Return to play after a lateral ligament ankle sprain

Key points

1. 01Ankle sprain is the most common sports injury, and the anterior talofibular ligament (ATFL) is torn in 90 to 95% of inversion injuries.
2. 02The large majority of grade I to III sprains are managed conservatively with good to excellent outcomes and full return to play.
3. 03No formal return-to-play criteria exist; clinicians aim for restored function, cardiovascular fitness, and no apprehension, using functional tests targeting about 90% of pre-injury or the uninjured side.
4. 04A delayed clinical exam at 4 to 5 days is more accurate than an exam within 48 hours for grading the injury.
5. 05Bracing and balance training reduce re-injury, and prior sprain raises future risk 2 to 5 fold.

How it was conducted

Design

Narrative review of current evidence on sports-related ankle injuries

Focus

Lateral ligament ankle sprains and return to play in athletes

Scope

Diagnosis, conservative and surgical treatment, rehabilitation, and prevention

What they found

• The ATFL is injured in 90 to 95% of inversion injuries, and 67 to 72% of football ankle injuries are sprains.
• MRI shows combined ATFL plus CFL injury in 41% of cases and isolated PTFL injury in 5%.
• A delayed clinical exam at 4 to 5 days reaches sensitivity 96% and specificity 84%.
• Ultrasound has sensitivity 92% and specificity 64%, rising to sensitivity 100% and specificity 72% when combined with a delayed exam.
• MRI sensitivity and specificity for ATFL injury are 92 to 100% and 100%.
• About 40% of patients have medial malleolus tenderness without a medial collateral ligament rupture, and 60% have tenderness over the AITFL region.
• Reported return to sport is 7 to 15 days in amateur and professional football; after surgical repair, median return is 77 days for isolated injuries and 105 days with concomitant injuries.
• An external brace reduces recurrence by about 70% in previously injured athletes without impeding speed, agility, or kicking accuracy.

Limitations

• This is a narrative review, not a systematic review or meta-analysis, so studies were not pooled or formally graded.
• The literature provides no validated, formal return-to-play criteria for ankle sprains.
• Management of grade III (complete) tears remains controversial, with no clear consensus between surgery and conservative care.
• Reported return-to-play timelines vary widely and depend on injury severity and sport-specific demands.

Why it matters

For patients

If you sprain the outside of your ankle, expect that rehabilitation rather than surgery is usually enough and that you can return to your prior activity, often within a couple of weeks for milder sprains.

For clinicians

Examine the ankle at 4 to 5 days for more accurate grading, treat most grades I to III conservatively, and gate return to play on functional test performance near 90% of baseline plus restored fitness and confidence.

For readers

This review summarizes how common ankle sprains are diagnosed, treated, and rehabilitated, highlighting that most heal well but formal return-to-play standards are still lacking.