Objective: to discuss a lateral ankle sprain to a female soccer athlete and to show just
how important it is to take a full and detailed history and inspection and what a large roll
rehabilitation plays if the athlete wants a full and strong recovery.
Background: Lateral ankle sprains are very common within the athletic community, and
athletic trainers are very used to seeing and treating them. Because most sports are
played on the athlete’s feet, all athletes are subject to them and they are not sport specific.
In this case, a female soccer player was sprinting towards a ball and stopped sideways.
Her ankle rolled down and in injuring her anterior talofibular ligament, calcaneofibular
ligament and her posterior talofibular ligament.
Differential Diagnosis: Second degree lateral ankle sprain
Treatment: Initial ice and elevation. Then the athlete was put on crutches and given a
boot before finally advancing to a functional brace. She was given strengthening
exercises to perform during rehab that focused on balance.
Uniqueness: This case is a typical lateral ankle sprain. Her mechanism is very common
and most lateral ankle sprains occur in the manner that hers did. Her rehab was also
average, and she was asked to do exercises that are widely known and used.
Conclusions: Lateral ankle sprains are very common and many athletes who suffer them
are prone to do so again.
Lateral or inversion ankle sprains are one of the more common injuries that an
athlete can suffer in athletics. In fact ankle trauma accounts for about 10 to 30 percent of
all injuries that athletes suffer to their musculoskeletal system (Wolfe) and according to
Journal of Athletic Training, females are 25% more likely to experience a grade I ankle
sprain (Beynnon). The most common mechanism for lateral ankle sprains is inversion in
combination with plantar flexion. Athletes often describe their foot as “rolling in” or say
that their foot went “down and in” (Hockenbury). Generally, a person is more likely to
have an inversion ankle sprain as opposed to an eversion ankle sprain because of the
anatomy of the body. The tibia comes down to meet the calcaneous much lower on the
medial side than the fibula on the lateral side. This provides a great deal of stability to
the medial side. This is not to say that there is no stability on the lateral side, but the bony
anatomy coupled with the strength of the deltoids on the medial side make it the stronger
side of the ankle.
There are three ligaments on the lateral side of the ankle, all of which are
susceptible to being stretched, torn or even ruptured, depending on the severity of the
sprain. Lateral ankle sprains are graded based on the damage that is done to these three
ligaments. In a grade I ankle sprain, the anterior talofibular ligament (ATF) and the
calcaneofibular ligament (CF) are stretched (Wolfe). Grade II ankle sprains generally
consist of a tearing of the anterior talofibular ligaments and stretching of the
calcaneofibular ligaments. During a grade III lateral ankle sprains both the anterior
talofibular ligaments and the calcaneofibular ligaments rupture completely and the
posterior talofibular ligaments (PTF) tears partially (Wolfe).
The purpose of this case study is to show just how easily the athlete sprained her
ankle and how easy it was in this case to diagnose her injury. Her initial symptoms could
be described as “textbook” and upon giving the athletic trainer her pain description it was
very obvious what her injury was.
On August 21, 2006, a female soccer player came into the athletic training room
to be treated for her ankle that she had hurt the previous day during practice. The athletic
trainers immediately noticed that she was walking with a pretty significant limp.
During practice the day before, the athlete and her team were scrimmaging. She
sprinted down the side line for a ball but stopped short sideways to retrieve it. The
athlete reported that her right ankle “just kind of gave out” and it rolled “down and in”.
There was immediate pain, but she continued to play and completed the sprint work at the
end of practice. The athlete has sprained her ankle before and has fractured her right
ankle in 2001.
Upon inspection of the right ankle, they found that there was a lot of swelling
and ecchymosis, but no deformity was noticed. The athlete had pain on the lateral
malleolus and the peroneal tubercle. She did not have pain however when the athletic
trainer palpated her fibula, tibia, or the head of the metatarsal. She also had a
considerable amount of pain during the palpation of her ATF, CF and PTF. She did not
have discomfort over her deltoids or her tibia fibula joint.
She was first asked to actively move her ankle so the athletic trainer could
examine what range of motion (ROM) her ankle still had. She was able to evert her foot
fully with no pain but her inversion was weak and very painful. Upon dorsiflexion she
displayed full ROM with pain, but her plantar flexion was very weak and very painful.
She displayed full and painless ROM during passive dorsiflexion and eversion. Her
passive plantar flexion was able to reach full ROM but it was painful. Inversion was
weak upon passive ROM and it was painful as well. There was no real strength deficits
however, her weakest motion being a 3 out of 5 in plantar flexion and inversion. The
athletic trainer then got a positive outcome on their anterior drawer test, posterior drawer,
and talor tilt.
The athletic trainer’s impression was that the athlete has a grade 2 lateral ankle
sprain, and referred the athlete to an orthopedic doctor to be sure that there were no
fractures. Before the athlete left the facility, she was given a boot and crutches and was
instructed to use the crutches for three days. She was also asked to do some
strengthening exercises. She was kept with in a pain free ROM. After the crutches were
returned she was required to continue to wear the boot for one month. During this time
the ankle was too swollen to perform any rehab. The x rays confirmed that there was
nothing broken in her foot.
After the boot came off, the athlete was given an active ankle brace and was
started on a strengthening program. She was experiencing some clicking in the lateral
portion of the ankle, but it was not painful. One month after she had initially sprained her
ankle, the athletic trainers started her strengthening program with some light jogging and
many balance exercises. She was asked to stand on the involved leg while on blue foam
and was required to catch a medicine ball. The athlete did a great deal of exercises with
the IT bands. She was also asked to stand in the middle of a star with points in all
direction from her foot. She had to stand on the involved foot and hop from the center to
each point, returning to the center before moving on to the next point. This helped her
regain proprioception. One week later she was able to return to practice, and she was
given a ball and asked to do some dribbling skills. She was allowed to take shots on goal
with her bad foot, although this was not an easily completed task. Before returning to
practice, she was asked to perform some functional skills to see if her ability level would
allow her to join the team. She had to demonstrate that she could do sprints and that she
was able to backpedal, with out pain or instability. Once she proved that she was ready
she was able to rejoin the team.
Ankle sprains are very common in the athletic world, and athletic trainers are very
likely to see multiple cases with in their career. Once an athlete has sprained their ankle,
they are very likely to re-sprain it with reoccurrence rates estimated to be as high at 80%
(Hertel). Most ankle sprains will be easily diagnosed just like the one that is written
about here. In order to properly identify an ankle sprain, the athletic trainer must take a
detailed history including the mechanism of injury, what was heard at the time of the
incident, and whether or not the patient has injured it before and they must carefully
inspect the foot and ankle for other deformities and underlying causes of pain such as
According to the Ottawa rules, there are certain circumstances that require
recommendation to an orthopedist for radiology. These rules say that if the patient
presents with an injury with in 10 days of initially hurting it and has pain in the distal and
posterior tibia or fibula or is unable to weight bare after the injury, then an x ray should
be obtained to rule out a fracture (Wolfe). This reduces unnecessary x-rays and reduces
the cost and waiting time for patients and allows the doctors to focus on the necessary
cases (Wolfe). They should also be obtained if there is bone tenderness over the base of
the 5th metatarsal or the navicular bone (Wolfe).
Because the likely hood of re-spraining the ankle is so high, rehabilitation and
strength training become very important. Athletes who sprain their ankle now have a
weaker joint and less stability than an athlete who has never sprained their ankle. The
injured athlete must make sure that their ankle is even stronger than it was before to
increase the likelihood that they will not re-injure the joint. Rehabilitation programs
should include a proprioceptive component as well as strength training. This will help
promote “joint dynamic and functional stability.” (Lephart)
Wolfe, Michael W., Uhl, Tim L., Mattacola, Carl G., McCluskey, Leland C. (2001,
January). Management of Ankle Sprains. American Family Physician, 63(1).
Hockenbury, R. Todd, Sammarco, G. James. (2001, February). Evaluation and
Treatment of Ankle Sprains. The Physician and Sports medicine, 29(2).
Beynnon, Bruce D., Murphy, Darlene F., Alosa, Denise M. (2002, October-December).
Predictive Factors for Lateral Ankle Sprains: A Literature Review. Journal of
Athletic Training, 37(4).
Hertel, Jay, Buckley, W.E., Denegar, Craig R. (2001, October – December). Serial
Testing of Postural Control After Acute Lateral Ankle Sprain. Journal of Athletic
Lephart, S.M., Pincuvero, D.M., Giraldo, J.L., Fu, F.H. (1997). The role of
proprioception in the management and rehabilitation of athletic injuries. The
American Journal of Sports Medicine, 25(1).
A Case Study of a Lateral Ankle Sprain.
Pathology and Evaluation I