All About Ankle Ligament Sprains

Whether you play sports or not, you may have experienced this common injury: ankle sprains. Walking and performing your daily activities may be painful and this does not go away for some time. People generally consider this injury as trivial and not very serious, but it limits movement and the ability to carry out certain activities due to the bothersome pain — so, what really happens when your ankle is sprained? There may be several causes, but a very common one is an ankle ligament sprain.

Joint and Ankle Anatomy and Possible Injuries

In the ankle, just like other joints (articulation between two bones), there are several anatomical structures that may be affected by an injury. These are summarised in the table below.

Structure	Description/Function
Ligament	Tissues connecting bones that prevent the joint from moving past its normal range of motion (ROM)
Tendon	Tissues connecting muscles to bones that enable movement
Bone	Attach to muscles to enable movement & support and maintain posture
Fascia	Connective tissue surrounding and holding together every organ in the body
Muscle	Attach to bones to enable movement

Functions of several joint structures, applicable to the ankle (Sproule, 2012)

Ankle anatomy diagram with bones, ligaments, muscle and fascia (from “The Basics of Ankle Anatomy and Foot Anatomy,” by Colorado Springs Orthopaedic Group Foot and Ankle Center, 2022, Colorado Springs Orthopedic Group, https://www.csog.net/the-basics-of-ankle-anatomy-and-foot-anatomy/) 

Ankle anatomy with muscles and tendons (from “Physical Therapy in Louisiana for Ankle,” by Moreau Physical Therapy, n.d., https://www.moreaupt.com/Injuries-Conditions/Ankle/Ankle-Anatomy/a~47/article.html) 

Structure	Possible Injuries
Ligament	Ligament sprain or rupture
Tendon	Tendon strain or rupture
Bone	Fracture (open, closed, avulsion, etc.)
Fascia	Plantar fasciitis
Muscle	Muscle strain or tear

There is a wide variety of ankle injuries, the above list covers only some of them. The joint (articulation) can also be injured in a dislocation or subluxation (partial dislocation), where a bone is forced out of its regular position.

Ankle Ligament Anatomy, Injuries and Mechanism of Injury

An ankle sprain is when one or more ligaments are overstretched or torn (American Academy of Orthopaedic Surgeons, n.d.). This is one of the most frequent injuries in sports (Wang et al., 2020), accounting for 16-40% of sports-related trauma cases (Polzer et al., 2012). Any ligament(s) in the diagram below may be affected.

A presents the lateral (side) view while B displays the medial (inside) view (from “Photographic Manual of Regional Orthopaedic and Neurological Tests,” by J. J. Cipriano, 2010, LWW)

Lateral ankle sprains are found to be the most common musculoskeletal injury in physically active populations (Gribble et al., 2016), accounting for 85% of all ankle sprains (Doherty et al., 2014). The anterior talofibular ligament (ATFL) is the weakest and is the most commonly sprained, with isolated ATFL injuries making up 65% of cases, while 20% comprises both ATFL and calcaneofibular ligament (CFL) injuries. ATFL injury mechanism typically involves plantar flexion (pointing the foot downwards) and inversion (inwards movement of the sole), whereas CFL injury mechanisms commonly involve dorsiflexion (pointing the foot upwards) and inversion. Posterior talofibular ligament (PTFL) injuries are less common as this is the strongest ligament of the lateral ligament complex; it is rarely injured in an inversion sprain (Melanson & Shuman, 2023; Wolfe et al., 2001).

Deltoid ligaments (e.g. tibiocalcaneal ligament/TCL, tibionavicular ligament/TNL, anterior tibiotalar ligament/ATTL, posterior tibiotalar ligament/PTTL) on the medial side of the ankle are strong. Medial ankle injuries are less frequent due to the bony structure of the medial malleolus and talus articulation. Isolated deltoid ligament injuries are rare. The mechanism of medial ankle injuries is excessive eversion (outward movement of the sole) and dorsiflexion. (Wolfe et al., 2001)

High-ankle sprains, or syndesmotic injuries, involve the anterior tibiofibular ligament and posterior tibiofibular ligament. They are less common than low-grade ankle sprains. Their typical mechanism of injury is external rotation and/or dorsiflexion. (Melanson & Shuman, 2023)

Ankle sprains are usually classified into different severity categories: grade I (overstretched or partial tear of a ligament), grade II (incomplete tear of a ligament with moderate functional impairment) and grade III (complete tear (rupture) and loss of integrity of a ligament) (Wolfe et al., 2001).

Ankle Ligament Injury Tests

Below is a list of some special tests that are performed to assess sprains of different ankle ligaments. (Wolfe et al., 2001; Aslan et al., 2014)

Ligament	Test
ATFL	Anterior drawer test
CFL	Inversion stress (talar tilt) test
Syndesmotic injuries	Squeeze test (compressing tibia and fibula midcalf) External rotation test
Deltoid ligaments	Eversion stress (eversion talar tilt) test

Acute Soft Tissue Injury Management

For management of acute soft tissue injuries, PRICE, which stands for protection (protecting the injured area from further damage, e.g. using a brace/support), rest (rest the injury and reduce movement), ice (regularly ice the injury for 10-15 minutes each time), compression (compress the injured area using, e.g. a bandage) and elevation (rest the injured area above heart level) is administered (Melanson & Shuman, 2023). This reduces pain, inflammation and swelling in the injured area. If needed, ankle radiographs (x-ray, magnetic resonance imaging/MRI, etc.) are performed to assess which structure(s) is affected.

After an injury, patients usually perform physiotherapy which includes a rehabilitation programme and therapeutic modalities (involves different equipment, e.g. ultrasonic therapy, for therapeutic purposes) to progressively return to daily activities (Chapman et al., 2007). In a sports physiotherapy clinic, the physiotherapist will guide the patient until the return-to-sports stage is reached. Rehabilitation programmes are in line with the healing process of wounds (haemostasis, inflammatory, proliferation, maturation/remodelling), which takes 4-6 weeks (Wallace et al., 2023). Strengthening exercises will be done to prevent re-injuries. Especially for ankle injuries, this is crucial as ankle injuries are often overlooked and treated improperly, leading to chronic ankle instability (Melanson & Shuman, 2023).

In conclusion, ankle injuries constitute damage to a wide range of structures. Ligaments are one of those that may be injured — different ligaments may be affected by different mechanisms of injury. Acute pain management generally involves the PRICE administration followed by the need for proper, sufficient rehabilitation and recovery through physiotherapy.

This article has been reviewed by licensed physiotherapist Fery Abdillah Haris, S.Tr.Ft

Reference List

American Academy of Orthopaedic Surgeons. (n.d.). Sprained ankle. OrthoInfo. Retrieved October 3, 2023, from https://orthoinfo.aaos.org/en/diseases--conditions/sprained-ankle/ 

Aslan, A., Sofu, H., & Kirdemir, V. (2014, March 11). Ankle ligament injury. OA Orthopaedics, 2(1), Article 5. https://www.researchgate.net/publication/261510098_Ankle_Ligament_Injury_Current_Concept 

Chapman, B. L., Liebert, R. B., Lininger, M. R., & Groth, J. J. (2007, May). An introduction to physical therapy modalities. Adolescent Medicine: State of the Art Reviews, 18(1), 11-23, vii-viii. https://pubmed.ncbi.nlm.nih.gov/18605388/ 

Cipriano, J. J. (2010, November 23). Photographic manual of regional orthopaedic and neurological tests (5th ed.). LWW.

Colorado Springs Orthopaedic Group Foot and Ankle Center. (2022, March 9). Colorado Springs Orthopedic Group. Retrieved October 23, from https://www.csog.net/the-basics-of-ankle-anatomy-and-foot-anatomy/

Doherty, C., Delahunt E., Caulfield, B., Hertel, J., Ryan, J., & Bleakley, C. (2014, January). The incidence and prevalence of ankle sprain injury: A systematic review and meta-analysis of prospective epidemiological studies. Sports Medicine, 44(1), 123-140. https://doi.org/10.1007/s40279-013-0102-5 

Gribble, P. A., Bleakley, C. M., Caulfield, B. M., Docherty, C. L., Fourchet, F., Fong, D. T., Hertel, J., Hiller, C. E., Kaminski, T. W., McKeon, P. O., Refshauge, K. M., Verhagen, E. A., Vicenzino, B. T., Wikstrom, E. A., & Delahunt, E. (2016, December). Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine, 50(24), 1496–1505. https://doi.org/10.1136/bjsports-2016-096189 

Melanson, S. W., & Shuman, V. L. (2023, May 23). Acute ankle sprain. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459212/ 

Physical therapy in Louisiana for ankle. (n.d.). Moreau Physical Therapy. Retrieved October 23, 2023, from https://www.moreaupt.com/Injuries-Conditions/Ankle/Ankle-Anatomy/a~47/article.html 

Polzer, H., Kanz, K. G., Prall, W. C., Haasters, F., Ockert, B., Mutschler, W., & Grote, S. (2012). Diagnosis and treatment of acute ankle injuries: Development of an evidence-based algorithm. Orthopedic Reviews, 4(1), e5. https://doi.org/10.4081/or.2012.e5 

Sproule, J. (2012). Sports, exercise and health science. Oxford University Press.

Wallace, H. A., Basehore, B. M., & Zito, P. M. (2023, June 12). Wound healing phases. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470443/ 

Wang, D. Y., Jiao, C., Ao, Y. F., Yu, J. K., Guo, Q. W., Xie, X., Chen, L. X., Zhao, F., Pi, Y. B., Li, N., Hu, Y. L., & Jiang, D. (2020, May 26). Risk factors for osteochondral lesions and osteophytes in chronic lateral ankle instability: A case series of 1169 patients. Orthopaedic Journal of Sports Medicine, 8(5), Article 2325967120922821. https://doi.org/10.1177/2325967120922821 

Wolfe, M. W., Uhl, T., Mattacola, C. G., & McCluskey, L. C. (2001, January 1). Management of ankle sprains. American Family Physician, 63(1), 93-105. https://www.aafp.org/pubs/afp/issues/2001/0101/p93.html