphaet. 2005; 88
Suppl 4: S90-4.

35. Mild sprain
 Acute phase (0-3 days): reducing pain and swelling, partial load-bearing
 Information/advice: rest, elevate foot, perhaps ice, load-bearing (perhaps with
 crutches) determined by pain, actively moving foot and toes
 Instruction: compression bandage
 If necessary re-evaluation / check-up after 1 week.
Severe sprain
 Acute phase: as in mild sprain
 Proliferation phase: regaining functions and activities; increasing loads
 tape or brace: depending on load-bearing capacity required and patient's preference
 exercises for functions and activities: range of motion, active stability, coordination, and
walking
 Early remodeling phase: increasing muscular strength, active (functional) stability,
walking
 exercises for functions and activities: dynamic stability, balance, coordination
 Late remodeling phase: regaining ADL activities
 exercises for activities: progression to normal load-bearing, exercises at home
 If recovery normal, treatment once a week, maximum duration of treatment 6 weeks.
Wees P, Lenssen A, Feijts Y, Bloo H, van Morsel S, Ouderland R, et al. KNGF guideline for physical
therapy in patients with acute ankle sprain-practice guidelines. Suppl Dutch J Phys Ther. 2006;
116: 1-30.

36. •PRICE
•Ankle Taping/Bracing/ splints
•Gentle Mobilization
•Strengthening ex for intrinsic foot Muscles
•Proprioception training
•Balance training
•Plyometric training to regain functional level of
activity
Acute Injury/
Minor Tear
•Surgical Repair
Chronic or
recurrent Ankle
Sprain
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