Beyond the Sprain: Associated Injuries and Their Management

An ankle sprain should never be viewed as a simple ligament injury. Many patients present with co-existing pathology or develop secondary conditions, which require specific and often more comprehensive management strategies. Below is a deeper clinical dive into the most common associated conditions, their presentation, and evidence-based physiotherapy management. 

1. Syndesmosis (High Ankle) Injuries 

What is it? 

A syndesmosis injury involves the distal tibiofibular ligaments, which stabilise the ankle mortise. These injuries often occur with external rotation and dorsiflexion mechanisms.  

Clinical Features 

  • Pain above the ankle joint (anterolateral lower leg) 

  • Pain with weight-bearing (often more than lateral sprains) 

  • Positive squeeze test or external rotation test 

Why It Matters 

  • Associated with osteochondral lesions, tendon injuries, and fractures  

  • Delayed diagnosis increases risk of chronic pain, instability, and osteoarthritis  

Management 

Early Phase: 

  • Relative immobilisation (boot or brace depending on severity) 

  • Protected weight-bearing 

Rehabilitation Phase: 

  • Gradual restoration of ankle dorsiflexion and rotation control 

  • Progressive strengthening of calf, tibialis posterior, and peroneals 

  • Avoid early forced external rotation stress 

Advanced Phase: 

  • Sport-specific loading (cutting, pivoting) 

  • Return-to-sport criteria (e.g., hop tests, pain-free function) 

These injuries often require longer rehab timelines (6–12+ weeks) compared to typical sprains. 

 

2. Osteochondral Lesions of the Talus (OLT) 

What is it? 

An osteochondral lesion is damage to the cartilage and underlying bone of the talus, often caused by compression or shear forces during injury. 

Clinical Features 

  • Deep ankle pain that persists beyond expected healing 

  • Clicking, catching, or locking sensations 

  • Swelling that fluctuates with activity  

Why It Matters 

  • Occurs in 15–25% of associated ankle injuries  

  • Can progress to early osteoarthritis if untreated 

Management 

Conservative Management (stable lesions): 

  • Activity modification and load management 

  • Progressive strengthening and joint unloading strategies 

  • Proprioceptive training 

Rehabilitation Focus: 

  • Restore ankle mobility without excessive compression 

  • Improve shock absorption (hips, knees, calves) 

  • Gradual return to impact activities 

When to Refer: 

  • Persistent mechanical symptoms 

  • Failure of conservative care → may require orthopaedic referral 

 

3. Peroneal Tendon Injuries 

What is it? 

The peroneal tendons stabilise the lateral ankle and are commonly injured in inversion sprains. 

Clinical Features 

  • Pain along the outer ankle/behind lateral malleolus 

  • Pain with resisted eversion 

  • Feeling of instability or “snapping” 

Why It Matters 

  • Occurs in up to 25% of complex ankle injuries  

  • May be overlooked, leading to chronic lateral ankle pain 

Management 

Early Phase: 

  • Relative rest and reduction of aggravating loads 

  • Bracing/taping for support 

Rehabilitation: 

  • Progressive peroneal strengthening (eccentric + concentric) 

  • Foot intrinsic strengthening 

  • Address contributing factors (e.g., cavovarus foot posture) 

Advanced: 

  • Dynamic stability drills (single-leg balance, perturbation training) 

Failure to rehabilitate tendon function increases risk of recurrent sprain and instability. 

 

4. Associated Fractures 

What are they? 

Fractures may occur alongside ligament injury, commonly involving: 

  • Fifth metatarsal base 

  • Talar dome or processes 

  • Calcaneus or fibula  

Clinical Features 

  • Localised bony tenderness 

  • Inability to weight-bear 

  • Significant swelling and bruising 

Why It Matters 

  • Missed fractures can lead to delayed healing or non-union 

  • Syndesmosis injuries may include fibular fractures  

Management 

Initial Care: 

  • Imaging guided by Ottawa ankle rules 

  • Immobilisation if fracture confirmed 

Rehabilitation (post-immobilisation): 

  • Gradual weight-bearing progression 

  • Range of motion restoration 

  • Strength and functional retraining 

 Timely diagnosis ensures appropriate immobilisation vs mobilisation decisions. 

 

5. Deltoid Ligament and Medial Ankle Injuries 

What is it? 

The deltoid ligament complex stabilises the medial ankle and is less commonly injured but often associated with more significant trauma. 

Clinical Features 

  • Medial ankle pain and swelling 

  • Pain with eversion or external rotation 

  • Often combined with syndesmosis or fracture injuries 

Why It Matters 

  • Indicates greater ankle instability or more severe injury mechanism  

Management 

  • Similar to lateral ligament rehab but includes: 

  • Medial stability strengthening 

  • Careful progression of eversion loading 

  • May require longer protection phase 

 

6. Chronic Ankle Instability (CAI) 

What is it? 

CAI develops after an initial ankle sprain and is characterised by recurrent sprains, instability, and persistent symptoms. 

Key Statistics 

  • Affects up to 46% of people with prior ankle sprain  

  • Recurrence rates are as high as 80% in high-risk sports  

Clinical Features 

  • Repeated ankle “giving way” 

  • Poor balance and proprioception 

  • Reduced confidence with movement 

Why It Matters 

  • Alters biomechanics across the lower limb 

  • Increases risk of knee injuries, including ACL injury  

Management 

Core Components (strong evidence): 

  • Balance and proprioceptive training 

  • Strength training (ankle + hip stabilisers) 

  • Plyometrics and neuromuscular control 

Advanced Rehabilitation: 

  • Sport-specific drills 

  • Movement retraining (cutting, landing mechanics) 

 High-quality rehabilitation is essential to break the injury cycle. 

 

Why Comprehensive Management Matters 

An ankle sprain is often the starting point of a cascade of dysfunction, rather than an isolated event. Without appropriate intervention: 

  • Secondary injuries may go undiagnosed 

  • Poor movement patterns become ingrained 

  • Risk of re-injury and long-term degeneration increases 

Physiotherapy plays a key role in: 

  • Identifying associated pathology early 

  • Delivering targeted, progressive rehabilitation 

  • Preventing recurrence and optimising return to sport 

 

Key Message 

If your ankle sprain: 

  • isn’t improving within 1–2 weeks 

  • feels unstable or painful long-term 

  • includes catching, locking, or sharp pain 

 It’s worth getting a thorough physiotherapy assessment to rule out more complex injury. 

 

References (APA 7th Edition) 

Lin, C.-I., Houtenbos, S., Lu, Y.-H., Mayer, F., & Wippert, P.-M. (2021). The epidemiology of chronic ankle instability with perceived ankle instability: A systematic review. Journal of Foot and Ankle Research, 14(1), 41. https://doi.org/10.1186/s13047-021-00480-w 

Orthobullets. (2026). Ankle sprain. https://www.orthobullets.com/foot-and-ankle/7028/ankle-sprain 

Orthobullets. (2026). High ankle sprain and syndesmosis injury. https://www.orthobullets.com/foot-and-ankle/7029/high-ankle-sprain-and-syndesmosis-injury 

Physiotutors. (2023). Syndesmotic injuries: Diagnosis & treatment. https://www.physiotutors.com/conditions/syndesmosis-injury/ 

Physiopedia. (n.d.). Ankle syndesmosis injuries. https://www.physio-pedia.com/Ankle_Syndesmosis_Injuries 

Radsource. (2010). High ankle sprains. https://radsource.us/high-ankle-sprains/ 

Skwiot, M. (2025). A systematic review of rehabilitation interventions for athletes with chronic ankle instability. Journal of Clinical Medicine, 15(1), 220. https://doi.org/10.3390/jcm15010220 

Xu, Y., Song, B., Ming, A., & Zhang, C. (2022). Chronic ankle instability modifies proximal lower extremity biomechanics during sports maneuvers that may increase the risk of ACL injury: A systematic review. Frontiers in Physiology, 13, 1036267. https://doi.org/10.3389/fphys.2022.1036267 

Stuart McKayComment