Ankle Sprain Assessment and Diagnosis

Ankle sprain assessment and diagnosis

The signs and symptoms of ankle sprains can vary from very mild to very severe depending on how bad the injury is. However, the main symptoms are pain, swelling, bruising and the possible feeling of instability.

Pain is usually felt around the ankle joint itself although more specifically on the outside of the ankle where the damaged ligaments are located. Swelling or bruising may present immediately or may not develop until later on over the next 48 hours (depending on the types of structures damaged and the severity of the sprain) but in milder cases this may never appear at all.

Occasionally, pain may also be felt on the inside of the ankle where the bones have been pressed together (kissing contusion) or where soft tissues are pinched (impingement) between the bones.

How bad is my ankle sprain?

Sprains are graded 1, 2 or 3 depending on their severity and a professional therapist will be able to tell you which grade of injury you have sustained after carrying out a full ankle assessment.

This will include a number of movement, muscle and ligament tests in order determine which structures have been injured and how badly.

Grade 1 injuries result in mild symptoms with some pain and little or no swelling. There may be a feeling of joint “stiffness” with some degree of difficulty in walking or running however more often than not, the athlete is able to play on and finish the training session or game. In these type of injuries, the ligaments are usually stretched rather than completely torn and the ankle should feel better relatively quickly. Recovery time for mild (grade 1) ankle sprains is usually somewhere between 2 and 4 weeks.

Grade 2 injuries result in symptoms of moderate to severe pain with severe difficulty on walking. The athlete is unlikely to be able to play on and will often limp heavily. Minor bruising and swelling may present immediately but can take several hours (up to 48) to develop. The ankle will feel very stiff but may also feel unstable resulting from a number of torn ligament fibres (this can be tested more accurately by a professional therapist). Recovery time for moderate ankle sprains (grade 2) takes between is 4 and 8 weeks.

Grade 3 injuries result in almost complete tears or total ruptures of the ligament(s). There will be severe pain immediately and the ankle may feel very unstable and weak. Swelling usually develops immediately and bruising often develops over the next 48 hours. These injuries need to be assessed in a hospital and often require and x-ray to ensure no bones have been broken. Severe ankle sprains (grade 3) can take up to 3 months to recover.

A thorough assessment is required to accurately diagnose a sprained ankle and we outline some of the techniques that a therapist may use to assess and diagnose the injury.

The following is for information purposes only and therefore we strongly recommend seeing a professional therapist or Doctor to receive a full assessment of your injury.

Ankle sprains are fairly easy to recognise as the athlete is always aware of when and how the injured happened. However, before starting to assess the ankle, there are other serious associated injuries that can occur at the same time and need be ruled out first.

Possible Complications

Before the standard assessment for sprained ankles is explained, it should be noted that in addition to the ligament damage that usually occurs in ankle sprains, there may be associated damage to tendons, the joint capsules, the bones, the cartilages, the nerves or other soft tissues. Severely sprained ankles more often than not result in complete (or almost complete ruptures) of the ligaments and this may be associated with dislocations and fractures of the ankle bones. It is very important to rule out any of these serious associated injuries before assessing the sprain.

Types of bone/joint injuries in that may occur as part of an ankle sprain

  • An avulsion fracture occurs when an overstretched ligament pulls a small piece of bone away with it. This is not always obvious initially but should be suspected if the injury fails to heal and the ankle remains tender to touch after a number of weeks.
  • Osteochondral lesions are tears of the cartilage that lines the bony surfaces of the ankle joints and often occurs in moderate to severe injuries. If missed or not treated this may lead to osteoarthritis developing later on and therefore in severe cases this may require surgery to fix.
  • Ankle Fractures may also occur as a result of severe ankle sprains. These can occur in both INVERSION and EVERSION injuries and diagnosis is only confirmed using x-rays.

In view of the above, moderate (grade 2) and severe (grade 3) ankle injuries should always be assessed by a doctor to decide if an x-ray is required, especially if a fracture is suspected. However, it should be noted that X-rays are not required for all ankle sprains (especially minor injuries) as fractures are rare.

Ankle Sprain assessment

Assessment of any injury should include questions concerning the patient’s general health, any previous injuries and focused questions on the current injury. The aim of these questions is to determine which structure may be causing the pain and which treatment is appropriate. Following this, the therapist will perform a series of tests which may include the following:


  • Observation is usually the first stage of any injury assessment.
  • The therapist will usually observe the patient in both standing and lying down and will be looking closely for swelling, bruising and deformity, as well as postural issues such as over pronation of the feet or problems putting the foot on the floor.


  • The therapist will then palpate the entire ankle joint and surrounding area to assess if the joint is warm (due to acute inflammation) and swollen and if the ligaments are painful to touch.

Range of Motion

  • The therapist will usually assess both active (the patient moves) and passive (the therapist moves the joint) movements of the ankle with the knee both straight and then bent.
  • The ankle is often painful to move after an ankle sprain.
  • Passive range of motion is usually pain-free as the muscles are not contracting, although the end of range into dorsiflexion (toes pointing upwards) may be painful as the muscles stretch.

Assessing Ankle flexibility

  • Depending on the severity of the ankle injury, the therapist may assess the patient in standing to test the movement of the ankle when weight bearing.

Resisted Muscle Tests

    • These tests are used to assess strength of the muscles around the ankle joint compared to the other side.
    • They may be tested with the knee straight and then bent.

Special Tests

Special tests are used to assess the integrity of the ligaments and how badly damaged they are.

      • “Anterior drawer test” will be used to assess the ATFL ligament
      • “Talar Tilt” test will be used to test the CFL ligament
      • External rotation and squeeze tests will be used to assess the high ankle ligaments (syndesmosis complex)

Functional Tests

Functional tests are used to asses how the patient moves and how the ankle injury affects walking, hopping, jumping. The severity of the ankle injury will dictate which tests are selected.

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