Ankle ligament injuries: Assessment and Rehabilitation


Lateral ankle ligament sprains are the most common injury affecting both general and athletic populations.[1-7] Within the UK and the US approximately 5,000 and 27,000 injuries respectively occur per day,[1] with research showing that the anterior talofibular ligament (ATFL) is injured most frequently.[1-2] The ATFL connects the lateral malleolus to the neck of the talus, forming part of the lateral ligamentous structure of the ankle joint; alongside the calcaneofibular and posterior talofibular ligaments (PTFL).[1,5,9] Due to the biomechanics of the ankle joint, as plantar flexion (PF) increases the soft tissues are more susceptible to strain/injury;[1] with most sprains occurring in PF, adduction and inversion, leading the ATFL to be injured before any other ligament;[1,5] the classic ‘rolled ankle’ or ‘going over on your ankle’


In the acute setting, to assess the ankle, simply placing the ankle into: PF, abduction and inversion will be sufficient to elicit pain in the ATFL – this is if the patient will let you. This in conjunction with the anterior draw test[2] and palpation can lead to the diagnosis of an injury to the ATFL. In addition to this assessment a clinician should also check the syndesmosis, via the syndesmosis squeeze test,[9] and assess for creptius at the foot/ankle: for possible Lisfranc injury or a 5th metatarsal fracture, and for crepitus at proximal fibula: attempting to rule out a Maisonneuve fracture. In the acute setting the Owatta ankle rules [1,5,10,11] can be applied to help the clinician decided if an ankle x-ray is required. Research suggests, that due to the bodies healing mechanisms initial soft tissue injury management, P.O.L.I.C.E (Protection, Optimal Loading, Ice, Compression and Elevation),[12] should be commenced and a more thorough assessment should be completed 4 days post injury.[1,4] There are several grading systems available,[1,13] for musculoskeletal injuries and are dependent on the clinician present as to which is used.


As research suggests,[1,3-5,14] the treatment of choice for this type of injury should start with P.O.L.I.CE, to reduce pain and swelling; continuing with exercises when able. These early mobilisation exercises should take the form of gentle active range of motion (ROM) exercises e.g. plantar flexion, dorsiflexion, inversion, and eversion.[1,3-5] Early mobilisation provides controlled stresses to the ankle joint and has been shown to speed up the recovery of acute ankle injuries.[1] My personal favourite to say to patients for ROM exercises, is to get them to write the alphabet or spell their name with their foot. To maintain cardiovascular fitness and to help work the ankle functionally, although in a controlled manner, one can use the stationary bike or elliptical.


When the patient is able to progress with their exercises, the progressions should always be functional in nature, with an element of proprioception/neuromuscular control (NMC).[1,3-5] Due to the importance of restoring NMC,[3,5] NMC exercises should be afforded their own time slot; as insufficient NMC is a contributing factor to both initial and secondary injuries.[15] Functional treatment is based on the healing process of a ligament: during the first 3 weeks as new collagen tissue forms it is necessary to prevent unwanted inversion as this will lead to a weaker collagen being laid down, after 3 weeks the collagen begins to mature and responds to controlled stresses by correcting fibre alignment.[1] The collagen will continue maturing, with a return to activities expected at approximately 4-8 weeks.[1] Manual mobilisations, ultrasound, laser and electrotherapy were shown to have limited/no added value to ankle ligament rehabilitation.[4]


Rehabilitation exercises, no matter their guise; be it strength, flexibility, or NMC, are always commenced on a stable surface. During a NMC session, the goal is to provide greater kinesthesia through better communication between the neural and muscular systems. Therefore to progress NMC exercises from a stable base, the exercise could include external perturbations (catching/throwing an object), be conducted on an unstable surface (foam pad/mat/beam), having a flight phase included,[16-17] or by combining progressions. An example here would be a single leg stand; this can be progressed by: throwing and catching a ball (reaching out of the base of support), standing on an unstable surface, and standing on an unstable surface whilst throwing and catching a ball.


An example rehabilitative exercise for the ATFL is the Step-up; whilst this may primarily be used for strength, it can have a great NMC adage. The step-up should only be commenced once the patient is: 1) fully weight bearing, 2) able to take their full weight on a single leg, and 3) is confident in stepping up through their injured side. Initially the step-up can be conducted onto a shallow box (Figure 1), which can be made higher (Figure 2) as the patient progresses.

Figure-1- Shallow-box
Figure 1: Shallow box
Figure 2: Deeper box


  1. To start, the patient will stand facing the box (Figure 3), before stepping onto it leading with the injured side (Figure 4). The patient will stand up achieving full extension (Figure 5), before stepping back down in a controlled manner.
    Figure 3: Start position
    Figure- 4-Stepping- onto- box
    Figure 4: Stepping onto box
    Figure 5: Top position
    Figure 5: Top position

2.Adding a foam pad/mat onto the top of the box to create an unstable surface (Figure 6), then continuing as in 1.


Figure 6: Foam pad progression
Figure 6: Foam pad progression

3. Stable box; upon stepping up onto the box, adding in a hip/knee drive of the contralateral leg (Figure 7)

Figure 7: Hip/knee drive progression
Figure 7: Hip/knee drive progression

4. Foam pad/mat on box; stepping up onto the box with a hip/knee drive of the contralateral leg (Figure 8)

Figure 8: Foam pad + hip/knee drive progression
Figure 8: Foam pad + hip/knee drive progression

5. Stable box, hip/knee drive of the contralateral leg: achieving flight phase (Figure 9)

Figure 9: Flight phase progression
Figure 9: Flight phase progression

6. Foam pad/mat on box, hip/knee drive of the contralateral leg: achieving flight phase (Figure 10)

Figure 10: Foam pad + flight phase progression
Figure 10: Foam pad + flight phase progression

In addition to the foam pad/mat to progress the exercise the therapist can add in perturbations, these could be visual or physical perturbations. Visual perturbations could be advantageous for athletes, as they have to take in a lot of external information whilst remaining focused for their task at hand. The step-up is a very versatile exercise; in that it can be altered to conduct a side step-up (Figure 11), a step-up with an eccentric step down (Figure 12), a weighted step-up (Figures 13 and 14) +/- an eccentric step down

Figure 11: Side step up
Figure 11: Side step up
Figure 12: Eccentric step down
Figure 12: Eccentric step down
Figure 13: Weighted step up
Figure 13: Weighted step up
Figure 14: Weight step up
Figure 14: Weight step up

In summary, from the available research lateral ankle ligament sprains are the most common injury to affect both the general and the athletic populations, with the ATFL is injured most frequently. An increase in pain when placing the ankle into: PF, abduction, and inversion, combined with an increase in pain during the anterior draw test, and pain on palpation over the ATFL is sufficient to point towards an ATFL injury. Although it is very important for the clinician to still think about concurrent injuries: Ottawa ankle rules, Syndesmosis injury, Maisonneuve fracture, Lisfranc injury, 5th metatarsal fracture etc. An acute injury to the ATFL responds well to the P.O.L.I.C.E principle and early mobilisation, and should then be fully assessed 4 days post injury. This early mobilisation will provide the basis for sport specific training i.e. strength and NMC. NMC is one method by which the ankle can be made more stable; and as such reduce the likelihood of recurrent sprains/ankle instability.


Opinions expressed by physiogramworld contributors are their own.


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