Sprained Ankle Syndrome: Prevalence

and Analysis of 639 Acute Injuries

Lawrence Fallat, DPM, Douglas J. Grimm, MS, DPM, and Joseph A. Saracco, DPM
The ankle sprain is often thought of as an injury involving only the lateral ankle ligaments. Frequently
other structures are also injured. However, the literature describes only some of the associated injuries.
The authors feel that a thorough analysis of each structure injured with the inversion and eversion ankle
sprain along with the incidence would be invaluable in making an accurate diagnosis and providing
appropriate treatment. The authors conducted a prospective study using a standardized evaluation
during the initial examination of patients reporting with an ankle sprain. Over a 33-month period, 639
patients were studied at Oakwood Hospital Downriver Center Emergency Room and Occupational
Medicine Clinic. Of the 639 patients, 92 had an associated avulsion or compression fracture of the
foot or ankle. Of the remaining 547 patients, the anterior talofibular ligament was injured 453 times,
the calcaneal fibular ligament was injured 366 times, and the posterior talofibular ligament was injured
187 times. Injuries to the ankle joint capsule were noted in 180 cases, the extensor digitorum brevis
was involved in 111 cases, the sinus tarsi was involved in 88 cases, the peroneal tendons in 83 cases,
the Achilles tendon in 67 cases, the calcaneal-cuboid ligament in 41 cases, and the syndesmosis was
injured in 31 cases. Additionally, neuritis was seen in 80 patients presenting with a sprained ankle.
Because of the varied and multiple components to the common sprained ankle, the authors feel that
this condition would more appropriately be designated as the sprained ankle syndrome. The findings of
this study may aid the examiner in exploring a more knowledgeable approach in evaluation, leading to
an accurate diagnosis and appropriate treatment. (The Journal of Foot & Ankle Surgery 37(4):280-285,
1998)
Key words: ankle injuries, ankle sprain, capsulitis, neuritis, tendinitis

The ankle is one of the most commonly injured joints

in the body due to the forces applied and the body
weight it supports. The ankle bears more weight per unit
area than any other joint in the body (1). The sprained
ankle is the most common injury in sports, consisting
of 38%-45% of all injuries (2-6). Most studies point to
basketball as the most common athletic cause of injury.
However, the most common cause of injury in any given
geographical region varies with the prevailing athletics
of that region, as others have reported soccer, skiing,
cross-country running, and falls from heights as the main
culprits (7 -9). People are spending more time engaged in
physical activity, whether it is for competitive or recreational purposes (10). Inversion ankle sprains have been
estimated at 1 per 10,000 persons per day (5, 11, 12),
with 1 million people presenting to emergency rooms,
clinics, and offices each year with acute ankle injuries
(13). Jackson et a1. found this to be the most common
From Podiatric Surgical Residency Program, Oakwood Healthcare
System, Dearborn, MI. Address correspondence to: Lawrence Fallat,
DPM, 20555 Ecorse, Taylor, MI 48180.
Received for publication October 1997; accepted in revised form for
publication March 1998.
The Journal of Foot & Ankle Surgery 1067-2516/98/3704-0280$4.00/0
Copyright 1998 by the American College of Foot and Ankle Surgeons

280

THE JOURNAL OF FOOT & ANKLE SURGERY

injury at the United States military academy, West Point,

with one-third of the cadets spraining an ankle during
their 4 years there (14). Reported injury rates probably
underestimate the true injury rate (15). The sprained ankle
has been commonly described as a result of stretching
or tearing of the fibers of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL), occurring as a result of
excessive supination and inversion of the plantarflexed
foot while the tibia is externally rotated (16). The most
common approach to ankle sprain management consists
of rest, ice, compression, and elevation, with gradual
resumption of mobilization. Complete rehabilitation has
been reported to take 36-72 days with a cost range of
$300-$900 per patient not considering surgery (13). It has
been estimated that the evaluation and treatment of ankle
injuries may amount to annual aggregate dollar charges
of approximately 2 billion dollars, an amount comparable
with that spent for coronary artery bypass graft surgery
(17). Many simple ankle sprains resolve with this conservative approach while others linger on with persistent
pain, weakness, and other symptoms of functional instability, with the literature reporting one-third to 40% of
patients having residual symptoms (18). There is also
evidence that a chronically unstable ankle will lead to

degenerative changes in the ankle joint (19). Previous

ankle sprains may predispose to future injury (3, 20).
In addition to the ankle ligaments, which are often
solely implicated, the patient should be evaluated for
concomitant injuries. These may include fractures, softtissue sprains, muscle strains, or neuritis. Frequently,
a diagnosis is made based on a single injury, when
in fact several anatomical structures may be damaged.
Without considering the components of the syndrome, an
incomplete diagnosis can be made, resulting in suboptimal
or inappropriate treatment. This may result in incomplete
healing, recurrence of injury, or chronic pain and edema.
Various studies have reported a high recurrence rate of
ankle injuries.
There are more components to the sprained ankle than
injury to the lateral collateral ligaments. By completing a
thorough evaluation at the initial visit, these components
may be differentiated. The acutely twisted ankle would
more appropriately be termed "sprained ankle syndrome,"
due to multicomponent involvement of osseous injury,
sprained ligaments, strained muscles, and neuritis, all
of which are most often underrepresented in current
literature. The purpose of this prospective study is to
examine and record the incidence of the components of
the sprained ankle. This approach takes into consideration the additional injuries that are often observed with
the common ankle sprain. In approaching an examination
of the ankle sprain syndrome, it is necessary to evaluate
the patient for ligamentous ankle disruptions, ankle avulsion fractures, transchondral fractures, anterior calcaneal
process fractures, extensor digitorum brevis avulsions,
sinus tarsi syndrome, cuboid traction and crush fractures,
lateral talar process fractures, posterior talar process fractures, peroneal subluxation, peroneal tendinitis, Achilles
tendinitis, fifth metatarsal avulsion and base fracture, and
neuritis. Each complication of the ankle sprain syndrome
may exist solely or jointly.
Materials and Methods

The study is a prospective study over a 33-month period

starting July 1994. All patients seen at the Oakwood
Hospital Downriver Center Emergency Room or Occupational Medicine Clinic, who reported at initial examination with an acutely twisted ankle, were included in the
study. These patients were able to relate a specific traumatic event that occurred within the last week in which
the ankle was not able to support the forces exerted on
it. Excluded from the study were any patients with an
ankle fracture other than avulsions of the tibia or fibula,
or patients presenting with a chronic injury.
At initial examination, patients were evaluated according to a standardized format by Ist- and 2nd-year podiatry residents, to maximize interevaluator reliability. A

thorough sequential examination was completed over the

ankle and associated structures. Anatomical areas were
palpated in the following order: high fibula, syndesmosis,
Achilles tendon, fifth metatarsal base, extensor digitorum
brevis, calcaneal-cuboid joint, medial malleolus, deltoid
ligament, anterior capsule, syndesmosis, lateral malleolus,
PTFL, CFL, ATFL, and the sinus tarsi. Tenderness was
assessed to be present or absent for each component.
Radiographs were obtained on each patient, reviewed with
the department radiologist, and diagnosed accordingly.
Every patient had a three-view series of foot and ankle
x-rays taken consisting of an AP, oblique, and lateral
radiograph. In patients reporting high fibular pain, proximal fibula x-rays were obtained as well. Following clinical and radiographic evaluation, an appropriate primary
diagnosis was given.
Patients with a primary diagnosis of lateral ankle ligament sprain were further classified in one of three grades,
based on increasing ligamentous damage and morbidity.
A grade I sprain was defined as a stretching or attenuation of the ATFL. Clinically, patients often presented
with mild pain on palpation of the ATFL, mild edema, no
ecchymosis, and mildly restricted range of motion. The
patient is usually able to bear full weight (21). A grade II
sprain implies a complete tear of the ATFL and an additional partial tear of the CFL. Examination often shows
restricted range of motion with moderate pain on palpation of the ATFL and CFL. Additionally, moderate edema
and mild to moderate ecchymosis are observed at the level
of the ankle. The patient is usually unable to bear weight
fully on the affected limb with minimal difficulty (21).
The most severe injury is a grade III sprain, signifying
complete rupture of the ATFL and CFL. Extreme pain
on palpation of the lateral ankle is evident, usually with
severe edema and moderate to severe ecchymosis (21).
Ankle range of motion is very restricted because of
pain. The patient is usually unable to bear any weight
on the affected limb. The suspected grade III injuries
were then confirmed through use of radiographic stress
examinations, as well as ankle arthrography and surgery if
warranted. Stress x-ray views were obtained on all patients
with suspected grade III injury.
Analysis and Results

Over the 33 months of study, 639 patients had incurred

a twisting injury to the ankle and were included in the
study. There were 350 (54.8%) male patients and 289
(45.2%) female patients. The emergency room injuries
totaled 321 (50.2%), while the occupational medicine
clinic injuries totaled 318 (49.8%). The age of the patients
ranged from 4 to 85 years old, with an average age of 34
years.
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281

The left ankle was affected 308 (48.2%) times,

while the right ankle was affected 331 (51.8%) times.
Ninety-two patients (14.4%) had avulsion or compression
fractures identified radiographically, four of which had
multiple fractures. The other 547 (85.6%) patients who
were not identified to have a fracture are listed in Table 1
according to primary diagnosis.
Each anatomical structure injured was evaluated based
on pain. The frequency and incidence of each structure
damaged based on the greatest amount of pain was diagnosed as the primary injury and is listed in order of
prevalence in Table 1. Many patients were found to have
multiple-component injuries and the incidence of these
injuries is ranked in Table 2. In accessing only the lateral
ligaments, the ATFL, CFL, and PTFL were solely involved
90 (16.5%), 4 (0.7%), and 9 (1.6%) times, respectively. Of
the 547 patients, 78 (14.3%) had no significant lateralligament involvement. The most common pattern was injury to
both the ATFL and CFL, occurring in 187 (34.2%) of the
patients. All three lateral ligaments were involved in 171
instances (31.3% of the time). Figure 1 shows the incidence
of lateral ligament involvement.
Ninety-two patients presented with 96 fractures. Table 3
lists the anatomical location of fractures diagnosed.

TABLE 1 List of primary diagnosis made for the 547

patients only incurring soft-tissue injury
Primary Diagnosis

Number and Percent

of Patients

Grade 1 sprain
Grade 2 sprain
Extensor digitorum brevis strain
Eversion sprain
Grade 3 sprain
Achilles tendinitis
Peroneal tendinitis
Ankle joint capsulitis
Posterior tibial tendinitis
Syndesmotic sprain
Peroneal subluxation
Os trigonum syndrome
Symptomatic STJ loose body
Sinus tarsi syndrome

All patients with osseous injury are excluded from this chart

The most common osseous injury was fractures to the

fifth metatarsal base. This occurred in 24 (3.8%) cases.
Osseous fractures are classified in Table 3. In addition,
all 639 patients were evaluated for involvement of neuritis
associated with the twisted ankle. Of the eighty (12.5%)

PTFL alone
None
14%

2%
ATFL alone
16%

ATFL + PTFL
1%
CFL alone
1%

ATFL + CFL +
PTFL
31%
CFL + PTFL
1%
FIGURE 1

282

Incidence of lateral ligament involvement in the 547 patients without osseous injury.

THE JOURNAL OF FOOT & ANKLE SURGERY

390 (71.3%)
52 (9.5%)
32 (5.9%)
19 (3.5%)
16 (2.9%)
13 (2.4%)
12 (2.2%)
3(0.5%)
3(0.5%)
3(0.5%)
2 (0.4%)
1 (0.2%)
1 (0.2%)
0(0%)

TABLE 2 Prevalence of anatomical structures in ankle

sprains in the 547 patients without osseous injury
Structure

Number and Percent of Patients

ATFL
CFL
PTFL
Deltoid ligament
Ankle joint capsule
Extensor digitorum brevis
Sinus tarsi
Peroneals
Achilles tendon
Calcaneocuboid ligament
Syndesmosis

453 (82.8%)
366 (66.9%)
187 (34.2%)
180 (32.9%)
173 (31.6%)
111 (20.3%)
88 (16.1%)
83 (15.2%)
67 (12.2%)
41 (7.5%)
31 (5.7%)

This table gives all associated components regardless of primary

diagnosis.

patients with associated neuritis, the intermediate dorsal

cutaneous nerve (IDCN), medical dorsal cutaneous nerve
(MDCN), sural nerve, and tibial nerve were involved
61 (11.2%), 31 (5.7%), 16 (2.9%), and I (0.2%) times,
respectively. Twenty-three (3.6%) patients had a neuritis
of both the mCN and MDCN.
Discussion

Not surprisingly, soft-tissue pathology dominated the

trauma in this study, consisting of 85.6% of all injuries.
Osseous pathology comprised the remaining 14.4% of
injuries. The most common soft-tissue injuries involved
the lateral ankle ligaments and these comprised 83.7%
of all soft-tissue injuries and 71.7% of the total injuries
evaluated.
The lateral ankle ligament injuries were evaluated based
on frequency of each ligament injured. We determined that
the most common ligament injured was the ATFL with
TABLE 3 Anatomical location of fractures for the 96
patients incurring osseous injury with prevalence given for
all ankle sprains reported
Type of Fracture
Fifth metatarsal base fracture
Lateral malleoli avulsion
Medial malleoli avulsion
Anterior calcaneal process fracture
Transchondral fracture
Cuboid avulsion fracture
Lateral process of talus fracture
Dorsal talar neck avulsion
Navicular avulsion
Posterolateral process talar fracture
Calcaneus avulsion of CFL
Talar body fracture
Medial talus avulsion
Lisfranc's fracture dislocation

Number and Percent

of Patients
24 (3.8%)
19 (3.0%)
13 (2.0%)
12(1.9%)
7 (1.1%)
5(0.8%)
3(0.5%)
3(0.5%)
3(0.5%)
2 (0.3%)
2 (0.3%)
1 (0.2%)
1 (0.2%)
1 (0.2%)

448 patients. The ATFL was the only lateral ligament

involved in 90 patients, while both the ATFL and CFL
were involved in 187 patients. The ATFL, CFL, and PTFL
combination was involved in 171 cases. These results
confirm the sequential pattern of ligament disruption that
has been documented in the literature (22, 23). The combination of ATFL and CFL was the most common presentation of the collateral lateral ankle ligaments. There were
four cases of isolated CFL involvement based on location
of pain. Isolated cases are rare but are possible, as seen
in subtalar dislocations. Perhaps these four cases represented a mechanism that would have resulted in dislocation if the force applied would have been greater. Nine
cases of isolated PTFL involvement were noted. No cases
of isolated PTFL, have been reported in the literature.
Because of proximity of peroneal tendons, it is possible
that there was a degree of tendinitis in the area of the
ligament rather than an injury to the PTFL.
This study's results indicate that 31 patients presented
with an injury to the syndesmosis. This represents
5.7% of the total soft-tissue injuries and this correlates
roughly with the incidence reported in other studies
(21, 24-26). Three cases were primarily diagnosed as
having a syndesmotic injury. With palpation of the deltoid
ligament, 180 patients reported pain, representing a 32%
occurrence rate, which is higher than the reported rate of
other studies (24, 27). Nineteen of the 180 patients were
diagnosed primarily as having an eversion sprain.
An injury found in this study that was previously
unreported with ankle sprains was strain of the extensor
digitorum brevis. A total of 111 patients were diagnosed
as having strained the extensor digitorum brevis. This
represents 20.3% of all soft-tissue injuries. Surprisingly,
32 of the 111 patients had the primary diagnosis of
an extensor digitorum brevis strain. Tendinitis of the
tendo-Achilles and peroneal tendons was encountered in
67 (12.2%) and 83 (15.2%), respectively. Incidence of
involvement of these structures with ankle sprains has not
previously been documented. We found no cases of sinus
tarsi syndrome and none were expected. This condition
is a chronic condition diagnosed weeks or months after a
sprain, and our study was based on the initial evaluation
of the acutely injured patient.
Neuritis resulting from ankle sprains has rarely been
reported. We found a 12.5% incidence of neuritis. The
IDCN was injured alone in 33 patients, MDCN in six,
sural in 11, and PT in one patient. The most common
presentation was the combination of both the IDCN and
MDCN. The nerves are believed to be strained when the foot
is plantarflexed and inverted. The diagnosis of neuritis was
based on tingling or burning sensation along the course of
the nerve, or decreased sensation to the foot or the toes along
the nerve distribution. In most cases the symptoms resolved
within a week, but occasionally symptoms persisted for
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283

several months. In several cases, the neuritis was the last

component of the ankle sprain to resolve.
Fractures constituted 14.4% of the total number of
injuries. These fractures were of the avulsion type or the
compression of two bones. Ninety-two patients presented
with 96 fractures of the foot and ankle. There were 13 (2%)
avulsion fractures of the medial malleolus and 19 (3%)
avulsion fractures of the lateral malleolus. There were no
other studies found in the literature indicating an incidence
of malleoli avulsion fractures in the sprained ankle.
Fifth metatarsal base fractures were noted in 24 cases
for an incidence of 3.8%. The authors have found no
studies indicating an incidence for this fracture, but 3.8%
appears lower than the commonly accepted occurrence
rate of 5%-10%. Transchondral fractures were noted in
seven cases for a percentage of 1.1 %. The literature
reports an incidence of 5%-7% with ankle sprains (13,
28, 29). The literature also reports that almost 90% of
the time the lesions are due to a traumatic event (30).
The authors' diagnosis was based on initial radiographic
examination when the patient presented for the first time.
The cases noted were frank fractures of the dome of the
talus. The compression or shear mechanism that results in
avascular necrosis is not diagnosed until much later when
the characteristic lucency of avascular necrosis is noted
on x-ray. Clearly, the rate of transchondral damage would
have been much higher if the patients had been evaluated
at a later date.
This study revealed that acutely twisted ankle injuries
are complex, with multiple characteristic anatomic
structures involved. The multiple components of injuries
observed with the sprained ankle defines it as a syndrome
that the authors refer to as the sprained ankle syndrome.
Many clinicians when faced with a sprained ankle initially
attempt to rule out an ankle fracture through radiographic
examination. If the ankle is not fractured, the injury is
assessed to be "just a sprain." Treatment would probably
consist of ACE bandage, instructions for RICE (rest, ice,
compression, elevation), and crutches if needed. Although
this treatment may be adequate for the grade I lateral
ankle sprain, it is not for most other injuries. This
scenario occurs in emergency rooms daily due to a lack of
appreciation for the injury once an ankle fracture has been
ruled out. In addition, other fractures such as avulsiontype fractures and fifth metatarsal fractures are often
overlooked. By linking these injuries into a syndrome,
the examiner will have a greater suspicion for the less
prevalent injuries associated with the ankle sprain, and
this will result in a more precise diagnosis.
Conclusions

From the present study of 639 patients prospectively

evaluated, it was concluded that the commonly injured
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THE JOURNAL OF FOOT & ANKLE SURGERY

ankle would more appropriately be termed the ankle

sprain syndrome because of the multicomponent involvement. Previous literature has generally inadequately
described this syndrome and is lacking in presenting
an incidence of components involved when the ankle is
twisted. Clinical signs may aid in the diagnosis of extent
of injury, but are not diagnostic for specific injuries. A
thorough examination must be completed on all patient
components involved. Only when a complete diagnosis is
made can the most appropriate treatment be instituted.
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