Ankle sprain

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Updated by: Allison Duey-Holtz, APP
Updated on: 8/2/17


Mechanism of Injury

  • Rotational/twisting mechanism (ie. inversion, eversion)
  • "High ankle sprain” (syndesmosis injury) - Forced dorsiflexion + eversion

Signs and symptoms

  • Pain
  • Swelling
  • Bruising
  • Limping or difficulty bearing weight
  • Instability

Differential Diagnosis

  • Ankle fracture
    • Salter Harris injury in skeletally immature patients
    • Posterior malleolus fracture
    • Medial malleolus fracture
    • Juvenile Tilleaux fracture
    • Triplane fracture
      • Syndesmosis injury
      • Maisonneuve fracture
      • Foot fracture

Referring provider's initial evaluation and management:

Physical Exam

  • Inspection, palpation, ROM, strength
  • Special tests:
    • Anterior drawer, Talar tilt tests for lateral ankle laxity
    • Syndesmotic squeeze test to assess for syndesmotic injury

Diagnostic Tests

Radiographs indicated if the following are present per the Ottawa ankle and foot rules:

  • Ankle:
    • Bony tenderness over the medial or lateral malleolus
    • Inability to bear weight (4 steps) immediately after injury, in ED or physician's office
  • Foot:
    • Bony tenderness of the base of the 5th metatarsal
    • Bony tenderness of the navicular
    • Inability to bear weight (4 steps) immediately after injury, in ED or physician's office

Recommended views

  • Ankle - AP/lateral/mortise (weightbearing if possible)
  • Foot – AP/lateral/oblique (weightbearing if possible)
  • If clinically indicated:
    • Tibia/fibula – AP/lateral


  • If no fracture:
    • Rest, Ice, Compression, Elevation
    • Ibuprofen/acetaminophen as needed for pain
    • ACE bandage wrap or lace-up ankle brace for compression/support
    • Crutches for protected weightbearing if limping/difficulty weightbearing. Wean off as tolerated.
    • For severe sprains, consider walking boot if available and able to be applied and fitted appropriately
  • If fracture present:
    • Apply splint
    • Crutches – no bearing weight
    • Refer to Orthopedics/Sports Medicine
  • Return to activity after ankle sprain:
    • Physically ready to return:
      • Able to ambulate and perform sport-specific activities (i.e. running, jumping and cutting) pain-free and with normal mechanics
    • Psychologically ready to return
    • Should perform ankle exercises for ROM, strength and neuromuscular control prior to return
    • Recommend lace-up ankle brace with PE/sports to decrease risk of re-injury

When to initiate referral to Sports Medicine/ Orthopedic Clinic:

  • Confirmed fracture
  • Severe sprain
  • Injury to syndesmosis
  • Uncertainty regarding diagnosis, treatment or and/or return to activity
  • Worsening symptoms or no/minimal improvement in 7-10 days

What can referring provider send to Sports Medicine/ Orthopedic Clinic?

1. Using Epic

  • Please complete the external referral order

In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:

  • Urgency of the referral
  • What is the key question you would like answered?

Note: Our office will call to schedule the appointment with the patient.

2. Not using Epic external referral order:

  • In order to help triage our patients maximize the visit time, please fax the above information to (414) 607-5288
  • It would also be helpful to include:
  • Chief complaint, onset, frequency
  • Recent progress notes
  • Labs and imaging results
  • Other Diagnoses
  • Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient's problems.

Specialist's workup will likely include:

If no fracture initially diagnosed:

  • History and physical exam
  • Potentially repeat x-rays
  • Potentially advanced imaging (CT or MRI)
  • Boot or brace
  • Plan for rehabilitation, including possible PT referral, and return to play

If confirmed fracture:

  • History and physical exam
  • Potentially repeat x-rays
  • Potentially advanced imaging (CT or MRI)
  • Immobilization in boot vs cast +/- crutches depending on type of injury


Wolfe MW, UHL TL, and McCluskey LC. Management of ankle sprains. Am Fam Physician. 2001; 63(1):93-104.

Tiemstra JD. Update on acute ankle sprains. Am Fam Physician. 2012; 85(12):1170-11-75.

Steill IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993; 269(9):1127-1132.

Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 2009; 16(4):277-287.