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Risk of ACL Injury Soars Five Times Higher after an Ankle Sprain

Ankle sprains are common. Given time, most begin to feel better on their own, and people return to full activity. Unfortunately, these circumstances may be lulling people into believing they have fully recovered

Ankle sprains are common. Given time, most begin to feel better on their own, and people return to full activity. Unfortunately, these circumstances may be lulling people into believing they have fully recovered. In fact, ankle stability can continue to be compromised, even when people are back to action. One example of this is the fact that people with ankle sprains have a five times higher risk of ACL injury due to unaddressed instability and proprioceptive deficits.(1,2) For instance, people with ankle sprains have delays in gluteus maximus and medius activation, predisposing them for decreased trunk stability and increased risk of leg injury.(3) Past ankle sprains also correlate with increased risk of future ankle sprains.

Nine out of ten people do not use physiotherapy after an ankle sprain.(4) However, guided rehabilitation can speed recovery and more fully restore function, especially when physiotherapy begins on the day of injury or as soon as possible.(4-7)

Tell-Tale Signs an Ankle is Not Fully Recovered

After an ankle injury, there are a number of predictors of future injury and increased risk of future problems such as osteoarthritis.

  • limited range of motion in the ankle (especially limited dorsiflexion)(11)
  • muscle weakness (especially peroneal)(12)
  • mechanical instability (13)
  • functional instability(3,14)

Functional instability refers to neuromuscular deficits, as opposed to structural deficits such as lengthened ligaments. For instance, Lofvenberg and colleagues found that patients with functional instability after an ankle injury had 33% slower reaction times in the peroneus longus and tibialis anterior.(14)

Physiotherapy can modify all of these risk factors.


  1. Kramer LC, Denegar CR, Buckley WE, Hertel J. Factors associated with anterior cruciate ligament injury: history in female athletes. Journal of Sports Medicine and Physical Fitness. 2007 Dec 1;47(4):446. (500% higher risk)
  2. Terada M, Pietrosimone B, Gribble PA. Individuals with chronic ankle instability exhibit altered landing knee kinematics: potential link with the mechanism of loading for the anterior cruciate ligament. Clinical Biomechanics. 2014 Dec 1;29(10):1125-30.
  3. Beckman SM, Buchanan TS. Ankle inversion injury and hypermobility: effect on hip and ankle muscle electromyography onset latency. Archives of Physical Medicine and Rehabilitation. 1995 Dec 1;76(12):1138-43.
  4. Feger M, Herb C, Fraser J, et al. Supervised rehabilitation versus home exercise in the treatment of acute ankle sprains: a systematic review. Clinics in Sports Medicine. 2015; 34 (2): 329-346.
  5. Gustafsson K, Fältström A, Öberg U, Kammerlind AS. Written instructions versus physiotherapist-supervised rehabilitation after acute ankle sprain. European Journal of Physiotherapy. 2017 Apr 3;19(2):76-83.
  6. Karlsson J, Lundin O, Lind K, et al. Early mobilization versus immobilization after ankle ligament stabilization. Scan J Med Sci Sports 1999; 9: 299-303.
  7. Stasinopoulos D. Comparison of three preventive methods in order to reduce the incidence of ankle inversion sprains among female volleyball players. Br J Sports Med. 2004 Apr; 38(2): 182-5.
  8. Holme E, Magnusson S, Becher K, et al. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports 1999; 9: 104-9.
  9. Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W. The effect of a proprioceptive balance board training program for the prevention of ankle sprains: a prospective controlled trial. Am J Sports Med 2004; 32: 1385-93.       
  10. Kerkhoffs G, Rowe B, Assendelft W, et al. Mobilisation for acute ankle sprain. A systematic review. Arch Orthop Trauma Surg 2001; 121:462-71.
  11. Tabrizi P, McIntyre W, Quesnel M, et al. Limited dorsiflexion predisposes to injuries of the ankle in children. J Bone Joint Surg Br 2000; 82: 1103-6.
  12. Thacker S, Stroup D, Branche C, et al. The prevention of ankle sprains in sports. A systematic review of the literature. Am J Sports Med 1999; 27: 753-60.
  13. Hubbard T, Kramer L, Denegar C. Contributing factors to chronic ankle instability. Foot Ankle Int. Mar 2007; 28 (3): 343-54.
  14. Lofvenberg R, Karrholm J, Sundelin G, et al. Prolonged reaction time in patients with chronic lateral instability of the ankle. Am J Sports Med. 1995 jul-Aug; 23 (4): 414-7.

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