2. Introduction:
A sprained ankle also known as,
twisted ankle, rolled
ankle, ankle injury or ankle
ligament injury, is a common
medical condition where there is
(complete or partial) trauma to
ligaments due to adduction or
abduction violence that causes
pain and disability depending on
the degree of injury to the
3. Incidence:
• Ankle sprains make about 15% of all
athletic injuries.
• These are particularly common in
Basketball, Volleyball, Soccer players and
Ballet dancers.
• Most patients fully recover, but an
estimated 20-40% develop chronic
symptoms of pain and instability.
• Incidence is increased in
a) Individuals with varus malallignment of
lower limbs.
b) Individuals with calf muscle tightness
4. Relevant Anatomy
• The ankle joint is a uniaxial joint
which permits one degree of
freedom; Dorsiflexion and
Plantar flexion.
• The stability of joint depends on
the inherent constraints provided
by the bony configuration and
the active and passive soft tissue
restraints.
• Talocrural joint:
Proximal articulating surface is
formed by inferior surface of
tibia, tibial malleolus,and fibular
malleolus known as MORTISE.
Distal articulating surface is
5. • Body of talus has 3
articular surfaces or
facets:
1. Central portion:
TROCHLEA.
2. Medial Facet.
3. Lateral facet.
• During dorsiflexion the
large anterior portion of
the trochlea sits in the
mortise, and during this
the mortise expands.
• During plantar flexion the
narrow posterior portion of
6. • Active soft tissue restraint
depends on the muscle tendon
units involved in movement and
support of the joint.
• Passive support of the ankle is
provided by the capsule of the
joint which is in turn
reinforced by the
medial(deltoid ligament) and
lateral collateral ligaments,
posterior ligaments and the
syndesmosis.
• The lateral collateral ligament
complex is the structure
consisting of 3 sets of fibers:
anterior and posterior talo
fibular ligaments and third the
calcaneo fibular ligament from
7. Mechanism of
injury
• The mechanism of
injury is usually
inversion of the
plantar flexed foot,
which involves an
isolated tear of
Anterior Talofibular
Ligament, followed
by a combined tear
of the Anterior Talo
fibular and the
Calcaneofibular
ligament.
8. Classification of Lateral Collateral
Ligament Sprain
GRADE 1 sprain: Mild
ankle sprain
a) Some stretching of
ligaments with no
macroscopic tear.
b) No joint instability.
c) Mild pain.
d) There may be mild
swelling or tenderness
e) Some joint stiffness or
difficulty walking or
running.
f) No functional
impairment.
9. GRADE 2 sprain:
Moderate ankle sprain.
a) Partial tear of the
ligament.
b) Moderate swelling and
tenderness.
c) Moderate to severe
pain, stiffness and
difficulty in walking.
d) Some loss of joint
function.
e) Mild joint instability.
f) Minor bruising may be
evident.
10. GRADE 3 sprain: Severe
Sprain
1. Complete tear of the
ligaments(ATFL and
CFL)
2. Severe swelling and
ecchymosis and
tenderness.
3. Severe pain initially
followed later by no
pain.
4. Inability to bear
weight on the
extremity.
5. Mechanical joint
11. Diagnosis:
• An inversion injury is commonly
associated with a tearing sensation or
a pop felt by the patient over the
lateral ankle.
• Swelling can be immediate in grades 2
and 3 sprains, and the initial intense
pain subsides after a few hours, only
to return more intensely as the
hemorrhage continues 6 to 12 hours
after injury.
12. Assessment:
Aims:
1. To assess the degree of
instability.
2. Grade of ligament damage.
3. Identify any reduction in range
of motion or reduced strength.
4. Identify any other additional or
associated injuries such as an
avulsion fracture where a piece
of bone at the end of a ligament
has come away from the main
13. History Taking:
• How did it happen?
• Was there any pain at the time?
• Was the pain sudden onset or gradual?
• Was there any swelling and was it sudden onset or
gradual? - a sudden swelling often indicates a
bleeding into the joint rather than a gradual
increase in synovial fluid within the joint.
• Did you hear any noises? - this could indicate
ligaments tearing or bone breaking.
• Did you apply any emergency procedures such
as RICE?
• Is there anything you do which makes it worse /
better?
14. Physical Examination:
Active movements
• The patient moves
the foot from plantar
flexion to
dorsiflexion.
• Looking for reduction
in normal range of
movement and any
pain in performing
these movements.
• Then repeat moving
from eversion to
inversion
15. Passive movements:
• The therapist moves the ankle
and foot from plantar flexion
to dorsi flexion and then
inversion to eversion looking
again at range of movement,
comparing one foot with the
other and painful movements.
• Any pain at the extreme
range of inversion may
indicate ligament damage as it
is the ligament that is being
stressed.
• The anterior drawer test is a
special test which assesses
the integrity of the ankle
ligaments, particularly the
anterior Talofibular ligament
16. Anterior drawer test
• It’s a test for ligament
instability.
• Grasp the patient’s foot at the
heel and pull forward while
maintaining the tibia in a fixed
position with the other hand at
the anterior distal tibia.
Translation greater than 3mm
or difference in anterior
translation from the
asymptomatic ankle suggests
the tear of the ATFL.
• Excessive anteroposterior
translation of the tibia on the
17. Resisted movements:
• The therapist gently
resists the movements as
they try to move the
ankle from inversion to
eversion.
• Pain when performing
this test may be an
indication of tendon
damage or inflammation
(possibly peroneal
tendons) as it is the
tendons connecting
muscle to bone that are
18. Syndesmosis injury:
Disruption of the syndesmosis
ligament complex
(tibiofibular ligaments and
interosseous membrane).
Rupture of the syndesmosis is
often associated with
deltoid ligament rupture
,and fracture of fibula is
common.
Mechanism may be pronation
and eversion of the foot
combined with internal
rotation of tibia on a fixed
foot, such as occurs in
football players who have
an external rotation force
applied to the foot
(stepped on) while lying
19. Clinical features:
• Point tenderness and pain are located
primarily on the anterior aspect of the
syndesmosis.
• The patient is unable to bear weight.
• This injury is more severe than ankle
sprains, with more pain swelling and
difficulty in weight bearing.
• Two tests are performed to diagnose this
injury:
1. Squeeze test
2. External rotation test.
20. Squeeze test:
• It is used to evaluate the
syndesmotic ligaments of
the ankle.
• Performed by grasping the
anterior of the leg
proximally and squeezing
the tibia and fibula, thus
compressing the
interosseous ligaments.
• If the injury exists, the
patient complains of distal
ankle pain at the joint.
21. External rotation test:
• Performed with patient’s
ankle in neutral position
and the knee flexed 90
degrees. Stabilizing the
tibia and fibula with one
hand, the therapist
rotates the ankle with
other hand.
• Pain in the syndesmotic
area indicates injury to
the same.
22. Radiographic evaluation:
Radiographs should
include 3 views
of the ankle:
a) AP view
b) Lateral view
c) Mortise views
To rule out
fractures of
the medial and
lateral malleoli,
the talus, and
the fifth
metatarsal
base.
23. References:
1. Clinical Orthopaedic Rehabilitation
(second edition) by S.Brent Brotzman,
M.D.
2. Outline of Fractures(including joint
injuries) (eleventh edition) by John
Crawford Adams and David L.
Hamblen.
3. Taber’s Cyclopedic medical
dictionary.(20th edition)
4. Joint structure and Function a
Comprehensive analysis. (fourth
edition)by Cynthia C. Norkin
5. Google search.
