Ankle Sprain Mgt Algorithm

High and Low Ankle Sprains

High = syndesmotic sprain/tear
Low = below this

osteochondral lesion at superolateral talus
peroneal tendon subluxation
fractured lateral talar process
fractured anterior process of calcaneus

Deltoid ligament sprain usually accompanied by fracture

Anterior Draw Test 
strong spec and sense for acute inversion trauma, weak for chronic laxity

1. supine, knee bent with towel, foot off edge of plinth, ankle PF 10-15deg supported, cup heel with ipsi hand (sole resting on therapist's forearm), draw calc anteriorly.

2. supine, knee bent with heel on plinth and sole resting at 10-15pf on folded towel. stabilize mid foot, and push posteriorly against tibia close to jt

positive  (lateral XR)
9 mm absolute drawer
5 mm cf opposite side

Talar Tilt Test

usually used for CFL while Ant Drawer determines ATFL
<5 deg is normal on ant XR

sit, pf to put atfl perpendicular to inversion mvt. reach hand under sole gripping calc/talus/cuboid and inverting while stablizing tib fib away from pain

sit, foot into neutral where cfl is perpendicular to talus long axis, then invert

Deltoid Lig
same position as for CFL, then evert

sit, max DF, then invert

pain or increased laxity vs other side.

High Ankle Sprain testing

Squeeze Test

at mid leg or a little proximally causes pain at high ankle sprain level

if positive, test for Maisonneuve Fracture (prox fibula fracture)

Anterior Rotation Stress Test
rotate anterolaterally

Mortise View XR
>5mm tib/fib gap = positive
>4mm medial space (talus/med mal) = positive

Ottawa Ankle and Foot Rules
Ottawa Ankle RulesOttawa Foot Rules
An ankle radiograph is required only if pain is indicated in the malleolar part and any of these is present:A foot radiograph is required only if pain is indicated in the mid-foot and any of these is present:
• Bone tenderness at lateral malleolus or posterior edge• Bone tenderness at the 5th metatarsal base
• Bone tenderness at medial malleolus or posterior edge• Navicular bone tenderness
• Unable to bear weight• Unable to bear weight


foot xr      mid foot pain
                 combined with either 1. tenderness at MT5 or navicular, 2. NWB
ankle xr   med or lat malleolar pain
                combined with either 1. tenderness of mal bone  2. NWB

Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline
Vuurberg G, et al. Br J Sports Med 2018;52:956

 Surgery or not? 

Nowadays, surgery is mainly reserved for patients who have chronic insta-bility after a LAS and who have not responded to a comprehen-sive exercise-based physiotherapy programme. Long-term effects of surgical treatment in cases of acute lateral ligament injury correspond with those of functional treatment. Surgery seems superior at decreasing the prevalence of recurrent LAS, which is important as recurrent LAS in turn may increase the risk for the subsequent development of osteoarthritis (one RCT, n=51)13(level 2). There is limited evidence for longer recovery times, higher incidences of ankle stiffness, impaired ankle mobility and complications in patients who received surgical treatment (20 RCTs, n=2562)150 (level 1). More recent studies show that outcomes in terms of recovery of ankle activity and instability are significantly better for surgical treatment than for functional treatment (12 RCTs, n=1413)152 (level 1). As a previous sprain is a predictor for recurrent ankle sprains, this may be related to increased ligament laxity. This laxity is resolved during surgery. Based on this indirect evidence, it may be suggested that surgical therapy helps prevent recurrent ankle sprains. However, a large percentage (60%–70%) of individuals who sustain a LAS respond well to non-surgical treatment programmes,149 and therefore treating all patients with LAS would mean unnecessary exposure to an invasive intervention for many patients, not to mention costs (level 1).What’s new: New evidence supports the rationale for being reserved with the recommendation of surgery for all patients following LAS. This lead to refinement of the recommendation regarding surgery.Recommendation (modified): Despite good clinical outcomes of surgery after both chronic injuries and an acute complete lateral ligament rupture, functional treatment is still the preferred method as not all patients require surgical treatment. This also helps to avoid unnecessary exposure to invasive (over) treatment and unnecessary risk of complications149 152 (level 1). However, treatment decisions have to be made on an individual basis. In professional athletes, surgical treatment may be preferred to ensure quicker return to play.151


EFORT Open Rev. 2016 Feb; 1(2): 34–44.
Acute ankle sprain: conservative or surgical approach?
Omar A. Al-Mohrej and Nader S. Al-Kenani

Croy (2013): Dijk (1996): (2016):

World J Orthop. 2015 Mar 18; 6(2): 161–171.
Management and prevention of acute and chronic lateral ankle instability in athletic patient populations
Brendan J McCriskin, Kenneth L Cameron, Justin D Orr, and Brian R Waterman


Acute and chronic lateral ankle instability are common in high-demand patient populations. If not managed appropriately, patients may experience recurrent instability, chronic pain, osteochondral lesions of the talus, premature osteoarthritis, and other significant long-term disability. Certain populations, including young athletes, military personnel and those involved in frequent running, jumping, and cutting motions, are at increased risk. Proposed risk factors include prior ankle sprain, elevated body weight or body mass index, female gender, neuromuscular deficits, postural imbalance, foot/ankle malalignment, and exposure to at-risk athletic activity. Prompt, accurate diagnosis is crucial, and evidence-based, functional rehabilitation regimens have a proven track record in returning active patients to work and sport. When patients fail to improve with physical therapy and external bracing, multiple surgical techniques have been described with reliable results, including both anatomic and non-anatomic reconstructive methods. Anatomic repair of the lateral ligamentous complex remains the gold standard for recurrent ankle instability, and it effectively restores native ankle anatomy and joint kinematics while preserving physiologic ankle and subtalar motion. Further preventative measures may minimize the risk of ankle instability in athletic cohorts, including prophylactic bracing and combined neuromuscular and proprioceptive training programs. These interventions have demonstrated benefit in patients at heightened risk for lateral ankle sprain and allow active cohorts to return to full activity without adversely affecting athletic performance.