Lateral Ankle Sprains

  • Common during landing, deceleration, change of direction
  • Court and field sports e.g. tennis, basketball, netball, football etc.

Studied Example 1

Fong et al. (2009)

  • Case report – accidental injury:
    • Inversion = 48°
    • Internal rotation = 10°
    • Ankle DF rather than PF

Studied Example 2

Gehring et al. (2013)

3D motion capture of accidental ankle sprain:

Rapid increase: - Plantar flexion (1240°/s) - Inversion (1290 °/s) - Internal rotation (580 °/s)

Studied Example 3

Fong et al. (2012)

Televised ankle sprains in tennis:

  • Model-based image matching approach to understand real time
  • Sampling frequency – 25 – 50 Hz
  • Large variation in motions resulting in the sprain
  • Mechanism likely a result of type of movement

Definition of Ankle Sprain

Gribble et al. (2016) International Ankle Consortium (IAC) consensus

“An acute traumatic injury to the lateral ligament complex of the ankle joint as a result of excessive inversion of the rear foot or a combined plantar flexion and adduction of the foot”

Prevalence and Consequences


How many have had a sprain?

  • 15% of all injuries are ankle sprains (Hootman et al., 2007)
  • 7 ankle sprains per 1000 exposures (Doherty et al., 2014)
  • 3 – 5% of all A&E presentations are for ankle sprains (UK) (Cooke et al., 2003; Lamb et al., 2009)


  • Swelling
  • Pain
  • Can’t put pressure on it

Ankle Anatomy

Structure Position Function Notes
ATFL Anterior edge of the lateral malleolus of the fibular Runs horizontally forward and downward and attaches to the neck of the talus, in front of the lateral malleolar facet Limits: Anterior displacement and medial shifting of the talus Posterior displacement and lateral rotation of the tibia and fibula, primarily in PF. Also prevents lateral talar tilt. Short ligament, widens slightly from top to bottom
CFL Originates from the anterior part of LM, often with a partial connection to ATFL at the fibula just distal to the ATFL It runs posteromedially, downward and backward, to be inserted into the calcaneus, distal to the subtalar joint. The insertion location on calcaneus is highly variable The fibres of the CFL pass through both the subtalar and ankle joints CFL stretches and comes under strain in the dorsiflexion position Responsible for resistance against inversion and internal rotation stress Strong flat oval or cord-like structure Thicker and stronger than ATFL

Key Point

ATFL = most vulnerable and main ligament affected

Ligament Structural Strength

Hauser & Dolan (2011)

  1. Toe region
  2. Uncrimping/ elongation
  3. Nearly linear elongation
  4. Microdamage/ plastic region
  5. Complete failure

Ligaments as a Sensory Organ

Hauser and Dolan (2011)

Ligament Healing

Phases of Healing

Difference following Healing

Normal ligaments Healed ligaments
Larger collagen fibrils Smaller collagen fibrils
Low cell and matrix turnover High cell and matrix turnover
Aligned collagen Disorganised collagen
Densely packed collagen Flaws between fibres
Higher matrix-cell ratio Lower matrix-cell ratio
Low cell density Higher cell density
Mature collagen cross-links Immature collagen cross-links
Primarily collagen Type I More collagen III
Primarily small proteoglycans Larger proteoglycans
Rare cell division More cell division

Is it all about the ligaments?

  • Tenderness along Peroneal tendon common in acute sprains (Nelson & Rottman, 2007)

  • Reported muscle weakness/ altered muscle activity in those with ankle sprain history

  • Cartilage damage and osteochondral defects - Evidence after an acute/ recurrent sprains


Factors we can change

Non-modifiable Modifiable
Sex Weight
Height Neuromuscular control
Race Postural stability
Foot/ ankle anatomy Muscle strength
Extremity alignemtn Exposure to sport
Previous ankle sprain Player position
Generalised joint laxity Footwear
Playing surface
Skill level

New Footwear

  • Spraino
    • Reduces shear force to allow sliding

Chronic Ankle Instability

Gribble et al. (2014)

Pathomechanical Impairments

Hertel & Corbett (2019)

  • Tissue adaptation
  • Pathologic laxity
  • Arthrokinematic restrictions
  • Osteokinematic restrictions
  • Secondary tissue injury

Sensory-Perceptual Impairments

Hertel & Corbett (2019)

  • Pain
  • Diminished somatosensation
  • Perceived instability
  • Kinesiophobia - Relates to the fear of movement or reinjury during functional activities.
  • Reduced health-related QoL
  • Lower self-reported function

Motor-Behavioural Impairments

Hertel & Corbett (2019)

  • Altered reflexes
  • Neuromuscular inhibition
  • Balance deficits
  • Reduced physical activity

  • Muscle weakness
    • Ankle evertors/ invertors and plantar flexors
    • Hip abductors/ extensors/ external rotators
    • Knee flexors/ extensors

  • Altered movement patterns
    • Employs a hip strategy ↑ flexion ↓ abduction
    • ↓ Ankle DF ROM
    • Inverted/ everted ankle at landing
    • ↑ Knee flexion/↓ Knee flexion


  • Different presentation of impairments

  • Ideally, an ankle sprain patient becomes a Coper without changing their activity

  • Currently, unclear what causes an individual to become a coper/ CAI individual

Minimising re-injury in the CAI Population

1. Lace-up Braces

Theoretical Effects

  • Reduce swelling

  • Restrict ankle motion

    • Provide mechanical resistance to inversion
    • Hall et al., 2016 = restricted inversion ROM, reduced maximum inversion, reduced inversion velocity


  • Protect against inversion – aid in promoting proper collagen fibre orientation
  • Useful during proliferation phase

Experimental Results

Found to reduce muscle activity during rehabilitation exercises (Feger et al., 2016)

  • Reduced peroneal longus activity
  • Aid in foot ankle alignment during weight bearing tasks
  • Potentially reduces reliance on peroneals to control motion
  • Mechanical support could be counter productive (long term use)?

2. Taping

Theoretical Effects

  • Provides support and proprioceptive feedback?

    • Limited evidence to support improve proprioception
  • Improve self efficacy

    • Improved perceptions of stability, confidence and reassurance (Delahunt et al., 2010; Halim-Kertanegara et al., 2017)


  • Does not affect performing e.g. jumping performance


  • Requires experience in taping
  • Not user friendly

3. Semi-Rigid Braces

Theoretical Effects

  • Provides some support to the ankle
  • Improves postural control (Hadadi et a;., 2011; Maeda et al., 2016)
  • Improved JPS


  • Improved proprioception
  • Stimulation of skin
  • Greater input to cutaneous mechanoreceptors
  • Enhances feedback


  • Lateral ankle sprains are common in sport
    • Damage occurs to the ligaments and other structures around the ankle which requires time for healing

  • Chronic ankle instability occurs in a high proportion of individuals following an acute sprain which can lead to long term consequences
    • Impairments include – pathomechanical, sensory-perceptual and motor-behavioural

  • Braces and taping can provide a range of support, resistance to movement and proprioceptive feedback to prevent recurrent sprains


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  • Doherty, C., Delahunt, E., Caulfield, B., Hertel, J., Ryan, J., & Bleakley, C. (2014). The Incidence and Prevalence of Ankle Sprain Injury: A Systematic Review and Meta-Analysis of Prospective Epidemiological Studies. Sports Medicine, 44(1), 123–140.

  • Feger, M. A., Donovan, L., Hart, J. M., & Hertel, J. (2014). Effect of ankle braces on lower extremity muscle activation during functional exercises in participants with chronic ankle instability. International Journal of Sports Physical Therapy, 9(4), 476–87.

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  • Gehring, D., Wissler, S., Mornieux, G., & Gollhofer, A. (2013). How to sprain your ankle - a biomechanical case report of an inversion trauma. Journal of Biomechanics, 46(1), 175–178.

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  • Hall, E. A., Simon, J. E., & Docherty, C. L. (2016). Using ankle bracing and taping to decrease range of motion and velocity during inversion perturbation while walking. Journal of Athletic Training, 51(4), 283–290.

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  • Maeda, N., Urabe, Y., Tsutsumi, S., Numano, S., Morita, M., Takeuchi, T., … Kobayashi, T. (2016). Effect of semi-rigid and soft ankle braces on static and dynamic postural stability in young male adults. Journal of Sports Science and Medicine, 15(2), 352–357.

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  • Pavailler, S., & Horvais, N. (2014). Sliding Allows Faster Repositioning during Tennis Specific Movements on Hard Court. Procedia Engineering, 72(72), 859–864.

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