Ankle Sprains, Ankle Instability, and Syndesmosis Injuries



Despite attempts to reduce the incidence of ankle sprain injuries worldwide, ankle sprains continue to account for a large proportion of sport-related injuries as reported consistently in epidemiological studies. In the US population in general, the incidence of ankle sprains was reported to be 2.15 per 1000 person-years with the peak incidence in ages 15–19 (7.2 per 1000 person-years). Almost 50% of those ankle sprains happened in athletic endeavors, with basketball, football, and soccer having the highest percentage of ankle sprain injuries among sports in the United States. Hootman et al. reported that ankle sprains accounted for 15% of all injuries in 15 sports analyzed using National Collegiate Athletic Association (NCAA) injury surveillance data from 1988–2004. They found ankle sprains to have an incidence of 0.83 per 1000 athlete exposures (AEs) compared with 0.15 per 1000 AEs for anterior cruciate ligament (ACL) injury and 0.28 per 1000 AEs for concussions. Thus, an ankle sprain is approximately five and a half and three times as common in occurrence as an ACL or concussion, respectively!

In an epidemiological study of ankle injuries in 255 countries, Fong et al. reported on 70 sports, with aeroball, wall climbing, and indoor volleyball having the highest prevalence of ankle injury, with ankle sprains accounting for over 50% of the ankle injuries in 30 of the 43 studies where injury type was defined. A systematic review and meta-analysis of prospective epidemiological studies was reported by Doherty et al. and concluded that higher risk for ankle sprain occurred in (1) females over males, (2) children over adolescents and adults, (3) court sports and indoor sports, and (4) lateral sprains over syndesmosis and medial sprains.

Combination Injuries

Ankle sprains include those to the lateral ligament complex, the deltoid complex, and the syndesmosis. Sprains of the lateral ankle ligament complex generally comprise up to 85% of all sprains to the ankle. It is important to realize that while this chapter is separated for discussion of these specific areas of injury, combination injuries occur and include multiple sprains, as well as other injuries including fractures, contusions, strains, tendon tears, cartilage injury, and tendon dislocations. Clearly, this requires a thorough evaluation of each patient to understand the mechanism of injury, the severity and nature of the symptoms, and any history of ankle problems. Coupling this with a detailed physical examination and appropriate imaging allows determination of the best treatment for the individual patient. Postinjury follow-up is also important, since persistent symptoms can exist in 32%‒74% of individuals with a history of lateral ankle sprain, and these symptoms may continue beyond 10 years. A checklist of potential sources of continuing symptoms is valuable ( Table 15.1 ).

Table 15.1
Sources of Chronic Pain or Instability After Ankle Sprain
Articular injury Impingement
  • Chondral fractures

  • Anterior tibial osteophyte

  • Osteochondral fractures

  • Anterior inferior tibiofibular ligament

Nerve injury Miscellaneous conditions
  • Superficial peroneal

  • Failure to regain normal motion (tight Achilles)

  • Posterior tibial

  • Proprioceptive deficits

  • Sural

  • Tarsal coalition

  • Tendon injury

  • Meniscoid lesions

  • Peroneal tendon (tear or dislocation)

  • Accessory soleus muscle

  • Posterior tibial tendon

  • Unrelated ongoing pathology masked by routine sprain

Other ligamentous injury Unsuspected rheumatologic condition
  • Syndesmosis

  • Occult tumor

  • Subtalar

  • Chronic ligamentous laxity (collagen disease)

  • Bifurcate

  • Neuromuscular disease (Charcot-Marie-Tooth disease)

  • Calcaneocuboid

  • Neurologic disorders (L 5 radiculopathy, poststroke)

Lateral Ankle Sprains

Acute Lateral Ankle Sprain


Approximately 70% of all lateral ankle sprains involve isolated anterior talofibular ligament (ATFL) injury. The ATFL is the weakest of the lateral ligament structures and is put under increased stress in the most common mechanism of injury, which is foot supination with heel inversion while the ankle is plantarflexed. Pain and swelling are present followed by bruising, loss of motion, and difficulty walking in more serious cases. The anterior drawer and talar tilt tests signify instability when positive, and this may vary from mild to severe. A classification of lateral ankle sprains related to the severity of injury and magnitude of the above findings has been published and validated for time to recovery ( Table 15.2 ).

Table 15.2
Classification System of Lateral Ankle Sprains
Modified from Malliaropoulos N, Papacostas E, Papalada A, Maffulli N. Acute lateral ankle sprains in track and field athletes: an expanded classification. Foot Ankle Clin . 2006;11(3):497-507, Tables 3 and 4.
Grade Clinical Tests Decreased ROM Edema Stress Radiographs Return to Sport (days)
I <5° <0.5 cm Normal 7.24 ±1.63
II + anterior drawer 5–10° 0.5–2 cm Normal 14.95 ± 2.1
IIIA + anterior drawer & talar tilt >10° >2 cm Normal 30.65 ± 3.07
IIIB + anterior drawer & talar tilt >10° >2 cm Joint laxity >3 mm 55.41 ± 4.92
ROM, Range of motion.

Acute lateral ankle sprains are typically treated nonoperatively (see Chapter 14 ) in almost all circumstances. Exceptions to this would include open injuries, large avulsion fractures, or other associated pathology such as dislocating peroneal tendons, an osteochondral fracture or loose body, or a bimalleolar fracture equivalent, which would essentially be a dislocated ankle that tears both medial and lateral ligaments. Among the remaining controversies related to acute lateral ankle sprains is whether to operate when faced with an athlete who clearly has a severe injury with major instability. Varying opinions can still be heard on this topic. Another situation that stimulates discussion over whether to operate is the athlete who has a history of significant prior ankle sprains and then presents with a recurrent severe sprain. This is the situation that requires a thorough discussion with the patient to determine the best course of action, and extenuating circumstances often play a role. In other words, is this the correct time to repair what is clearly chronic lateral ankle instability?

Nonoperative Treatment (see Chapter 14 )

When nonoperative treatment is the chosen course, a comprehensive plan needs to be drafted that includes evidence-based interventions. This includes functional rehabilitation with a supportive ankle brace in Grade I and II injuries, while Grade III injuries are more controversial regarding functional treatment versus a short period of immobilization in a walking boot or short-leg cast for 10–14 days. Additional treatment includes rest, ice, compression, and elevation method (RICE), antiinflammatory medication (if there are no contraindications), physical therapy with supervised early exercise when possible, and crutches, but only when weight bearing is not possible. In this latter situation, it is important to immobilize the ankle in neutral to slight dorsiflexion, or the ankle will naturally assume a plantarflexed position and heal with the ligaments in an elongated state. Improvement in ankle dorsiflexion, increased strength in the kinetic chain, manual therapy techniques, and balance training have all been shown to have evidence-based gains in ankle function and pain. Other treatments with less evidence include laser therapy, dry needling, vascular restriction, electrotherapy, vascular restriction, diathermy, and ultrasound. The majority of patients treated with evidence-supported methods improve relatively quickly. According to the classification of acute lateral ankle sprains as Grade I, II, IIIA, or IIIB, full recovery averages 8, 16, 25, and 39 days, respectively. However, when this is not the case, further evaluation is warranted, particularly in the high-level athlete where time loss is critical.

Operative Treatment

In the situation where surgical repair of the torn ligaments is necessary, it is important to define the tissues and repair them anatomically whenever possible ( Figs. 15.1 and 15.2 ). In the acute situation, the injured tissues typically become immediately evident on opening the skin incision. It is important to assess all local structures including the articular cartilage of the ankle joint, the anterior capsule, the deltoid ligament, the peroneal tendons, and superior peroneal retinaculum. At the same time, the surgeon should be protective of the superficial nerves.

Fig. 15.1, Position of Single Band Anterior Talofibular Ligament.

Fig. 15.2, Position of the Calcaneofibular Ligament.

In severe sprains, which are essentially dislocations of the ankle joint, one or more of these structures may be injured and need repair. Ligaments torn in midsubstance are repaired with sutures, while tears off bone or with a bony avulsion are repaired with suture anchors. Newer methods of augmentation of repairs have been introduced and proven to be effective. In cases of acute on chronic tears, tissue quality may be lacking and repair with augmentation may be more critical to obtain adequate stability versus reconstruction with a tendon autograft or allograft or a tendon transfer (see next section). The rehabilitation program in these cases is very important and is outlined in the section on rehabilitation ( Boxes 15.1 to 15.3 and Tables 15.3 to 15.5 ).

Box 15.1
Criteria for Progression—Phase I—Range of Motion
AROM, active range of motion; FAAM, Foot and Ankle Ability Measure; FAOS, Foot and Ankle Outcome Score; ICC, intraclass correlation coefficient; PROM, patient reported outcome measure; SANE, single assessment numeric evaluation; VAS, visual analog scale (for pain).
Tatros-Adams D, McGann SF, Carbone W. Reliability of the figure-of-8 method of ankle measurement. J Orthop Sports Phys Ther. 1995;22(4):161-163.
Konor et al., 2012 Konor MM, Morton S, Eckerson JM, Grindstaff TL. Reliability of three measures of ankle dorsiflexion range of motion. Int J Sports Phys Ther. 2012;7(3):279-287.
McKeon PO, Hertel J, Bramble D, Davis I. The foot core system: a new paradigm for understanding intrinsic foot. Br J Sports Med. 2015;49(5):290

Clinical Finding or Test

  • 1.

    Use objective outcome measures throughout recovery. Recommend FAAM, FAOS, SANE, VAS scores.

  • 2.

    Little to no edema, recommend Figure of Eight method, ICC = 0.99 (Tatras–Adams)

  • 3.

    Symmetrical AROM and PROM

  • 4.

    Weight Bearing Lunge Test, achieve at least 50% as compared with uninvolved side. Measure distance of foot from wall in cm and tibial angle with inclinometer. ICC = 0.96 to 0.99 (Konor et al.).

  • 5.

    Demonstrate proper open chain muscle recruitment for all lower extremity musculature through full available range of motion. Patient can resist increasingly difficult resistance bands × 15 reps through full ROM without pain.

  • 6.

    Demonstrate ability to perform short arch exercise in seated position, and intrinsic flexion exercises (McKeon et al.)

  • 7.

    Patient can ambulate with safe and appropriate gait pattern in boot without crutches.

Box 15.2
Criteria for Progression—Phase II—Endurance
Linens S, Ross S, Arnold B, Gayle R, Pidcoe P. Postural-Stability tests that identify individuals with chronic ankle instability. J Athl Train. 2014;49(1):15-23. doi: 10.4085/1062-6050-48.6.09.

Clinical Finding or Test

  • 1.

    Objective outcome measures score reassessed.

  • 2.

    Normal Gait pattern demonstrated at varied cadence on flat surface.

  • 3.

    Foot Lift Test, demonstrate <5 errors during testing period (Linens et al.)

  • 4.

    Weight-Bearing Lunge Test, within 75% of uninvolved leg.

  • 5.

    Standing Double-Leg Heel Raise, can demonstrate equal heel height.

  • 6.

    Double-Leg Squat, demonstrate proper technique.

  • 7.

    Isotonic Single-Leg Leg Press: Achieve 50–60% of body weight × 15 reps

  • 8.

    Demonstrate ability to perform seated towel curls with added weight, pulling weight equal to capability of uninvolved side

Box 15.3
Return-to-Sport Criteria
SANE, single assessment numeric evaluation .

  • 1.

    Criteria for progression met. If any goals are not achieved, this is reviewed and discussed with rehabilitation team and physician.

  • 2.

    Subjective outcome measure reassessed; progress suggests return-to-sport readiness. SANE score >93%.

  • 3.

    Athlete reports he/she has resumed preinjury training volume.

  • Return to practice noncontact × 1 week

  • Return to practice contact × 1 week

  • Return to game play, progressively working up to preinjury position time of play.

Table 15.3
Overview of Rehabilitation Orders: Ankle Stabilization Procedures
Procedure(s) Brostrӧm Repair Brostrӧm Repair + InternalBrace ATFL and CFL Reconstruction With Allograft Syndesmosis Repair of AITFL and Tight Rope Syndesmosis Repair, Deltoid Repair and Fibular ORIF (no cartilage injury)
Range-of-Motion Precautions No inversion or plantarflexion × 6 weeks
  • Full active, pain free range of motion

  • No passive inversion × 6 weeks

  • Full active, pain-free range of motion

  • No passive inversion × 6 weeks

None No eversion × 6 weeks
Weight-Bearing Orders
  • Splint × 7–10 days

  • When out of splint, PWB → FWB over 4-week period

  • Walk in boot without crutches, pain, or swelling for 5–7 days , then:

  • Wean out of boot over 2-week period

  • Splint × 7–10 days

  • When out of splint, PWB → FWB over 2-week period

  • Walk in boot without crutches, no pain or swelling for 5–7 days, then:

  • Wean out of boot as tolerated

  • Splint × 7–10 days

  • NWB × 4 weeks unless specified by surgeon

  • After 4 weeks, PWB to FWB over 2–4 week period as tolerated

  • Once FWB in boot × 5–7 days without crutches, no pain or swelling then:

  • Wean out of boot × 2 weeks

Return to Sport
  • Must pass all criteria for progression (Boxes 15.1-15.3 and Tables 15.4-15.5)

  • Outcomes measures match clinical findings

  • MD clearance for noncontact practice granted (Table 15.3)

AITFL, Anterior inferior tibiofibular ligament; ATFL, anterior talofibular ligament ; CFL, calcaneofibular ligament ; FWB, full weight bearing; NWB, Non-weight bearing; PWB , partial weight bearing; ORIF, open reduction internal fixation.

Table 15.4
Criteria for Progression—Phase III—Strength
Clinical Finding or Test
  • Subjective outcome measure reassessed.

  • Patient can demonstrate ability to maintain proper arch posture in single leg tasks.

Test Passing Score Notes
Weight Bearing Lunge Test Symmetry to uninvolved side, within 5∗ or 1.5 cm ICC = 0.96 to 0.99 (Konor et al.)
Heel Raise Endurance Test Within 90% of uninvolved side, recorded in successful repetitions ICC = 0.97 (Sman et al.)
Single Leg Squat Endurance Test Within 90% of uninvolved side, recorded in repetitions ICC = 0.95–1.0 (Garrison et al.)
Y Balance Test Composite score above 90%
Anterior reach within 4 cm of uninvolved side
ICC= 0.85–0.93 (Shaffer et al.)
Isotonic Leg Press Within 90% of uninvolved 3 × 5 reps
ICC , intraclass correlation coefficient(2013).
Konor MM, Morton S, Eckerson JM, Grindstaff TL. Reliability of three measures of ankle dorsiflexion range of motion. Int J Sports Phys Ther. 2012;7(3):279-287.
Sman AD, Hiller CE, Imer A, Ocsing A, Burns J, Refshauge KM. Design and reliability of a novel heel rise test measuring device for plantarflexion endurance. Biomed Res Int. 2014; 2014: 391646. doi: 101155/2014/391646.
Garrison JC, Shanley E, Thigpen C, Geary R, Osler M, DelGiorno J. The reliability of the vail sport test™ as a measure of physical performance following anterior cruciate ligament reconstruction. Int J Sports Phys Ther. 2012;7(1):20-30.
Shaffer SW, Teyhen DS, Lorenson CL, et al. Y-balance test: a reliability study involving multiple raters. Mil Med. 2013;178(11):1264-1270.

Table 15.5
Criteria for Progression—Phase IV—Power and Agility
Clinical Finding or Test
  • Pick Appropriate Test(s) from each category related to patient’s sport. Not all tests need to be performed.

  • Subjective outcome measure reassessed. Progress suggests return to sport readiness. SANE score >93%.

Test Passing Score Notes
Single hop for distance
Triple hop for distance
Within 90% of uninvolved side ICC = 0.92–0.97 (Ross et al.)
ICC = 0.84–0.98 (Kockum et al.)
Square Hop
Figure of 8 Hop
Side Hop
Cross-Over Hop
Within 90% of uninvolved side, measured in seconds Square Hop: ICC = 0.90
SEM 1.40 sec MDC 3.88 sec
Side Hop: ICC = 0.84 SEM 2.10 sec MDC 5.82 sec
6 Meter Cross Over Hop: ICC = 0.6
SEM 0.37 sec MDC 1.03 sec (Caffrey et al.)
MAT Test
Modified T Test
Within 90% of uninvolved side, measured in seconds ICC = 0.825 (Hickey et al.)
ICC, intraclass correlation coefficient; SANE, single assessment numeric evaluation; SEM, standard error of the mean; MDC, minimal detectable change, MAT, modified agility T Test.
Ross MD, Langford B, Whelan PJ. Test-retest reliability of 4 single-leg horizontal hop tests. J Strength Cond Res. 2002;16(4):617-622.
Sman AD, Hiller CE, Imer A, Ocsing A, Burns J, Refshauge KM. Design and reliability of a novel heel rise test measuring device for plantarflexion endurance. “ “. Biomed Res Int . 2014;2014:391646. .
Caffrey E, Docherty CL, Schrader J, Klossner J. The ability of 4 single-limb hopping tests to detect functional performance deficits in individuals with functional ankle instability. J Orthop Sports Phys Ther. 2009;(11):799-806.
Hickey KC, Quatman CE, Myer GD, Ford KE, Brosky JA, Hewett TE. Methodological report: dynamic field tests in an NFL combine setting to identify lower extremity functional asymmetries. J Strength Cond Res. 2009;23(9):2500-2506.

Chronic Lateral Ankle Instability

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