Lateral ankle sprain: a criteria-based return-to-sport framework

The lateral ankle sprain is the injury most of us have managed more times than we can count, and that familiarity is the problem. It gets treated as minor. Athletes are back in days, often on the strength of "it feels fine" and a calendar. Then a large share of them come back again: many go on to develop chronic ankle instability, with recurrent sprains, giving way and a long tail of reduced function (Gribble et al., 2016).

In elite sport we can't afford that. A player who re-sprains three weeks after return costs more time than the extra week it would have taken to get them properly ready. So we stopped asking "how long has it been?" and started asking "what can they do?"

IN SHORT

• Return should be earned against criteria, not given by the calendar.

• Rule out fracture and syndesmosis injury, then re-examine once swelling settles.

• Clear all five PAASS domains before full training.

• Run restore, rebuild and retrain in parallel, and keep the work going after return.

Start with a proper assessment

Return-to-sport decisions are only as good as the diagnosis underneath them. The International Ankle Consortium's ROAST recommendations (Delahunt et al., 2018) are a sensible baseline:

• Rule out fracture with the Ottawa ankle rules, and refer for imaging when they're positive.

• Grade the lateral ligament complex: ATFL alone, or ATFL plus CFL. A repeat examination around 4–5 days later, once swelling settles, tells you more than the first 48 hours.

• Screen the syndesmosis every time. A positive squeeze or external rotation test changes the timeline: high ankle sprains often take considerably longer to get back from.

• Record impairments early: swelling, weight-bearing dorsiflexion, strength and single-leg balance. These become the baseline you measure progress against.

Hands-on ankle assessment on the course

Use criteria, not time

The PAASS framework, from an international consensus of clinicians and researchers (Smith et al., 2021), gives five domains to clear before return. We use it as a checklist, with our own measures under each heading.

P Pain

Asking: Is pain low during and after sport-specific loading?

Measure: Pain over the last 24 hours of training, and the morning after.

A Ankle impairments

Asking: Have range, strength and power returned?

Measure: Weight-bearing lunge, single-leg calf raise endurance, eversion strength.

A Athlete perception

Asking: Does the athlete trust the ankle?

Measure: Confidence questions; any hesitation in cutting or landing.

S Sensorimotor control

Asking: Is balance and dynamic control back?

Measure: Single-leg balance, Y-balance anterior reach.

S Sport and function

Asking: Can they tolerate the demands of their sport?

Measure: Hop tests, change of direction, full unrestricted training.

Practical notes on the measures

• Weight-bearing lunge. Restricted dorsiflexion is common after sprains and easy to miss. Compare knee-to-wall distance side to side; as a rule of thumb, a gap of more than about 2 cm is worth addressing before return.

• Calf and peroneal capacity. Count single-leg heel raises to fatigue and compare sides. Peroneal strength matters as much as calf strength for a lateral sprain, and it is usually the weaker link.

• Hop tests. Side hop and figure-of-eight hop tests stress the ankle in the frontal plane, where lateral sprains happen. A linear hop for distance on its own misses it.

• Force plates. Where you have them, drop jumps and hop-and-stick landings show asymmetries in how quickly an athlete absorbs force that the eye won't catch.

Numbers beat the eye for the final return decision

Rehab that earns each criterion

There is good evidence that exercise therapy helps after an ankle sprain, and that exercise and bracing reduce the risk of the next one (Doherty et al., 2017). In practice we run three threads in parallel rather than in strict phases.

1 Restore

Early protected weight-bearing, swelling control and dorsiflexion work from the first days. Immobilise only the severe sprains, and briefly.

2 Rebuild

Progressive loading for calf, peroneals and the intrinsic foot muscles, from isometrics to heavy slow strength to fast, reactive work. Short foot work goes in early: it's simple, needs no kit, and is one of the basics that's easy to skip.

3 Retrain

Balance and perturbation training that becomes sport-specific: unstable surfaces, reacting to a ball or a partner, then a plyometric progression from two-footed jumps to single-leg hops and lateral bounds, and finally cutting, landing and deceleration at match intensity.

The mistake we see most often is the third thread starting too late. Doing the basics right, consistently, is what gets ankles back and keeps them there.

Sensorimotor deficits persist long after pain has gone, and they predict the recurrence we're trying to avoid.

Practising rehab progressions on each other

The return decision

When all five domains are cleared, the athlete returns to full training first, then competition. Two habits help here:

• Brace for the rest of the season. Bracing has the strongest evidence for reducing recurrence; tape is an option for athletes who won't wear one.

• Keep the balance and strength work in the programme. It takes minutes a session, and stopping it the day they're cleared undoes much of the protection.

GO DEEPER

Assessment, loading progressions and return-to-sport testing for the ankle are covered hands-on across both days of the Sporting Foot & Ankle course.

See the next course dates

References

1. Gribble PA, et al. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med 2016;50:1496–1505.

2. Delahunt E, et al. Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. Br J Sports Med 2018;52:1304–1310.

3. Smith MD, et al. Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework. Br J Sports Med 2021;55:1270–1276.

4. Doherty C, et al. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. Br J Sports Med 2017;51:113–125.