Ankle Sprain

• Apply cultural awareness and trauma-informed care principles.
• Sociodemographic information: Age, gender, sex, race/ethnicity.
• Main complaint: Description of ankle pain, swelling, and stiffness. Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.
• Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
• Health, lifestyle, and history: Past medical conditions, medications (anticoagulants, etc.), supplements, injuries, hospitalizations, surgeries, diet, exercise, sleep habits, footwear, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment. 
• Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social isolation.
• Previous treatments and responses: Document prior treatments, effectiveness and any adverse effects.
• Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.
• Flag considerations: Identify red, orange, and yellow flags for potential referrals.

​​Outcomes Assessments: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

• Pain: Use pain scales (e.g., NRS) and diagrams.
• Function and Participation: Evaluate impact on daily activities (PSFS, WHODAS, LEFS, FFI).
• Recovery: Use self-rated recovery scales.
• Quality of life: Assess using tools such as SF-12.
• Work/school status: Monitor return to activities.
• Individual goals: Set SMART goals (Specific, Measurable, Achievable, Relevant, Timely).
• Patient feedback: Gather and integrate patient experience and satisfaction.

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

• Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   
• Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
• Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

• Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

• Triage: Ensure primary management by medical/psychiatric providers.
• Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
• Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
  • PHQ-9 (depressive symptoms)
  • GAD-7 (anxiety symptoms)
  • FABQ (fear related to physical activity/work) 
  • PCS (catastrophic thoughts) 
  • ORT (opioid risk)

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

• Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
• Social: Lack of family/social support, limited connections.
• Socioeconomic: Employment status, financial stress, litigation/compensation.
• Environmental/cultural: Social inequality, unsafe/unsupportive environments.
• Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
• Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers: 

• Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  
• Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
• Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
  • PHQ-9 (depressive symptoms)
  • GAD-7 (anxiety symptoms)
  • FABQ (fear related to physical activity/work) 
  • PCS (catastrophic thoughts) 
  • ORT (opioid risk)

• Observation: Evaluate for abnormalities and asymmetries, including swelling, bruising, posture, balance, gait, and functional movements (e.g., weight-bearing tolerance, single-leg stance where appropriate).
• Range of motion (ROM): Assess active, passive, and resisted ankle ROM in dorsiflexion, plantar flexion, inversion, and eversion. Compare bilaterally and note pain, restriction, or apprehension.
• Palpation: Examine for tenderness, swelling, tightness, or temperature changes over bony landmarks, joints, ligaments (medial and lateral), tendons, and soft tissues of the ankle, foot, and lower leg.
• Neurological examination: Consider when neurological symptoms are reported or when there is suspicion of neurological involvement (e.g., tarsal tunnel syndrome, superficial or deep peroneal nerve irritation), including sensory changes, weakness, or altered reflexes as clinically indicated.
• Special/Orthopedic Tests: Perform as clinically indicated.
• Advanced Diagnostics: Radiography is indicated when Ottawa Ankle Rules criteria are met. In the absence of red flags, routine imaging is not recommended. Advanced imaging (e.g., MRI, ultrasound) may be considered in atypical, complicated, or refractory cases, or when symptoms fail to progress as expected.

Ankle sprain presentations vary by mechanism, severity, and stage of recovery. Most individuals present following a traumatic event, but symptom behavior, functional limitation, and recovery trajectory differ across presentations.

Acute Lateral Ankle Sprain

• Typically follows an inversion injury, often during sport, walking on uneven terrain, or sudden directional changes
• Common features include:
  • Lateral ankle pain and tenderness
  • Swelling and/or bruising
  • Pain with weight-bearing, walking, or pivoting
  • Reduced range of motion and functional stability
• Symptoms are often provoked by loading, uneven surfaces, or rapid changes in direction

Syndesmotic (High) Ankle Sprain

• Injury mechanism often involves external rotation and dorsiflexion rather than simple inversion
• Pain is typically located above the ankle mortise and may be disproportionate to visible swelling
• Functional features may include:
  • Difficulty with push-off, stair climbing, or pivoting
  • Pain with weight-bearing that persists longer than expected
• Recovery is often slower than lateral ankle sprain and may require closer monitoring

Chronic Ankle Instability (CAI)

• May develop following one or more ankle sprains
• Characterized by:
  • Recurrent sprains or episodes of the ankle “giving way”
  • Persistent pain, swelling, or stiffness
  • Impaired balance, proprioception, or confidence during activity
• Often associated with modifiable impairments, including:
  • Limited ankle dorsiflexion
  • Neuromuscular control deficits
  • Impaired proprioception
  • Inadequate rehabilitation or premature return to activity

Symptom Behavior and Functional Impact

Across presentations, individuals may report limitations in:

• Walking on uneven surfaces
• Occupational or sport-specific tasks
• Participation in physical activity or recreation

Fear of re-injury, movement avoidance, and reduced confidence are common and may influence recovery even when tissue healing has occurred.

Approach to Treatment

The treatments outlined in this section reflect core domains of care consistently identified across high-quality clinical practice guidelines and established clinical practices. These include interventions shown to improve patient-important outcomes such as pain, function, and quality of life. 

Management plans should be individualized based on injury severity, phase of recovery, clinical presentation, response to care, patient goals, and contextual factors (e.g., occupational or sport demands, access to care, psychosocial considerations).

Not all domains are required at every stage of recovery, and no single intervention is sufficient in isolation. Active rehabilitation strategies form the foundation of care, while passive or adjunctive therapies, where used, should support, not replace, these core components.

This pathway is not prescriptive and does not list every possible intervention. Readers are encouraged to consult individual guidelines for detailed protocols and condition-specific considerations.

While a range of other interventions may be in use, such as passive physical modalities, these have mixed or limited evidence of clinical benefit and are therefore not recommended for routine use. If applied, such therapies should be used as adjuncts to the core, evidence-based components of care, and not as standalone treatment.

1. Acute and Post-Acute Lateral Ankle Sprains (LAS)
   • Primary Prevention of First-Time Lateral Ankle Sprain 
     • Clinicians recommend prophylactic bracing to reduce the risk of a first-time LAS, particularly for individuals with identified risk factors.
     • Clinicians may recommend prophylactic balance training exercises for individuals without a prior LAS.
   • Secondary Prevention Following an Initial LAS
     • Clinicians should prescribe prophylactic bracing and proprioceptive and balance-focused therapeutic exercise programs to address impairments identified on physical examination and reduce the risk of recurrent injury. 
   • Protection and Optimal Loading:
     • Clinicians should advise individuals with an acute LAS to use external supports (e.g., braces or taping) and to progressively bear weight on the affected limb.
     • In more severe injuries, short-term immobilization (semi-rigid bracing to below-knee casting) may be indicated for up to 10 days post-injury.
   • Therapeutic Exercise:
     • Clinicians should implement structured rehabilitation programs that may include:
       • Protected active range of motion
       • Stretching exercises
       • Neuromuscular training
       • Postural re-education
       • Balance training
     • Programs should be delivered in clinic and at home, and tailored to injury severity, identified impairments, preferences, learning needs, and social barriers.
   • Occupational and Sports-Related Training:
     • Clinicians should implement graded return-to-work or return-to-sport strategies, including early use of bracing, task-specific training, and work-hardening or sport-specific conditioning where appropriate.
   • Manual Therapy:
     • Clinicians should use manual therapy procedures, such as lymphatic drainage, active and passive soft tissue techniques, joint mobilization, and anterior-to-posterior talar mobilization within pain-free ranges, alongside therapeutic exercise to reduce swelling, improve pain-free mobility, and normalize gait.
   • Physical Agents:
     • Intermittent cryotherapy may be used alongside therapeutic exercise in the acute phase.
     • Pulsed shortwave diathermy may be used to reduce edema and gait deviations.
     • Low-level laser therapy may be used for short-term pain reduction.
     • Ultrasound is not recommended.
2. Chronic Ankle Instability (CAI)
   • External Support:
     • Clinicians should not use braces or taping as stand-alone interventions to improve balance or postural stability.
   • Therapeutic Exercise:
     • Clinicians should prescribe proprioceptive and neuromuscular therapeutic exercise to improve dynamic postural stability and patient-perceived stability during functional activities.
   • Manual therapy:
     • Clinicians should use manual therapy procedures, such as graded joint mobilizations, manipulations, and non–weight-bearing and weight-bearing mobilization with movement, to improve weight-bearing ankle dorsiflexion and dynamic balance in the short term.
   • Dry needling:
     • Clinicians may use dry needling of the fibularis muscle group, in conjunction with proprioceptive training, to reduce pain and improve function.
   • Combined treatments:
     • Clinicians may use multimodal treatment approaches, including combinations of exercise and manual therapy, to supplement balance training over an episode of care.

Risk Factors for Lateral Ankle Sprain (LAS)

• History of lateral ankle sprain 
• Reduced ankle dorsiflexion ROM
• Inadequate warm-up prior to sport or high-risk activity
• Lack of external support (e.g., no bracing/taping) during high-risk activity, particularly in those with prior sprain
• Hip and lower-limb strength deficits, including reduced hip abductor strength
• Impaired neuromuscular control / balance deficits (including proprioceptive impairment)

Risk Factors for Chronic Ankle Instability (CAI)

• History of ankle sprain with incomplete rehabilitation and/or early return to activity before adequate functional recovery
• Not using external support during high-risk activity after an initial sprain (where indicated)
• Not participating in a balance/proprioceptive program following initial injury
• Persistent functional deficits, including impaired balance, proprioception, and movement coordination
• Anatomical factors that may predispose to instability (e.g., increased talar curvature)

Prognosis

Despite overall favorable recovery, approximately 5%–30% may report persistent pain, symptoms, or functional limitations at 1 year or longer, and some develop recurrent sprains or chronic ankle instability.

Following a lateral ankle sprain, most individuals experience a rapid decrease in pain and improvement in function within the first 2 weeks, with continued improvement over subsequent weeks.