Ankle Sprain

Lower Limb

Overview

Ankle sprain is the most common ligamentous injury of the lower limb, typically involving the lateral ligament complex due to inversion trauma. The severity ranges from mild stretching to complete ligamentous rupture, classified as Grade I (mild), Grade II (moderate), or Grade III (severe). Proper assessment and early intervention are critical to prevent chronic ankle instability and functional impairment.

Pathophysiology

Ankle sprain occurs when the ankle is forcibly inverted, most commonly affecting the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). The mechanism typically involves sudden inversion with the foot plantarflexed, causing ligamentous tearing and micro-ruptures. Subsequent inflammation, swelling, and proprioceptive deficits develop, with potential involvement of the syndesmotic ligaments in higher-energy injuries. Chronic instability can result from inadequate rehabilitation and proprioceptive retraining.

Typical Presentation

Site

Lateral ankle, particularly around the anterior talofibular and calcaneofibular ligaments; may involve medial ankle (less common) and anterior ankle syndesmosis

Quality

Sharp, stabbing pain at moment of injury; progressing to throbbing, aching pain; sensation of instability or 'giving way'

Intensity

Mild sprains: 2-4/10 pain with weight-bearing; moderate: 5-7/10; severe: 8-10/10 with inability to bear weight

Aggravating

Weight-bearing and walking, particularly on uneven surfaces; inversion movements; running and pivoting; stairs; prolonged standing

Relieving

Rest and elevation; ice application; immobilization; non-weight-bearing positions; gentle ankle movements within pain-free range

Associated

Swelling and ecchymosis (especially lateral ankle and foot dorsum); reduced ankle dorsiflexion and plantarflexion; proprioceptive deficits; difficulty with single-leg stance; peroneal muscle weakness; possible joint effusion; altered gait pattern

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Anterior Drawer Test

Procedure

Patient seated with the knee bent and the ankle relaxed in about 10–20° of plantarflexion. Stabilise the lower tibia with one hand and draw the heel forwards with the other. Compare the amount of movement and the end-feel with the other ankle.

Positive Finding

More forward movement of the talus than on the other side, with a soft end-point, sometimes with a visible dimple in front of the fibula.

Sensitivity / Specificity

54% (pooled, 6 studies, 885 observations)/87% (pooled)

Reference: Netterström-Wedin F, Matthews M, Bleakley C. Diagnostic Accuracy of Clinical Tests Assessing Ligamentous Injury of the Talocrural and Subtalar Joints: A Systematic Review With Meta-Analysis. Sports Health. 2022;14(3):336-347.

Interpretation

A positive test supports an anterior talofibular ligament tear; pain alone does not count. Swelling and pain make it less reliable in the first days; re-examine at about 4–5 days. Before stress testing, apply the Ottawa ankle rules to decide whether an X-ray is needed. Pooled in a 2022 meta-analysis (Netterström-Wedin et al.) against imaging or surgery. A positive drawer (more forward movement of the talus than on the other side, not just pain) supports an anterior talofibular ligament injury; a negative test does not rule one out. Palpation of the ligament is the sensitive test: no tenderness over it makes a tear unlikely. Examination is more accurate a few days after the injury, once swelling and pain settle.

Sources

Contested
Reported accuracy varies widely across studies — may be strong or weak depending on population and technique
Evidence is highly heterogeneous: reported figures span from a weak (D) to a strong (APlus) test across studies/populations. Interpret with caution and in context.

Talar Tilt Test

Procedure

Patient seated or supine, ankle in neutral. Stabilise the lower tibia and tilt the heel and talus into inversion, comparing the movement and end-feel with the other ankle.

Positive Finding

More inversion tilt than on the other side, with a soft end-point.

Sensitivity / Specificity

17–66% (3 studies)/82–100% (3 studies)

Reference: Netterström-Wedin F, Matthews M, Bleakley C. Diagnostic Accuracy of Clinical Tests Assessing Ligamentous Injury of the Talocrural and Subtalar Joints: A Systematic Review With Meta-Analysis. Sports Health. 2022;14(3):336-347.

Interpretation

A positive test supports a calcaneofibular ligament injury, usually together with the anterior talofibular ligament. A negative test does not rule one out. Range across three studies in a 2022 systematic review (Netterström-Wedin et al.); not pooled. A positive talar tilt supports a calcaneofibular ligament injury, usually together with the anterior talofibular ligament. A negative test does not rule it out.

Sources

No accuracy study

Inversion Stress Test (Supine or Sitting)

Procedure

Patient seated or supine. Stabilise the lower leg and gently invert the heel and foot, noting pain, the amount of movement and the end-feel compared with the other side.

Positive Finding

Pain over the lateral ligaments, or more inversion movement than on the other side.

Interpretation

Pain supports a lateral ligament sprain; increased movement suggests a more significant tear. It overlaps with the talar tilt test. Bony tenderness at the back edge or tip of either malleolus, the base of the fifth metatarsal or the navicular, or inability to take four steps, calls for an X-ray (Ottawa ankle rules).

Sources

No accuracy study

Syndesmotic Squeeze Test (Tibia-Fibula Compression)

Procedure

Patient seated or supine. Squeeze the tibia and fibula together at mid-calf level.

Positive Finding

Pain felt down at the front of the ankle, between the tibia and fibula, rather than in the calf.

Sensitivity / Specificity

—/88% (87 ankle sprains)

Interpretation

Screens for a syndesmosis ('high ankle') sprain alongside the ordinary lateral sprain. A positive test, especially with pain on dorsiflexion–external rotation and difficulty hopping, needs imaging, as these injuries take longer to recover and some need surgery. From 87 people with an ankle sprain seen within 2 weeks, with MRI as the reference (Sman 2015). Only the specificity reported in the abstract is shown. A positive squeeze test makes a syndesmosis injury more likely; a negative test does not rule one out. Combine it with inability to hop, tenderness over the front of the syndesmosis and the dorsiflexion–external rotation test.

Sources

Not a diagnostic test

Single Leg Stance (Balance) Test

Procedure

Ask the patient to stand on the injured leg for up to 30 seconds with eyes open, then eyes closed, and compare with the other leg.

Positive Finding

Clearly worse balance than on the other side (arm movements, touching down, excessive sway).

Interpretation

Poor single-leg balance after a sprain is common and is linked to a higher risk of re-injury. It guides balance training and return to sport; it is not a diagnostic test.

Sources

Not a diagnostic test

Weight-Bearing Ankle Dorsiflexion Test

Procedure

Knee-to-wall lunge: the patient stands facing a wall with the foot a few centimetres from it and bends the knee to touch the wall, keeping the heel down. Move the foot back until the knee just touches, and measure the toe-to-wall distance. Compare sides.

Positive Finding

A shorter distance than on the other side, or pain at the front of the ankle.

Interpretation

Measures dorsiflexion range, which is often reduced after a sprain and is a key rehabilitation target. Pain at the front of the ankle in this position may suggest anterior impingement. Not a diagnostic test.

Sources

⚠ Red Flags

  • •Severe, uncontrolled swelling or signs of compartment syndrome (increasing pain with passive stretching, paresthesia, pallor)
  • •Signs of neurovascular compromise (absent dorsalis pedis or posterior tibial pulses, cold foot, persistent numbness)
  • •Fracture suspected (inability to bear weight on foot, severe deformity, bony tenderness at lateral malleolus or base of fifth metatarsal)
  • •High-energy mechanism with syndesmotic involvement (tibia-fibula separation, positive anterior drawer or external rotation tests)
  • •Open wound or signs of infection (fever, spreading erythema, purulent discharge)
  • •Recurrent sprains with progressive instability despite conservative management

⚡ Yellow Flags

  • •Fear-avoidance beliefs regarding ankle movement and weight-bearing
  • •Catastrophizing about ankle stability and future re-injury
  • •Secondary psychological distress affecting rehabilitation motivation
  • •Unrealistic expectations regarding recovery timeline
  • •History of multiple previous ankle sprains suggesting behavioral or proprioceptive deficits
  • •Delayed presentation or reluctance to engage in rehabilitation
  • •Social or occupational factors limiting compliance with exercise program

Osteopathic Techniques

Most sprains, including most grade III sprains, are managed without surgery: brief protection, then early motion and functional rehabilitation. Reviews give strong evidence for NSAIDs and early mobilisation, and moderate evidence for exercise and manual therapy. In one emergency department trial (n=50), early osteopathic treatment added to usual care improved mobility and stability over 3 weeks.

Safety: Tenderness over either malleolus calls for the Ottawa ankle rules to check for a fracture. Also palpate the base of the 5th metatarsal, the navicular and the midfoot for a Lisfranc injury. High ankle (syndesmotic) sprains are less common but carry more morbidity.

Region

Talocrural and subtalar joints

Technique

Articulation, ankle and foot
Grade B
Moderate evidence: supported by at least one good study
Reviews give moderate evidence for manual therapy after an acute sprain. Joint mobilisation improved balance immediately and weight-bearing dorsiflexion in the short term, but not pain.

Rationale

Ankle, subtalar and midfoot glides, mainly to restore dorsiflexion and foot mobility.

How it's done, cautions & evidence

How it's done

Passive, rhythmic, low-velocity glides of the ankle (talocrural), subtalar, midfoot and toe joints, within or up to the end of the available range, often aimed at restoring ankle dorsiflexion.

Cautions

Before mobilising an acute ankle injury, check for fracture with the Ottawa ankle rules (tenderness over either malleolus), and palpate the base of the 5th metatarsal, the navicular and the midfoot for a Lisfranc injury.

Evidence in Ankle Sprain

Doherty 2017 (overview of 46 systematic reviews): moderate evidence that manual therapy techniques help pain, swelling and function after an acute ankle sprain. Weerasekara 2018 (SR/MA, mostly moderate-quality studies): joint mobilisation improved posteromedial dynamic balance immediately and weight-bearing dorsiflexion in the short term, with no effect on pain intensity; long-term effects not studied.

Region

Lateral ankle ligaments (ATFL, CFL, PTFL)

Technique

Soft tissue, foot and ankle
Grade C
Limited evidence: indirect or low-quality support only
Reviews give moderate evidence for manual therapy after an acute sprain, and an osteopathic package helped in one trial. No trial tested soft tissue to the ligaments on its own.

Rationale

Soft tissue to the plantar fascia, foot muscles and the tissues around the heel and ankle ligaments.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the plantar fascia, the small muscles of the foot and the tissues around the heel and the ankle ligaments.

Evidence in Ankle Sprain

Doherty 2017 (overview of 46 reviews): moderate evidence that manual therapy techniques help pain, swelling and function after an acute sprain. Bournon 2026 (RCT, n=50, emergency department, sprain under 72 hours): osteopathic treatment guided by tissue tension, added to usual care, improved dorsiflexion and functional stability and reduced pain and oedema over 3 weeks. Neither isolates soft tissue technique.

Region

Calf and lower leg

Technique

Soft tissue, calf and lower leg
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials of lower-leg soft tissue on its own after ankle sprain. A tailored osteopathic package added to usual care helped in one emergency department trial.

Rationale

Calf and lower-leg soft tissue is usually given alongside a loading or stretching programme.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the calf (gastrocnemius and soleus), the Achilles tendon and the peroneal and tibial muscles of the lower leg. In trials it was given alongside exercise, such as eccentric calf loading.

Evidence in Ankle Sprain

Searched 25 Oct 2026: no trials of calf or lower-leg soft tissue alone. Indirect: Bournon 2026 (RCT, n=50): early osteopathic treatment plus usual care improved mobility, stability, pain and oedema over 3 weeks.

Region

Lateral ankle and peroneal tender points

Technique

Counterstrain, foot and ankle tender pointsNo trials found

Rationale

Gentle indirect technique: tender points in the foot and ankle are eased by passive positioning.

How it's done, cautions & evidence

How it's done

Find a tender point in the foot, ankle or calf. Passively move the foot and ankle into the position where the tenderness and tissue tension ease most, and hold it for about 90 seconds while monitoring the point. Return slowly to neutral and re-check.

Cautions

Do not use over an acute fracture, or in a patient who cannot give feedback.

Evidence in Ankle Sprain

Searched 25 Oct 2026: no trials of counterstrain in ankle sprain.

Rehabilitation Exercises

Ankle Alphabet Exercise

Range of MotionBeginner

Ankle Dorsiflexion and Plantarflexion Pumps (Supine)

Range of MotionBeginner

Calf Stretch (Standing Wall or Lunge Position)

StretchingBeginner

Anterior Tibialis Stretch (Kneeling or Seated)

StretchingBeginner

Isometric Ankle Inversion with Resistance Band (Seated)

StrengtheningBeginner

Isometric Ankle Eversion with Resistance Band (Seated)

StrengtheningBeginner

Seated Heel Raises

StrengtheningIntermediate

Standing Calf Raises (Double Leg Progression to Single Leg)

StrengtheningIntermediate

Single-Leg Stance on Firm Surface

BalanceIntermediate

Single-Leg Stance on Foam or Balance Pad

BalanceAdvanced

Single-Leg Stance with Upper Limb Movements (Head Turns, Arm Reaches)

BalanceAdvanced

Lateral Hop-and-Hold (Controlled Lateral Weight Shifts)

FunctionalAdvanced

Referral Criteria

  • •Suspected fracture (lateral malleolus, medial malleolus, base of fifth metatarsal, talar dome) requiring imaging and orthopedic evaluation
  • •Signs of syndesmotic involvement (high ankle sprain) with persistent instability or inability to weight-bear after 1 week
  • •Neurovascular compromise requiring urgent vascular assessment
  • •Signs of compartment syndrome requiring emergency intervention
  • •Grade III (severe) ankle sprain with complete ligamentous rupture or persistent significant instability after 2-3 weeks of conservative management
  • •Recurrent ankle sprains (≥3 in previous 12 months) suggesting chronic instability or neuromuscular deficit requiring specialist assessment
  • •Failure to progress in pain or functional recovery after 4 weeks of appropriate conservative treatment
  • •Associated injuries to other structures (syndesmotic ligaments, peroneal tendon subluxation, osteochondral lesions of talus) detected on imaging
  • •Psychological distress, catastrophizing, or fear-avoidance significantly impacting rehabilitation adherence
  • •Chronic ankle instability affecting quality of life or occupational/sporting function despite conservative management