Lateral ankle sprains or lateral ligament tears are the most common lower extremity musculoskeletal injury, affecting individuals of all ages participating in organised sports or unstructured play. (Wikstrom et al., 2021)
Up to 40% of ankle sprains go on to develop chronic symptoms, including pain, swelling and instability that persists at least 12 months post-injury. (Mugno et al., 2023)
What is a Lateral Ankle Sprain?
A lateral ankle sprain occurs when the ankle is forced into excessive inversion and plantarflexion, leading to damage and tearing of one or more of the ligaments in the lateral ligament complex, situated on the outside of your ankle. This complex consists of:
- Anterior Talofibular Ligament (ATFL) – the most commonly injured ligament.
- Calcaneofibular Ligament (CFL) – often involved in more severe sprains.
- Posterior Talofibular Ligament (PTFL) – rarely injured, usually in high-grade tears.
Severity Classification
Lateral ligament sprains are classified into three grades:
- Grade I: Up to 20% of ligament fibres are torn, resulting in mild pain, swelling, and minimal loss of function.
- Grade II: Between 20-80% of fibres are torn, with moderate swelling, bruising, and difficulty weight-bearing.
- Grade III: More than 80% of fibres are torn, leading to complete ligament rupture, severe pain, and significant instability.
High Ankle Sprains (syndesmosis injuries) must be carefully diagnosed as they require a longer recovery period, slightly different management and, in some cases, surgery.
Diagnosis and Physiotherapy Assessment
comprehensive physiotherapy examination is essential to determine the severity of the injury and helps guide an appropriate treatment plan. Assessment includes:
- Subjective History: Understanding the mechanism of injury, weight-bearing ability, and presence of swelling/bruising. Aggravating activities, occupational and domestic requirements and demands of sport and exercise are explored helping to set rehabilitation goals. This information is vital for both diagnosis and when formulating a patient specific treatment plan.
- Objective Testing:
- Functional Movement Testing – Assesses gait, active and passive ankle movement, balance, and weight-bearing capacity.
- Ottawa Ankle Rules (OAR) – Guidelines to determine if an X-ray is needed to rule out fractures.
- Anterior Drawer Test – Assesses ATFL integrity.
- Talar Tilt Test – Evaluates CFL involvement.
- Squeeze Test & External Rotation Stress Test – Identifies high ankle sprains (syndesmosis injuries).
Should a Patient Be Placed in a Boot?
Research suggests that early functional mobilisation is key to recovery. Prolonged immobilisation in a boot or cast can lead to longer recovery times (Perera et al., 2025). However, in cases of high-grade ligament tears or syndesmosis injuries, a CAM boot and/or crutches are often required for a period before progressive rehabilitation begins. This helps to protect the area from further damage while encouraging early weight bearing.
Physiotherapy Treatment for Lateral Ankle Sprains
Physiotherapy plays a crucial role in reducing pain, restoring function, and preventing future injury. A structured rehabilitation plan includes:
1. Acute Phase (0-7 Days)
- Early weight-bearing is encouraged as tolerated.
- Ice and compression to reduce swelling and pain. In our clinic we use the Active Force Ice/Compression pump
- Taping, bracing or a CAM boot to support the ankle during movement whilst encouraging weight bearing.
- Gentle range of motion (ROM) exercises to prevent stiffness, gait retraining exercises and pain free strengthening as tolerated.
2. Subacute Phase (1-4 Weeks)
- Manual therapy techniques (joint mobilisation, soft tissue release) to restore mobility.
- Progressive strengthening exercises targeting:
- Ankle stabilisers (peroneals, tibialis posterior)
- Calf and foot intrinsic muscles
- Proximal hip and core stabilisers
- Balance and proprioception training to restore neuromuscular control (e.g., single-leg stance, balance board exercises).
3. Advanced Phase (4-8 Weeks+)
- Sport-specific agility drills (running, cutting, jumping mechanics).
- Plyometric training to prepare for high-impact activities.
- Return-to-sport testing to assess strength, stability, and confidence in the ankle.
- Ongoing neuromuscular training to reduce re-injury risk (Kazemi et al., 2024).
Preventing Recurrent Ankle Sprains
Patients with a history of ankle sprains have approximately 70% higher chance of recurrence in the following 3-12 months (Kawabata et al., 2023).
Strategies for prevention include:
- Ongoing ankle strengthening to maintain joint stability.
- Balance and proprioception exercises to improve neuromuscular control.
- Taping or bracing during high-risk activities.
- Gradual return to training and sport with physiotherapist guidance.
What Does the Evidence Say?
- Early physiotherapy intervention results in greater functional improvement than the RICER method alone (Dewi et al., 2022).
- Proprioception and Strength training is effective in reducing the risk of re-injury (Baral et al., 2021).
- Supervised rehabilitation programs lead to faster return to sport and lower recurrence rates (Wagemans et al., 2022).
- Taping and bracing during sports reduces the risk of re-injury (Megalaa et al., 2024).
- Individuals with recurrent ankle sprains demonstrated altered landing mechanics, which has been found to heighten the risk of ACL injury with decreased knee and hip muscle control (Xu et al, 2022). It is thus important that the whole kinetic chain is also assessed and exercise is prescribed based on findings, as research identifies reduced muscle control and postural stability in people following ankle sprains (Simpson et al, 2019).
Conclusion
Lateral ligament ankle sprains are highly treatable with evidence-based physiotherapy rehabilitation and early physiotherapy intervention is essential for the best long-term outcomes. A physio rehabilitation plan that addresses strength, stability, and movement patterns ensures optimal recovery and reduces the risk of re-injury.
Exercise
Calf Raises:
Aim: Improve calf strength, push off power and lower limb function
How: Standing on one leg rise up onto your toes, then slowly return to the starting position for reps.
Bosu Balance
Aim: To improve ankle stability, enhance balance and proprioception (body awareness), and strengthen surrounding muscles, ultimately reducing the risk of future sprains and improving overall function
How: Stand on one leg balancing on the soft side of the bosu Ball. For increased difficulty move your floating leg out to the side.
Lateral Hop:
Aim: Improve ankle stability, simulating cutting and landing movements. It is also a test to assess readiness for return to sport after a sprain.
How: Hop laterally over a 30cm distance, with the goal of completing 10 hops as quickly as possible
If you or someone you care for has an injury, a flare up, requires some rehabilitation or experiences an increase in pain, give the clinic a call on 9713 2455 or book online.