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Ankle Sprains Most Common High School Sports Injury, Study Finds

Ankle sprains are the most common single injury in high school sports, accounting for one in six of all high school sports-related injuries, finds a 2013 study. (1)

Sprained ankle black and blue

Analyzing data collected through the National High School Sports-Related Injury Surveillance System (RIO), an Internet-based reporting system, researchers found that ankle sprains accounted for16% of sports-related injuries in 20 high school sports serious enough to require medical attention by a certified athletic trainer or physician and restrict an athlete's participation for 1 or more days.  

Most ankle sprains healed relatively quickly, the study found, resulting in a loss of participation of less than a week nearly 50% of the time. Fewer than 1% required surgery, and rates were decreasing over time.  Nevertheless, "the large number of ankle sprains demonstrates the need for targeted injury-prevention measures," said lead author, David M. Swenson, MD, MPH, of the College of Medicine and College of Public Health at The Ohio State University in Columbus, Ohio. 

The study is reported in the May 2013 issue of the Clinical Journal of Sports Medicine. 

Injury rates

  • The overall rate for ankle injuries in 20 high school sports over the study period was 3.13 per 10,000 AEs (an athletic exposures = 1 athlete participating in 1 practice or competition).
  • While the overall injury rate for boys (3.14 per 10,000 AEs) and girls (3.11 per 10,000 AEs) were the same, the rate for girls in gender-comparable sports (soccer, volleyball, basketball, baseball, softball, lacrosse, swimming and diving, track and field) were higher for girls. 
  • Sports with the highest rates were boys' basketball (5.16 per 10,000 AEs), girls' basketball (5.03), and girls' gymnastics (4.88). 
  • Girls were significantly more likely to sustain ankle sprains than boys in soccer, softball/baseball, and track and field, but no evidence of a gender difference existed in volleyball, basketball, or lacrosse.
  • Ankle sprains decreased significantly over time in boys' football and girls' volleyball.  Gender-comparable sports showed more significant decreases in rates for boys than girls in soccer, basketball, and baseball/softball.

Exposure type

  • Ankle sprain rates were higher overall in competition than in practice for boys and girls.
  • Only boys' and girls' volleyball, boys' track and field, and cheerleading had no differences between competition and practice ractes.
  • The highest competition rates were in boys' football (15.01 ankle sprains per 100,000 AEs), girls' basketball (9.45), girls' soccer (9.41, and girls' gymnastics (9.36). 
  • Practice rates were highest in boys' volleyball (3.83), girls' gymnastics (3.82), girls' volleyball (3.79) and boys' and girls' basketball (3.79 and 3.13 respectively).

Specific structure involved

  • The anterior talofibular ligament (ATFL) was involved in 85.3% of sprains, much higher than any other ankle ligament;
  • The most common ligament injury pattern was an isolated ATFL (39.9% of all ankle sprains).

Surgery and lost time from participation

  • The most common outcome after ankle sprain was time lost from participation for 1 to 6 days (49.7% of all ankle sprains for which outcomes were reported) or 1 to 3 weeks (40.8%).
  • Injuries involving multiple ligaments resulted in more time lost compared with other injury patterns.
  • Recurrent ankle sprain outcomes (recurrence of a previously sprained ankle in the same or a previous academic year) did not differ significantly from primary ankle sprains.
  • Only 0.5% of ankle sprains were treated surgically, with recurrent ankle sprains (1.1%) more likely than primary injuries (0.4%) to require surgery.  Sprains involving the deltoid ligament (6.6% of total) more often were treated with surgery than ankle sprains involving other ligaments.

Risk factors

  • Prior injury is a strong risk factor for future ankle sprains, with recurrent ankle sprains accounting for 15.7% of all ankle sprains,the highest proportion of recurrent ankle sprains in sports involving frequent jumping and landing, including cheerleading (20.8%), boys' basketball (20.1%), and girls' gymnastics (20.0%). 
  • Braces: Athletes were wearing braces when 10.6% of ankle sprains occurred.  Braces worn at the time of injury included lace up (75.4% of all braces worn at the time of injury), rigid frame (14.1%) and neoprene sleeves (8.6%). The proportions of ankle sprains that occurred while the athlete was wearing a brace were highest in girls' volleyball (19.1%), boys' basketball (17.1%), girls' basketball (15.3%), boys' football (11.7%) and girls' gymnastics (10.0%); and
  • Player-player contact: 42.4% of all ankle sprains occurred as a result of contact with another person. Contact with the playing surface (26.7%) and non-contact (25.5%) accounted for most of the other sprains.

Effectiveness of braces unclear

The study failed to shed any additional light on the efficacy of ankle braces and taping. Some studies suggest they are effective at preventing ankle sprains, especially in college athletes at high ankle injury risk, but a review of the literature (meta-analysis) found ankle supporting devices, including taping, semirigid braces, and lace-up braces, to have minimal effects on nonelite athletes, and others even found increased risk with brace use.  As a result there is no current recommended "best practice,"  prompting the authors to call for "large-scale trials evaluating brace efficacy, specifically effectiveness across sports, boady mass index categories, and athlete with and without prior ankle injury to determine the appropriate role of bracing in ankle sprain prevention efforts."

Adequate physical therapy and rehabilitation urged

That 15.7% of all ankle sprains were recurrent, said Swenson, "underscored the need for adequate rehabilitation and postinjury protection to speed the healing process and minimize risks of reinjury."  "All students who sustain an ankle sprain,"  Swenson said, "should be encouraged to participate in postinjury physical therapy or other training programs such as balance boards, which have been shown to have beneficial effects in reducing ankle sprain risk." 

September 17, 2015 update: To put a finer point on this advice, studies show that of those who suffer repeated ankle sprains as many as three-quarters will go on to suffer chronic ankle instability (CAI).[2]

Research shows that long-term patients who develop CAI often go on to develop post-traumatic ankle osteoarthritis,[3] which a 2015 study[4] by researchers at the University of North Carolina - Charlotte suggests may be a direct consequence of the approximately 50% of patients who suffer an ankle sprain but do not seek any medical treatment or evaulation. 

That study found a single severe ankle sprain significantly decreased physical activity levels across the lifespan in mice, and followed closely on the heels of a study by the same researchers[5] reporting that college students with CAI took on average more than 2,000 fewer steps per day than healthy controls.

The findings of the two studies led the authors of the rat study to warn that, "[a]though [an] initial ankle sprain may be thought of as a relatively minor or insignificant injury, if not treated appropriately, or with lack of guidance with rehabilitation and exercise prescription, physical activity levels across a lifespan may decrease," which is a "significant public health concern given the cost associated with treating chronic disease development as well as the further loss of function the patient may experience." 

1.  Swenson D, Collins C, Fields S, Comstock R.  Epidemiology of US High School Sports-Related Ligamentous Ankle Injuries, 2005/06-2010-11. Clin J Sport Med 2013;23(3):190-196. 

2. McKay GD. Ankle injuries in basketball: injury rate and risk factors. Br. J. Sports Med.2001;35:103-108.

3. Hinterman B, Boss A, Schafer D. Arthroscopic findings in patients with chronic ankle instability.  Am J Sports Med 2002;30(3):402-409. 


4. Hubbard-Turner T, Wikstrom EA, Gudarian S, Turner MJ. An Acute Lateral Ankle Sprain Significantly Decreases Physical Activity across the Lifespan.  J Sports Sci Med. 2015;14:556-561 (published online ahead of print August 11, 2015) 


5. Hubbard-Turner T, Turner MJ. Physical Activity Levels in College Students With Chronic Ankle Instability.  J Athl Tr. 2015;50(7):742-747.  

Most recently updated September 17, 2015