Snapshot A 23-year-old man presents to the emergency department for ankle pain. He says that prior to symptom development, he was at soccer practice running exercise drills. He then rolled his ankle and subsequently developed severe pain. He says he was able to walk off the field with assistance, but walking exacerbated his pain. On physical exam, the ankle appears swollen. There is anterior displacement of the talus from the tibia. He has an antalgic gait and requires rest after walking 15 steps. He is advised to rest, ice, compress, and elevate the ankle for the next 2-3 days. Introduction Clinical definition ankle ligament injury (e.g., stretching and partial or complete rupture) Epidemiology Incidence a common injury seen by primary care physicians ETIOLOGY Pathoanatomy the ligaments of the ankle provide mechanical stability proprioceptive information joint motion lateral ankle sprain inversion of a plantar-flexed foot injures the ankle's lateral ligament complex medial ankle sprain forced ankle eversion injures the ankle's medial deltoid ligament complex syndesmotic sprain syndesmotic structures become injured with forced dorsiflexion and/or eversion syndesmotic structures include anterior tibiofibular ligament posterior tibiofibular ligament transverse tibiofibular ligament interosseous membrane Presentation Symptoms pain swelling muscle spasms Physical exam tenderness to palpation anterior drawer test assesses for anterior displacement of the talus on the tibia suggests injury to the anterior talofibular lateral ligament talar tilt test assesses the integrity of the calcaneofibular ligament Imaging Radiography indication depend on the Ottawa ankle rules in patients with malleolar zone pain and bone tenderness at the lateral or medial malleolus in patients who are unable to bear weight either immediately after the injury after taking a few steps in the emergency department Differential Fracture differentiating factor the appearance of a fracture on imaging patients who are unable to bear weight on the foot DIAGNOSIS Making the diagnosis a clinical diagnosis that can be supported by injury Treatment Conservative RICE (Rest, Ice, Compression, and Elevation) therapy indication initial treatment for an ankle sprain physical therapy indication follows RICE therapy Operative ligament repair indication considered in certain clinical conditions (e.g., severe sprain of the distal talofibular ligament that widens the ankle mortise) Complications Prolonged pain Ankle stiffness and instability Recurrent ankle sprain Prognosis Usually excellent