Differential Diagnoses which can be treated using this pathway:

Ankle soft tissue injury

Significant History/Physical symptoms

*If this injury occurred less than 4 weeks ago, then please refer to sub acute lateral ankle guidance.*

Chronic Ankle Pain and Instability

Significant History/Physical symptoms

Chronic ankle instability results when injured ligaments following a sprain do not regain the mechanical integrity necessary to stabilise the ankle against physiologic stress. Symptomatic ankle instability develops in up to 40% following acute injury in which capsuloligamentary damage leads to laxity of the ankle. Varus foot types may be predisposed to lateral ankle sprains. Lateral ankle sprains compromise 85% of all ankle sprains, and of those an estimated 70-80% will go onto have a recurrent sprain.

Video on testing ATFL

Video on testing syndesmosis

Peroneal Tendon Pathologies

Significant History/Physical symptoms

Peroneal Brevis and Longus tendon injuries should be considered every time a patient presents with chronic lateral ankle pain. The Peroneal tendons are the primary evertors of the foot and function as stabilisers of the lateral ankle. Accurate diagnosis and knowledge of current treatment approaches for the various pathologies is critical in achieving favourable outcomes. Common in people undertaking highly repetitive activities e.g. running

Video on testing peroneal strength

Less Common Differential Diagnoses not included in this pathway:

• Osteochondral Defect
• Syndesmosis damage
• Sinus Tarsi Syndrome
• Spring ligament damage
• Missed Fractures- Osteochondral, Lateral Talar process
• Osteochondral lesions
• Posterior Tibial pathology
• CRPS
• Fracture of the lateral malleolus or anterior calcaneal process
• Peroneal tubercle hypertrophy or spurring of the retromalleollar groove
• Osteochondritis Dessicans
• Os Peroneum Syndrome

Ottowa Ankle Rules: Apply Ottawa rules for foot and ankle fracture. If positive refer to A&E.

The first line intervention should focus on educating the patient about the condition, and prescribing therapies that can be self-administered by the patient.

Leaflets should be given to patients to reinforce verbal advice and links to NHS website resources where available.  Leaflet on Ankle Sprain.

Initial Patient Directed Treatment Options

After 72 Hours

PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate. Load, Optimism, Vascularisation, Exercise)

• Footwear Advice
  • Increased width of heel sole / increase support around ankle, for lateral instability, running shoes with medial posting or rigid materials along the medial aspect should be avoided
  • Give leaflet to reinforce verbal advice - NHSGGC Footwear Advice Leaflet and/or Alternative Shoe Lacing Options
• Exercise Prescription
  • Stretching and strengthening exercises
  • Proprioceptive Exercise Treatment
  • The use of a proprioception program after usual care of an ankle sprain is effective in the prevention of self-reported occurrences
• Heel Raise
  • These should be given bilaterally so as to avoid Leg Length Discrepancy
• Advise weight loss if appropriate
  • Signposting to activities which may promote weight loss link exit/parallel pathways
  • Referral to Weight Management Service if BMI greater than 30.
  • NHS Choices - Lose weight
  • Leisure Pathway 
• Activity modification and management advice
• Analgesia & Non-Steroidal Anti Inflammatory Drugs as appropriate.
  • See guidance on good practice 
• Ankle bracing
  • Taping and bracing appear to be more effective in preventing ankle sprains in athletes with a history of ankle sprain than in those without a history of ankle sprain.
  • When deciding whether athletes should be taped or braced, the increased cost and time of ankle taping compared with bracing must be considered. Ankle bracing, therefore, may be a better way to provide the support necessary to prevent ankle sprains.

Non evidenced treatments

The following treatments are not supported by high quality evidence therefore they should not be considered as a treatment option for patients unless all other evidenced treatments have been tried unsuccessfully and there is clear clinical justification as to why these treatments are being used.

• Acupuncture
  • Insufficient evidence to support use in this condition
• Low Level Laser Therapy LLLT
  • Some limited evidence but more research needed to determine optimum dosage to provide a significant effect
• Therapeutic Ultrasound
  • Minimal benefit and no conclusion on effective dosage parameters
• Corticosteroid Injection

If a patient is not improving as expected they should be referred on to another AHP who can deliver an escalated evidenced intervention or referred to orthopaedics as per the escalation guidance on the pathway.

Biomechanical assessment and prescription of Foot Orthosis

• Address biomechanical deficit if indicated by assessment.
• Off the shelf or custom made insoles should be prescribed dependant on the severity of biomechanical deficit
• The orthotic prescription should be decided by the clinician, who should describe the prescription in detail in the patient records

One reason for referring to the orthopaedic department is for a surgical opinion. This is not a guarantee that surgery is the correct option for your patient so it’s important that this is not the expectation given to the patient by the referring clinician.

It is important that the patient has the option of a surgical opinion if this may be an appropriate treatment option for them so that they can discuss what is involved in surgery and make an informed decision.

Common conditions which are operated on include, hallux valgus, hallux rigidus, Morton’s neuroma, lesser toe issues, tendon pathology and degenerative changes of the joints of the foot and ankle.

The indications for surgery include persistent pain, worsening symptoms, significant limited mobility or failure of conservative therapy.

Foot and ankle surgery is generally successful with many of the common foot operations achieving 85% success rate, however complications can occur and will be considered as part of the decision making process for surgery.

Remember to exhaust all conservative means ie: orthotics, footwear advice , physiotherapy, pain relief medication , if appropriate steroid injections, before considering surgical opinion.

Further Investigation

The other reason for referral to Orthopaedics is for “Further Investigations”.

MRI and CT are helpful and can be arranged within orthopaedics as appropriate – if your patient does not have a clear diagnosis or there is a concern about a diagnosis and as above, struggling with symptoms, referral on to orthopaedics is appropriate

Things to consider before referring for further investigation are the severity of the symptoms and whether there are odd/suspicious symptoms making it difficult to make a clear diagnosis.

Things to consider before referring to Orthopaedics:

Before referring to orthopaedics ensure the following:

• Vascular status – palpable pulses (for surgery)
• Patient is happy to attend for further review, possible further investigation and possible surgery as an outcome.
• Conservative means have been attempted.

This is a referral guide however please do not hesitate to contact your local ESP Orthopaedic clinician if you are unsure whether to refer.

The majority of the papers included here are level 1 or level 2 evidence, however other papers have been included to allow for further reading around the subject. Articles are listed in Harvard format.

Brukner, P., 2012. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill.
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Demetrious, T. and Harrop, B., Updated 2018
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Doherty, C., Bleakley, C., Delahunt, E. and Holden, S., 2017. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. British journal of sports medicine, 51(2), pp.113-125.
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Dombek, M.F., Lamm, B.M., Saltrick, K., Mendicino, R.W. and Catanzariti, A.R., 2003. Peroneal tendon tears: a retrospective review. The Journal of foot and ankle surgery, 42(5), pp.250-258.
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Ferran, N.A., Oliva, F. and Maffulli, N., 2006. Recurrent subluxation of the peroneal tendons. Sports Medicine, 36(10), pp.839-846.
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Guskiewicz, K.M. and Perrin, D.H., 1996. Effect of orthotics on postural sway following inversion ankle sprain. Journal of Orthopaedic & Sports Physical Therapy, 23(5), pp.326-331.
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Heckman, D.S., Gluck, G.S. and Parekh, S.G., 2009. Tendon disorders of the foot and ankle, part 1: peroneal tendon disorders. The American journal of sports medicine, 37(3), pp.614-625.
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Hertel, J., 2002. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of athletic training, 37(4), p.364.
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Hupperets, M.D., Verhagen, E.A. and Van Mechelen, W., 2009. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. Bmj, 339.
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Klammer, G., Benninger, E. and Espinosa, N., 2012. The varus ankle and instability. Foot and Ankle Clinics, 17(1), pp.57-82.
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Loudon, J.K., Reiman, M.P. and Sylvain, J., 2014. The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review. British journal of sports medicine, 48(5), pp.365-370.
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Manoli, A. and Graham, B., 2005. The subtle cavus foot,“the underpronator,” a review. Foot & ankle international, 26(3), pp.256-263.
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Mansour, R., Jibri, Z., Kamath, S., Mukherjee, K. and Ostlere, S., 2011. Persistent ankle pain following a sprain: a review of imaging. Emergency radiology, 18(3), pp.211-225.
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Mattacola, C.G. and Dwyer, M.K., 2002. Rehabilitation of the ankle after acute sprain or chronic instability. Journal of athletic training, 37(4), p.413.
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Mills, K., Blanch, P., Chapman, A.R., McPoil, T.G. and Vicenzino, B., 2010. Foot orthoses and gait: a systematic review and meta-analysis of literature pertaining to potential mechanisms. British journal of sports medicine, 44(14), pp.1035-1046.
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Olmsted, L.C., Vela, L.I., Denegar, C.R. and Hertel, J., 2004. Prophylactic ankle taping and bracing: a numbers-needed-to-treat and cost-benefit analysis. Journal of athletic training, 39(1), p.95.
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Orteza, L.C., Vogelbach, W.D. and Denegar, C.R., 1992. The effect of molded and unmolded orthotics on balance and pain while jogging following inversion ankle sprain. Journal of Athletic Training, 27(1), p.80.
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Philbin, T.M., Landis, G.S. and Smith, B., 2009. Peroneal tendon injuries. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 17(5), pp.306-317.
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Richie Jr, D.H., 2001. Functional instability of the ankle and the role of neuromuscular control: a comprehensive review. The journal of foot and ankle surgery, 40(4), pp.240-251.
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Richie Jr, D.H., 2007. Effects of foot orthoses on patients with chronic ankle instability. Journal of the American Podiatric Medical Association, 97(1), pp.19-30.
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Sammarco, G.J. and Mangone, P.G., 2000. Diagnosis and treatment of peroneal tendon injuries. Foot and ankle surgery, 6(4), pp.197-205.
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Stiell, I., Wells, G., Laupacis, A., Brison, R., Verbeek, R., Vandemheen, K. and Naylor, C.D., 1995. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Bmj, 311(7005), pp.594-597.
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The National Institute for Health and Care Excellence (NICE) Guidance on Sprains and Strains
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Thompson, C., Schabrun, S., Romero, R., Bialocerkowski, A., van Dieen, J. and Marshall, P., 2018. Factors contributing to chronic ankle instability: a systematic review and meta-analysis of systematic reviews. Sports Medicine, 48(1), pp.189-205.
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Tourné, Y., Besse, J.L. and Mabit, C., 2010. Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options?. Orthopaedics & Traumatology: Surgery & Research, 96(4), pp.433-446.
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van den Bekerom, M.P., van der Windt, D.A., ter Riet, G., van der Heijden, G.J. and Bouter, L.M., 2011. Therapeutic ultrasound for acute ankle sprains. Cochrane Database of Systematic Reviews, (6).
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Verhagen, E.A., van Mechelen, W. and de Vente, W., 2000. The effect of preventive measures on the incidence of ankle sprains. Clinical Journal of Sport Medicine, 10(4), pp.291-296.
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Verhagen, E.A.L.M., Van Tulder, M., van der Beek, A.J., Bouter, L.M. and Van Mechelen, W., 2005. An economic evaluation of a proprioceptive balance board training programme for the prevention of ankle sprains in volleyball. British journal of sports medicine, 39(2), pp.111-115.
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Watson, A.D., 2007. Ankle instability and impingement. Foot and ankle clinics, 12(1), pp.177-195.
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Wolfe, M.W., Uhl, T.L., Mattacola, C.G. and McCluskey, L.C., 2001. Management of ankle sprains. American family physician, 63(1), p.93.
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