Treatment of acute ankle ligament injuries

Ankle sprains are among the most common injuries affecting the musculoskeletal system, especially in sports activities, where they account for approximately 15 to 20% of all injuries.

The typical mechanism of injury involves a combination of inward twisting and bending of the foot, known as inversion and adduction, while the foot is pointed downward (plantar flexion). This motion can cause damage to the ligaments on the outer side of the ankle. When the anterior talofibular ligament is injured while the inner ligaments remain intact, it can result in instability with a tendency for the ankle to rotate outward (anterolateral rotary instability). If the calcaneofibular ligament is also damaged, it can lead to tilting of the talus bone (talar tilt).

Ankle ligament sprains are often classified based on their severity. Grade I involves mild stretching of the ligaments without significant tearing or joint instability. Grade II indicates a partial tear of the ligament, resulting in moderate pain, swelling, and some level of instability. Patients may have difficulty bearing weight. Grade III is the most severe, with a complete rupture of the ligament, causing marked pain, swelling, and bruising. In grade III injuries, there is significant impairment of function and instability.

The healing process of ligament injuries typically occurs in three phases: the inflammatory phase (lasting up to 10 days after injury), the proliferation phase (occurring between the 4th and 8th week), and the remodeling or maturation phase (lasting up to 1 year after injury). However, the duration of each phase can vary from person to person.

Various treatment options are available for ankle sprains, including surgery, immobilization with casts or braces, and functional treatments such as taping or bracing combined with balance training. Currently, non-surgical approaches are often recommended by healthcare professionals for the treatment of lateral ankle sprains.

However, numerous studies have revealed that ankle sprains are more significant than commonly assumed, as many patients experience ongoing issues following the injury. These issues include persistent pain, recurring swelling, and lasting instability. Moreover, evidence suggests that athletes face twice the risk of experiencing another ankle sprain within a year after the initial injury. Surprisingly, research by Malliaropoulos indicates that even mild ankle sprains pose a higher risk of re-injury compared to severe sprains.

The frequent lack of success in treating ankle sprains might stem from overlooked associated injuries, such as damage to the syndesmosis or cartilage. Another factor could be inappropriate treatment considering the severity of the injury and its healing stages.

To determine the most suitable treatment approach, a thorough review of the literature published in the past decade was conducted. This review aimed to address the following questions:

  • Is there evidence supporting surgical or non-surgical treatment for acute ankle sprains?
  • Is functional treatment or immobilization more effective?
  • What type of external stabilization is the most effective for treating acute ankle sprains?
  • Is there evidence supporting neuromuscular training for rehabilitating acute ankle sprains?
  • Is there evidence supporting neuromuscular training for preventing ankle sprains?
  • What role does prophylactic bracing play in ankle sprain prevention?



Surgery versus non-surgery for treating new ankle sprains Presently, surgery is rarely recommended as the primary treatment for new ankle sprains. Most review articles advocate for non-surgical approaches instead.

However, a comprehensive review conducted by Cochrane revealed some benefits to surgical ligament reconstruction. Surgical intervention appeared to lower the risk of ankle injury recurrence, chronic ankle issues, and both subjective (how patients feel) and objective (measured) ankle instability. Nonetheless, the review also highlighted potential drawbacks, including longer recovery times, increased risk of ankle stiffness, reduced ankle mobility, and more complications post-surgery. Due to limitations in the quality of the studies analyzed, the effectiveness of surgery versus conservative (non-surgical) treatment for new ankle sprains remains inconclusive.

Subsequent randomized trials supported similar conclusions. Pihlajamäki and colleagues discovered that surgery reduced the likelihood of future lateral ligament injuries, but it was associated with a higher incidence of moderate osteoarthritis. Likewise, Takao and team found that relying solely on functional treatment led to around a 10% failure rate and slower return to full athletic activity compared to surgery.

Interestingly, both studies found no significant difference in clinical outcomes between surgical and non-surgical approaches.

Considering these findings, it is concluded that while surgery may offer benefits such as reduced instability and lower risk of recurrence, most grade I, II, and III ankle sprains can be effectively managed without surgery. However, surgery may still be appropriate, particularly for athletes or individuals with significant instability. Additionally, surgery might be considered for extensive grade III injuries involving all three lateral ankle ligaments with significant swelling.


Does it help to keep moving or to keep still after an ankle sprain?

Research conducted by Kerkhoffs and colleagues provides insights into this question. They analyzed data from 21 trials involving over 2,000 participants and found that keeping active (functional treatment) seems to be better than long-term rest (immobilization) for treating new ankle sprains. However, these findings should be taken cautiously as some differences were not significant when low-quality trials were excluded. Additionally, there was a wide range of functional treatments evaluated.

Recent studies also suggest that for severe grade III injuries, a short period (around 10 days) of wearing a below-knee cast may be beneficial.

Why might resting in a cast for a short time be helpful? Initially, it may help reduce swelling and pain during the early healing phase. However, prolonged immobilization could hinder the healing process later on. The principle of causal histiogenesis suggests that some stress is needed for tissues to remodel properly. Extended immobilization can also negatively affect muscles, ligaments, and joint surfaces.

As a result, many experts recommend a focus on reducing swelling and preventing further injury during the initial inflammatory phase. The RICE method (Rest, Ice, Compression, and Elevation) is often recommended for the first few days to manage pain and swelling. Following this, a short period (usually 5-7 days, maximum 10 days) of immobilization in a below-knee cast or removable boot may be beneficial.


What’s the best way to support your ankle after a sprain?

For most ankle sprains, doctors agree that surgery isn’t usually needed.

During the healing process, it’s important to protect your ankle from further strain. This helps the tissue grow back stronger. It’s also important to keep your ankle moving to prevent stiffness and weakness.

There are a few options for supporting your ankle externally: bandages, tape, lace-up braces, and semi-rigid ankle supports. Research suggests that using an elastic bandage has fewer complications than tape, but it might take longer to return to normal activities. Lace-up braces can help reduce swelling in the short term compared to other supports.

Recent studies show that semi-rigid ankle braces are effective for short-term relief. They can even help people with mild to moderate sprains get back to walking and climbing stairs sooner than other supports.

Overall, it seems that semi-rigid ankle braces provide the best protection during the healing phase. For more severe sprains, a semi-rigid brace is usually recommended after a short period of immobilization.


Is balance training helpful for treating ankle sprains?

Decades ago, experts believed that training to improve balance and coordination might help with ankle injuries. More recent research suggests that this type of training could have benefits for the body’s sensorimotor system.

However, there’s still uncertainty about how well balance training works for ankle sprains. Some early studies didn’t find much evidence to support it. But more recent studies have shown promising results.

For example, two recent trials found that people who did balance exercises had fewer sprains in the year following their injury.

But not all studies agree. Some research didn’t find a difference in sprain rates between people who did balance training and those who didn’t. However, these studies did show that exercise could help improve ankle function and activity levels.

One large study found that a home-based balance training program reduced sprains, especially in people who followed the program closely.

So, while the evidence isn’t crystal clear, it seems that balance training could be worth trying after an ankle sprain to help prevent future injuries.

Is balance training helpful for preventing ankle sprains?

A study from 2001 suggested that athletes who had previous ankle sprains might benefit from doing exercises to improve their balance on a special disk.

In the review, studies published between 2002 and 2012 were analyzed. Two of these studies focused on preventing ankle sprains using balance training. They found that athletes who had previous ankle sprains had fewer sprains after doing balance exercises. But for athletes without a history of ankle sprains, the results were less clear.

These studies suggest that balance training could help prevent ankle sprains, especially for athletes who have had sprains before. But more research with larger groups of people is needed to confirm these findings.

The reason previous sprains increase the risk of more sprains is likely because they can affect how well you sense your ankle’s position. Some studies have shown that people with previous sprains have slower reaction times and poorer balance. So, improving these skills through training could help prevent future injuries.

In summary, the studies from 2002 to 2012 suggest that balance training might reduce the risk of ankle sprains in athletes who’ve had previous injuries.

Is using a brace helpful in preventing ankle sprains?

Studies have shown that wearing lace-up braces can reduce the number of ankle injuries in sports like football and basketball, but they don’t necessarily make the injuries less severe. One study compared using braces to taping ankles in high school football players and found that both methods had similar rates of ankle sprains, but using tape was less cost-effective.

These findings support what a meta-analysis from 2001 found: wearing ankle braces can lower the risk of ankle sprains during activities where the risk of injury is high, like soccer and basketball.

In summary, based on well-conducted studies, using a brace can be effective in preventing ankle sprains.



Balancing the advantages and disadvantages of surgical and non-surgical treatment, the majority of grades I, II, and III lateral ankle ligament ruptures can be managed without surgery. The indication for surgical repair should be always made on an individual basis. This systematic review supports a phase adapted non-surgical treatment of acute ankle sprains with a short-term immobilization for grade III injuries followed by a semi-rigid brace.
Types I and II injuries might best be treated with a semi-rigid brace. Neuromuscular training should support functional rehabilitation after ankle sprain. Balance training is effective for the prevention of resprains of athletes with previous sprains. Braces are also effective for the prevention of ankle sprains in athletes. More prospective randomized studies with a longer follow-up are needed to find out what type of non-surgical treatment has the lowest resprain rate.


A seasoned orthopedic surgeon and foot and ankle specialist, Dr. Mohammad Athar welcomes patients at the offices of Complete Orthopedics in Queens / Long Island. Fellowship trained in both hip and knee reconstruction, Dr. Athar has extensive expertise in both total hip replacements and total knee replacements for arthritis of the hip and knee, respectively. As an orthopedic surgeon, he also performs surgery to treat meniscal tears, cartilage injuries, and fractures. He is certified for robotics assisted hip and knee replacements, and well versed in cutting-edge cartilage replacement techniques.
In addition, Dr. Athar is a fellowship-trained foot and ankle specialist, which has allowed him to accrue a vast experience in foot and ankle surgery, including ankle replacement, new cartilage replacement techniques, and minimally invasive foot surgery. In this role, he performs surgery to treat ankle arthritis, foot deformity, bunions, diabetic foot complications, toe deformity, and fractures of the lower extremities. Dr. Athar is adept at non-surgical treatment of musculoskeletal conditions in the upper and lower extremities such as braces, medication, orthotics, or injections to treat the above-mentioned conditions.