This tool provides information to facilitate the management of ankle sprain in adults.
Ankle sprain occurs when ligaments that support the ankle stretch beyond their limits and tear. Ankle sprain can present with pain, bruising, swelling, and tenderness.
1. Patient History
Assess level of concern for major structural or other pathologies. If required, refer to an appropriate healthcare provider.
Identify and assess other conditions and co-morbidities. Manage using appropriate care pathways.
Address prognostic factors that may delay recovery.
Major structural or other pathologies may be suspected with certain signs and symptoms (red flags):
Positive Ottawa Ankle Rules, children <12 years of age, elderly patients, erythema, warmth, fever, chills, prolonged pain, swelling, catching and/or instability of the ankle joint, pain at rest, awakening due to pain at night, bilateral pain
Examples of other conditions/co-morbidities:
Physical conditions: patellofemoral pain, lumbar strain
Psychological conditions: depression, anxiety
Co-morbidities: diabetes (peripheral neuropathy), chronic venous insufficiency
Examples of prognostic factors that may delay recovery:
Symptoms of depression or anxiety, passive coping strategies, job dissatisfaction, high self-reported disability levels, disputed compensation claims, somatization
2. Physical Examination
Assess levels of concern regarding major structural or other pathologies.
Rule out fracture using the Ottawa Ankle Rules
Identify patient's baseline status relative to pain, function and disability, determine the patient's readiness to return to activities using appropriate assessments.
Offer information on nature, management, and the course of ankle sprain recovery.
Discuss the range of effective interventions with the patient and, together, select a plan.
Emphasize active rather than passive treatment options.
Grade I ankle sprain: partial tear of a ligament
Mild tenderness and swelling, slight or no functional loss (patient is able to bear weight and ambulate with minimal pain), no mechanical instability
Grade II ankle sprain: incomplete tear of a ligament, with moderate functional impairment
Moderate pain and swelling, mild to moderate ecchymosis, tenderness over involved structures, some loss of motion and function (patient has pain with weight-bearing and ambulation), mild to moderate instability
Grade III ankle sprain: complete tear and loss of integrity of a ligament
Severe swelling (more than 4cm about the fibula), severe ecchymosis, loss of function and motion (patient is unable to bear weight or ambulate), mechanical instability
Therapeutic Recommendations - Recent-onset (≤3 months symptom duration)
Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice)*.
Consider one of the two interventions:
semi-rigid brace, semi-rigid boot or below-knee immobilization walking cast for grades II/III ankle sprains¹ or
mobilization of the distal and proximal tibiofibular joints, talocrural, and subtalar joints²
Consider appropriate home-based intervention(s):
home-based exercise program³
home-based cryotherapy for grades I/II ankle sprains⁴
Do Not Offer supervised progressive exercise program⁵
Do Not Offer low-level laser therapy⁵
*The guidelines does not include interventions for which there is a lack of evidence of effectiveness. The ordering of interventions does not reflect superiority of effectiveness
¹Semi-rigid brace during the daytime (4 weeks), semi-rigid boot during the daytime (4 weeks) or below-knee immobilization walking cast (10 days)
²The program should include 5 repetitions (30 seconds; grades I-IV mobilization at the provider’s discretion), twice per week for 4 weeks
³The program should include therapeutic exercises with cryotherapy adapted from a standard protocol that includes: active circumduction mobility (20 repetitions), active plantar flexion/dorsiflexion mobility (20 repetitions); static muscle strengthening: eversion, inversion, plantar flexion, dorsiflexion (5 repetitions each); functional movement pattern (lower limb triple flexion/extension; 30 repetitions); and triceps surae stretch (3 repetitions) 4 times per week for 4 weeks
⁴The program should include standard application of 20 minutes of continuous ice treatment performed every two hours; or, ice applied for 10 minutes, the ankle is rested at room temperature for 7 minutes, ice is reapplied for 10 minutes and performed every two hours; over the first 72 hours.
⁵Based on evidence of no benefit to patients
Therapeutic Recommendations - Persistent (>3 months symptom duration)
Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities,
self-care advice) and the following therapeutic intervention*:
Consider mobilization of the distal and proximal tibiofibular joints, talocrural, and subtalar joints¹
*The guidelines does not include interventions for which there is a lack of evidence of effectiveness.
¹The program should include 5 repetitions (30 seconds; grades I-IV mobilization at the provider’s discretion), twice per week for 4 weeks.
Care Pathway for the management of ankle sprain