LATERAL ANKLE SPRAIN IN ATHLETES: What the current research evidence really suggests

Ankle Sprains: More Than Just a “Simple Twist”

A sudden roll, a sharp twist, and Boom! Your game is on pause. Ankle sprains are often dismissed as minor bumps in everyday life, but in the world of sports, they can be a game-changer. What starts as a sudden twist can sometimes lead to long-term problems like repeated sprains, persistent instability, or even end up in surgery if not properly managed.

Fast-paced sports like football, basketball, netball, and handball put athletes at risk of ankle sprains, with rapid cuts, jumps, and sudden stops pushing the ankle to its limits. Around 75% of these injuries target the lateral ligaments, making them the most common ankle injury in football.

In this blog, we’ll take you through everything you need to know about ankle sprains, from assessment, early diagnosis, rehab strategies, to return-to-sport decisions. Understanding the latest evidence can guide you to protect your ankles and get back in the game smarter and faster by understanding the difference between a quick recovery and a lingering problem.

The Assessment

History matters the most:

A thorough history is the cornerstone of every assessment. Understanding the story behind the injury can reveal a lot and often provides critical insights. A careful assessment can uncover key information, such as:

Mechanism of injury – Was the ankle twisted, subjected to a fall, or hit directly?
Weight-bearing capacity – Were you able to stand or walk immediately after the injury?
Sensations during the injury – Did you hear a popping sound or experience instability in the joint?
Previous injuries– Have you had prior sprains or ankle problems that could affect recovery?
Red flag symptoms – Are you experiencing locking, catching, numbness, or tingling, which may indicate more serious complications?

A well-documented history, combined with a structured physical exam, often offers more diagnostic value than imaging alone, guiding effective and timely care.

Ottawa Ankle Rules (OAR):

The Ottawa Ankle Rules help doctors decide if an ankle X-ray is necessary. According to OAR, radiological imaging is recommended only when a patient has:

Pain around the posterior edge or tip of the lateral malleolus (outside of the ankle), or
Pain around the posterior edge or tip of the medial malleolus (inside of the ankle).
Inability to bear weight – Not being able to walk four steps, both right after the injury and during the examination at the hospital.

Why Do These Rules Matter?

According to a systematic review, OARs have consistently demonstrated high sensitivity in ruling out ankle fractures, making them a reliable first-line screening tool. So, they are helpful for:

Reducing unnecessary X-rays – Avoid over-testing and extra radiation when it’s not needed.
Speeding up care – Faster decision-making helps patients get the right treatment sooner.
Co-relating with clinical judgment – When combined with professional expertise, OAR ensures safer, smarter care.

Use of special tests: What You Need to Know

Accuracy is limited – No single test consistently delivers accurate, reliable or valid results.
Some tests are useful but never in isolation – A 2022 systematic review by Smith J, et al. shows that Anterior drawer, anterolateral palpation, and reverse anterolateral drawer have either good sensitivity or specificity, but aren’t definitive on their own.
Clinical expertise is key – Tests should be interpreted alongside the patient’s history and symptoms to ensure a more accurate diagnosis and effective care. (2)

The Imaging

Know when to Image

X-ray: Only when OAR is positive
Ultrasound: Dynamic, cost-effective, and good for visualising ligament tears, joint effusion, or peroneal tendon pathology.
MRI: Gold standard if symptoms persist beyond 4–6 weeks or when suspecting osteochondral lesions, syndesmotic injuries, or unexplained instability.

Start with clinical judgment and OAR. Escalate to imaging only when red flags or persistent dysfunction suggest “something more than a sprain”.

The Treatment

Does Ice Actually Help?

Clinician’s note: Ice has long been prescribed to reduce pain and swelling. But a 2021 systematic review found no clear benefit for pain, swelling, range of motion, or function compared with other treatments.

Athlete’s Takeaway: Ice may provide temporary relief from pain, but it doesn’t speed up healing or prevent further injury. Use it for comfort if needed, but focus more on structured rehab and movement rather than relying on cold therapy alone. (3)

What About Compression Bands?

Clinician’s note: Compression bandages have been widely used in the past, but current research does not support them as a standalone treatment for acute ankle sprains. While compression may offer subjective support, it does not improve clinical outcomes.

Athlete’s Takeaway: Compression wraps may provide a sense of support, but they won’t necessarily speed up your recovery. So, focus on active rehabilitation and movement instead. (4)

Should I Do Weight-Bearing or Not?

Clinician’s Note: Strong evidence supports early, supported weight-bearing even in Grade III injuries. Early weight bearing using aids like lace-up or semi-rigid braces encourages faster pain reduction, mobility, and swelling control compared to rigid immobilisation.

Athlete’s Takeaway: Start walking as soon as it feels safe, with support if needed. The sooner you move, the better your recovery. (5)

So, what can be done?

As per the Clinical Practice Guidelines 2021,

✅ Strongly Advised

– Early protected activity: Gradual return to function with the help of external support (semi-rigid braces, taping) if needed in the early phase, but it isn’t a long-term solution.

– Early supervised rehabilitation: Therapeutic exercises for strength, balance, and coordination speed recovery and reduce time away from sport. Careful monitoring ensures better outcomes.

– Tailored rehab program: Customised to the individual’s injury, goals, and recovery; progression guided by symptoms

➖ Can Be Considered

– Manual therapy & joint mobilisation: Offers short-term relief when combined with exercises, but shouldn’t be used alone.

❌ Not Necessary

– Electrotherapy, diathermy, ultrasound: Limited and inconsistent evidence; should only be used as adjuncts, not as core treatments.

– Long-term immobilisation: Rarely needed except in severe injuries or fractures; delays functional recovery. (6)

When do I have to consider surgery?

Surgery is considered when severe ankle instability or failed conservative rehab prevents patients from returning to their desired activities. It’s most commonly recommended for chronic lateral ankle instability (CLAI), where repeated sprains lead to persistent instability, reduced performance, and impaired function. As indicated in a systematic review, surgery offers excellent outcomes, with most athletes returning to sport within a few months, but factors like age and BMI must be considered, and recovery should also address psychological readiness and sport-specific rehab for the best long-term results. (7)

The Return To Sports

Returning to sport after an ankle sprain is often the biggest milestone for athletes, and is also the stage with the highest risk of re-injury if not handled carefully. Current evidence-based approaches ensure that athletes don’t just return quickly, but return safely, with reduced risk of setbacks and stronger long-term performance.

PAASS framework:

The PAASS framework provides a structured, evidence-based approach for guiding return-to-sport decisions following an acute lateral ankle sprain developed through an international multidisciplinary consensus using the Delphi method. (8)

Category	What to Assess	Observable Factors / Cut-offs
P – Pain severity	Pain during sport participation Pain over the last 24 hours	Pain > 4/10 during activity Pain persists > 24–72 hours → may indicate incomplete healing
A – Ankle impairments	Ankle range of motion (dorsiflexion, plantarflexion, inversion, eversion) Ankle muscle strength, endurance, and power	Dorsiflexion < 20–25° Plantarflexion < 30–40° Strength deficit > 20% compared to non-injured limb Power deficit > 15–20%
A – Athlete perception	Perceived ankle confidence/reassurance Perceived ankle stability Psychological readiness to return to sport	Self-reported readiness scale < 7/10 Avoidance of cutting or jumping drills Fear of reinjury interfering with performance
S – Sensorimotor control	Proprioception Dynamic postural control and balance	Single-leg stance < 30 seconds SEBT anterior reach < 4 cm deficit compared to uninjured limb Poor corrective reactions during perturbations
S – Sport / Functional performance	Hopping and jumping ability Agility Sport-specific activities	Ability to complete a full training session without symptoms Limb Symmetry Index (LSI) < 90% Inability to perform or compensations in: – Single-leg hop for distance – Triple hop – Side hop test – Agility T-test Unable to train at full intensity

Ultimately, return-to-sport decisions after an ankle sprain should be guided by a comprehensive, multidimensional assessment rather than relying on a single test or measure. Frameworks like PAASS remind clinicians to consider pain, functional impairments, sensorimotor control, athlete confidence, and sport-specific performance together and never based on time alone. Combined with clinical judgment and individualised rehab progress, this approach ensures safety and supports a confident, sustainable return to play.

Is the limb symmetry index enough for decision-making?

While the Limb Symmetry Index (LSI) has long been used to guide return-to-sport decisions, recent evidence suggests it cannot tell the full story on its own. Athletes can achieve symmetrical scores yet still have subtle deficits in balance, agility, or power that increase re-injury risk.

To make return-to-sport decisions safer and more individualised, LSI should be combined with functional performance testing, including

Y-Balance Test
Star Excursion Balance Test
Single Leg Squat
Side Hop Test
Figure-of-8 Hop
Modified Agility T-Test
Single Hop for Distance
Triple Crossover for Distance

Research evidence advocates that this multidimensional approach captures both strength and movement quality, ensuring better accurate evaluation of readiness for returning to play. (9)

The Prognosis

Most patients can experience pain relief and improved function within two weeks after a lateral ankle sprain, but recovery can vary. Studies show that 5–33% still experience pain after one year, and 5–25% have symptoms even after three years. Around 50–85% fully recover within three years, regardless of the sprain’s severity. Persistent instability beyond a year may lead to chronic ankle instability, affecting up to 33% of cases. Early, structured rehabilitation is the strongest factor in determining long-term recovery rather than the initial injury severity. (6)

The Risk of Re-injury

Recurrent ankle sprains are a common challenge, especially for athletes returning to sport after an initial injury. The report says that several factors may influence this risk, such as

Higher BMI
Delayed or insufficient rehab
Persistent ankle instability
Poor pain management (10)

Gender-Specific Risk Factors:

What’s more interesting is that the risk factors differ between men and women

Men: Weak hips, poor balance, higher body weight
Women: Limited ankle strength

These insights highlight the need for gender-specific assessments and tailored prevention strategies, helping athletes break the cycle and stay strong, confident, and injury-free. (11)

Personalisation is the Key:

Even though recent studies strongly recommend exercise-based rehabilitation significantly lowers the risk of re-injury compared to usual care, it’s never a one-size-fits-all approach. The type, intensity, volume, frequency and type of exercises need to be tailored to each person’s unique needs to ensure the best and safest return to sport. (12)

The Wrap Up

Ankle sprains may seem simple, but the journey from injury to safe return to sport is far from straightforward.

Successful recovery is not just about exercises; it’s about holistic care, which means addressing not only strength, balance, and movement quality, but also rest, sleep, nutrition, mental readiness, and other lifestyle habits that influence healing and recovery.

The key is listening to the body, following structured rehabilitation, and making every decision thoughtfully. With the right combination of exercises, guidance, supportive strategies, and overall wellness, most people can recover completely, prevent future injuries, and regain confidence in their activities and sports.

Every ankle has its own story. Approach it wisely, progress steadily, and you’ll not only heal, but also come back stronger and more resilient.

HAPPY LEARNING

References

Gomes, Yolanda E., et al. “Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis.” BMC musculoskeletal disorders 23.1 (2022): 885.
Beynon, Amber et al. “Reliability and validity of physical examination tests for the assessment of ankle instability.” Chiropractic & manual therapies vol. 30,1 58. 19 Dec. 2022, doi:10.1186/s12998-022-00470-0
Miranda, Júlio Pascoal et al. “Effectiveness of cryotherapy on pain intensity, swelling, range of motion, function and recurrence in acute ankle sprain: A systematic review of randomised controlled trials.” Physical therapy in sport: official journal of the Association of Chartered Physiotherapists in Sports Medicine vol. 49 (2021): 243-249. doi:10.1016/j.ptsp.2021.03.011
Borra, Vere et al. “Compression Wrapping for Acute Closed Extremity Joint Injuries: A Systematic Review.” Journal of athletic training vol. 55,8 (2020): 789-800. doi:10.4085/1062-6050-0093.20
Halabchi, Farzin, and Mohammad Hassabi. “Acute ankle sprain in athletes: Clinical aspects and algorithmic approach.” World Journal of Orthopaedics vol. 11,12 534-558. 18 Dec. 2020, doi:10.5312/wjo.v11.i12.534
Martin, Robroy L et al. “Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021.” The Journal of Orthopaedic and Sports Physical Therapy, vol. 51,4 (2021): CPG1-CPG80. doi:10.2519/jospt 2021.0302
Wang, YuChia et al. “Ankle ligament reconstruction-return to sport after injury scale and return to sports after ankle ligament reconstruction or repair-A systematic review.” Journal of experimental orthopaedics vol. 11,3 e12077. 2 Jul. 2024, doi:10.1002/jeo2.12077
Smith, Michelle D et al. “Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework-an international multidisciplinary consensus.” British journal of sports medicine vol. 55,22 (2021): 1270-1276. doi:10.1136/bjsports-2021-104087
Flore, Zacharias et al. “Return to Play Assessment After Lateral Ankle Sprains – German Male Elite Youth Football (Soccer) Academy Baseline Data.” International journal of sports physical therapy vol. 19,8 976-988. 1 Jul. 2024, doi:10.26603/001c.120201
Wikstrom, Erik A et al. “Lateral Ankle Sprain and Subsequent Ankle Sprain Risk: A Systematic Review.” Journal of athletic training vol. 56,6 (2021): 578-585. doi:10.4085/1062-6050-168-20
Mason, Joel et al. “Intrinsic Risk Factors for Ankle Sprain Differ Between Male and Female Athletes: A Systematic Review and Meta-Analysis.” Sports medicine – open vol. 8,1 139. 18 Nov. 2022, doi:10.1186/s40798-022-00530-y
Wagemans, Jente et al. “Exercise-based rehabilitation reduces reinjury following acute lateral ankle sprain: A systematic review update with meta-analysis.” PloS one vol. 17,2 e0262023. 8 Feb. 2022, doi:10.1371/journal.pone.0262023

Azarudheen

Azarudheen is a passionate physiotherapist and exercise prescriptor with a deeply rooted belief in the transformative power of movement and education. His journey began in 2013 as a first-year physiotherapy student, balancing academics with part-time work to support his ambitions. Early in his career, he sought practical experience and began working at a fitness center, eventually transitioning into roles that expanded his knowledge and skill set in both clinical practice and teaching.

Driven by a relentless curiosity and desire for growth, Azarudheen took on an anatomy tutor position, believing in the value of continuous learning. A pivotal turning point came with his experience in cardiopulmonary rehabilitation at PSG Hospitals, where he worked closely with lung transplant patients. This experience emphasized the life-changing impact of functional movement and patient education, inspiring him to dive deeper into respiratory and cardiovascular physiology.

With strong support and belief in his vision, Azarudheen pursued a Master’s in Exercise and Sports Science at Manipal University—choosing it over conventional MPT programs to focus more on biomechanics, exercise physiology, strength and conditioning, and lifestyle health. His dedication was evident as he spent late nights at the library, worked part-time in gyms and cricket academies, and honed his craft through practical application.

In 2022, despite initial doubts, he opened his first clinic in his hometown—an act of courage and self-belief supported by his family and mentors. Built from the ground up, this clinic marked the start of a new era. Today, Azarudheen leads a growing team of 21 physiotherapists across two thriving clinics in Chennai and Coimbatore. His philosophy centers on patient education, movement optimization, and professional growth, and he continues to evolve both as a clinician and a leader.

Azarudheen’s journey reflects the power of perseverance, vision, and lifelong learning. He is not only a practitioner but also a mentor and advocate for a more thoughtful, movement-centered approach to healthcare.