Sprain injuries to the ankle joint

Anatomy: What can be affected when twisting an ankle

The ankle joint consists of the upper (OSG) and lower ankle joint (USG). Bones, capsules and ligaments as well as the muscles provide stability. During the typical “inward twisting” (inversion/supination), the outer ligaments in particular are stressed.

• External ligament complex: anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), posterior talofibular ligament (PTFL)
• Inner band (Delta band): stabilizes the inside of the OSG
• Syndesmosis: Ligament connection between the tibia and fibula above the ankle joint (important for fork stability)
• Peroneal tendons (fibularis tendons): dynamic stabilizers on the outside
• Talus cartilage/bone: with severe trauma, risk of osteochondral lesions (OCL)

What is a sprain injury?

A sprain injury is a sudden, unphysiological movement of the ankle joint with overstretching or tearing of ligament structures. In around 80-90% this affects the outer ligaments by bending inwards. Injuries to the syndesmosis (“high ankle sprain”) or the medial ligament (eversion) occur more rarely.

• Grade I: overstretching, no instability
• Grade II: Partial tear with moderate swelling/pain, beginning instability
• Grade III: complete tear, significant instability; Concomitant injuries possible

Typical symptoms

• Acute pain on the outer ankle (less often on the inside or higher on the front of the lower leg in the event of a syndesmosis injury)
• Rapid swelling and bruising
• Pain on exertion, limping, possibly inability to walk 4 steps
• Feeling of “folding away” or instability
• Cracking or tearing noise at the moment of the accident (not proof of a crack)

Causes and risk factors

• Sports with changes of direction/jumps (football, basketball, handball, trail running)
• Uneven ground, incorrect footwear
• Previous sprain injuries, inadequately trained proprioception
• Ligament laxity, foot deformities (e.g. hollow foot, varus heel)
• Muscular fatigue, lack of warm-up

Diagnostics: Clinical, imaging, evidence-based

Diagnosis is based on history, clinical examination and, if necessary, imaging. The aim is to rule out fractures, assess the extent of the ligament injury and identify relevant accompanying injuries.

• Clinical tests: anterior drawer test (ATFL), talar tilt (CFL), external rotation/squeeze test (syndesmosis)
• X-ray if fracture is suspected according to established decision-making rules (e.g. Ottawa Ankle Rules)
• Ultrasound: Assessment of ligament continuity and effusion, dynamic tests possible
• MRI: in case of unclear findings, persistent symptoms, suspected osteochondral lesion (OCL), tendon/syndesmosis damage
• Rare: functional/stress images, especially in unstable injuries

Differential diagnoses and accompanying injuries

• Fracture of the lateral malleolus or medial malleolus, base fracture of the 5th metatarsal bone
• Syndesmosis injury (“high ankle sprain”)
• Osteochondral lesion of the talus (cartilage/bone damage)
• Peroneal tendon injury or dislocation
• Torn ligaments of the tarsus (e.g. near Chopart/Lisfranc)
• Impingement syndrome after repeated sprains

Severity levels and classification

The practical classification into grades I–III guides therapy planning. In addition, a differentiation is made according to location (lateral, medial, syndesmosis). If there is significant mechanical instability or pain higher up (above the ankle joint), the likelihood of significant ligament injuries, including syndesmosis, increases.

First aid: The PECH rule (first 24-48 hours)

Painkillers can help in the short term, but should be tailored to the individual. If there is a significant misalignment, severe swelling, numbness or inability to stand, please seek medical advice promptly.

Therapy: First conservative and functional

Most sprain injuries heal well with consistent conservative treatment. The focus is on early functional stabilization, swelling management and the gradual development of mobility, strength and coordination.

• Short-term immobilization depending on the pain (e.g. walkers/boots for higher degrees), otherwise early functional mobilization
• Orthosis or functional tape 2-6 weeks, longer depending on the sport
• Physiotherapy: mobility (dorsiflexion), strengthening v. a. Peroneal muscles, proprioception/balance training
• Gradual increase in load: pain-adapted full load as soon as possible
• Secondary prevention: balance pad, jump/landing control, sensorimotor training
• Adaptation to work/everyday life: short-term relief, if necessary aids (crutches) in the early phase

If you are immobilized for a longer period of time, we individually check the risk of thrombosis and any prophylaxis. Self-exercise and education are crucial to preventing relapses.

When does an operation make sense?

Surgery is the exception. In our practice, it is only recommended after careful diagnosis and when there is a clear indication - especially if conservative measures have been exhausted or there is structural instability.

• Marked mechanical instability with failure of conservative therapy
• Syndesmosis rupture with diastasis (surgical stabilization)
• Avulsion fractures or relevant accompanying fractures with displacement
• Repeated sprains with chronic instability (e.g. ligament reconstruction, Broström-like procedures)
• Accompanying osteochondral lesion of the talus with persistent discomfort (arthroscopic therapy)

The aim of surgical measures is to restore stability, not to “heal faster”. The postoperative course includes protected mobilization, physiotherapy and a sport-specific return according to objective criteria.

Rehabilitation and return to everyday life, work and sport

• Everyday life: early, pain-adapted full weight bearing promotes healing
• Office work: usually possible after a few days; Standing/walking activities may be delayed
• Sport: depending on the degree - light cycling/swimming after 1-2 weeks, jogging 3-6 weeks, change of direction/contact sports often 6-12 weeks
• Return-to-sport criteria: pain-free full weight bearing, full dorsi/plantar flexion, single-leg stance > 30 s, jump/landing control, side comparison of strength/balance
• Protection: Sports bandage or tape temporarily for 6-12 weeks

Course, prognosis and possible complications

Healing is individual and depends on the severity. Swelling may persist longer than the pain. Consistent rehabilitation reduces the risk of subsequent problems.

• Good prognosis for grades I–II with functional therapy
• Grade III: longer rehabilitation, mostly conservatively successful
• Complications: chronic instability, recurrent twisting, cartilage damage (OCL), impingement, tendon problems, rarely CRPS
• Relapse prevention: Proprioception training significantly reduces the risk of relapse

Prevention: How to reduce your risk

• Regular balance/coordination training
• Strengthening the peroneal muscles and foot muscles
• Sport-specific warm-up, jumping/landing training
• Appropriate footwear, if necessary a temporary ankle bandage when exercising after a recent injury
• Individual analysis of foot axes and gait

Special cases: children, competitive sports, repeated twisting of an ankle

• Children/adolescents: open growth plates – careful clinical and imaging clarification
• Competitive sports: structured return-to-play strategies, close coordination with trainer/physio
• Chronic instability: if persistent despite 3-6 months of therapy - consider further diagnostics and, if necessary, surgical stabilization

When should you see a doctor quickly?

• Inability to walk 4 steps immediately after the accident and in practice
• Significant misalignment, increasing swelling despite immobilization
• Numbness, poor circulation, severe pain at rest
• Pain above the ankle (suspected syndesmosis injury)
• Persistent symptoms > 2–3 weeks despite adequate measures

Our approach in Hamburg: Diagnose carefully, strengthen conservatively

At Orthopedics on the Alster at Dorotheenstrasse 48, 22301 Hamburg, we clarify sprain injuries in a structured manner. We combine clinical tests with targeted imaging and create an individual, conservative treatment plan. In the case of special findings (e.g. syndesmosis damage or osteochondral lesion), we transparently discuss possible surgical options - without promising a cure, with realistic expectations.

Practical tips for at home

• Cool briefly several times a day, taking breaks
• Elevate your foot and apply the compression bandage correctly
• Early, pain-free movement exercises (tightening/stretching toes, circling in the pain-free area)
• Use crutches in the early stages if necessary
• No risky sporting activities until stability and coordination are back