Eversion Ankle Sprain

Eversion Ankle Sprain: Rehabilitating a Medial Ligament Injury

What Is an Eversion Ankle Sprain?

An eversion ankle sprain occurs when the foot rolls outward, overstretching or tearing the ligaments on the inner side of the ankle (primarily the deltoid ligament). This is different than in inversion ankle sprain, where the ankle rolls inward. Eversions sprains are less common and more severe than inversion sprains, as they often involve higher-force trauma.

Anatomy of the Deltoid Ligament Complex

Function

The deltoid ligament has a crucial role in ankle stabilization. The deltoid ligament is a primary stabilizer against eversion (outward rolling) and external rotation of the ankle. This ligament works with the bony architecture, such as the medial malleolus to prevent overstretching. The lateral malleolus also plays a crucial role in lateral ankle stability. Since the lateral malleolus drops lower than the medial malleolus, it works with the deltoid ligament to prevent eversion. The increase in lateral ankle stability makes eversion ankle sprains more rare, but more serious.

Deltoid Ligament Components

1. Superficial Deltoid Layer

• Function: resisting eversion
• Components:
  • Tibiospring ligament
  • Tibiocalcaneal ligament
  • Posterior superficial tibiotalar ligament
  • Tibionavicular ligament
• Vascularity: Moderate blood flow (from posterior tibial artery branches).
• Healing Implications:
  • Better healing potential than deep layer due to richer vascular network.
  • Grade I-II sprains often heal well with conservative care (bracing, PT).

2. Deep Deltoid Layer

• Function: resist rotational forces
• Components:
  • Anterior tibiotalar ligament
  • Posterior deep tibiotalar ligament
• Vascularity: Poor blood supply (relies on diffusion from synovial fluid).
• Healing Implications:
  • Slower healing; prone to chronic instability if torn.
  • Complete tears (Grade III) may require surgery if causing persistent instability.

Why Is This Important?

• Superficial tears: Typically heal in 4–6 weeks with protection.
• Deep tears: May take 8–12+ weeks and need prolonged rehab or surgical fixation.

Causes and Risk Factors

Eversion ankle sprains are often caused by:

• Awkward landings (e.g., jumping onto uneven surfaces).
• Sports collisions or tackles that push the foot laterally.
  • For example, getting slide tackled in soccer.
• Overpronation (flat feet) during running/cutting.
• High-impact trauma, such as falls.
• Sudden twists
• Underlying ankle instability

Physiotherapy for Eversion Sprain Recovery

Deltoid ligament injuries in the ankle, though less common than lateral sprains, can lead to chronic instability if not properly managed. These injuries often occur in conjunction with ankle fractures or multi-ligament injuries. Managing the injury with physiotherapy early on is crucial for a smooth rehabilitation process and return to sport and daily activities.

Phase 1: Protection & Mobility (Weeks 0–2)

Goals:

• Reduce pain/swelling.
• Protect ligament healing.
• Prevent stiffness without stressing injured tissues.

1. Acute Management (First 72 Hours)

• RICE Protocol:
  • Rest: Avoid weight-bearing (use crutches if painful to walk).
  • Ice: 15–20 mins every 2–3 hours to reduce swelling.
  • Compression: Elastic bandage or ankle brace (e.g., lace-up or rigid stirrup).
  • Elevation: Keep ankle above heart level to minimize edema.

2. Early Mobility (Day 4–14)

• Ankle Pumps:
  • Sit with leg extended; slowly pump ankle up/down 10–15 reps every 2 hours. Promotes circulation without strain.
• Toe Circles/Tracing Alphabet:
  • Gentle clockwise/counterclockwise circles or "write" letters with toes. Maintains joint mobility.
• Non-Weight-Bearing (NWB) Stretches:
  • Towel Stretch: Loop towel around foot; gently pull toes toward you (hold 15–30 sec). Stretches Achilles/calf safely.

3. Protection Strategies

• Bracing: Wear a walking boot or rigid brace if moderate/severe injury.
• Weight-Bearing: Progress from NWB → partial weight-bearing (PWB) only if pain-free.

Things to Avoid in Phase 1:

• Eversion motions (outward rolling).
• Stretching the inner ankle aggressively.
• Walking without support if painful.

Progression Criteria to Phase 2:

✔ Minimal swelling/pain at rest.

✔ Tolerates PWB in brace.

✔ Restored 50% passive dorsiflexion/plantarflexion.

Phase 2: Strengthening & Stability (Weeks 2–6)

Goals:

• Restore strength in deltoid ligament and dynamic stabilizers.
• Improve balance/proprioception.
• Prepare for functional movements.

1. Strengthening Exercises

A. Resisted Ankle Motions (Band/Cable)

• Inversion (3x15 reps): Anchor band to a fixed object; pull foot inward against resistance.
  • Targets tibialis posterior (key stabilizer for medial arch).
• Eversion (3x15 reps): Band around forefoot; push outward (controlled).
  • Strengthens peroneals to balance forces on deltoid ligament.

B. Calf Raises (2x10–15 reps)

• Double-leg → single-leg progression (on flat ground → step).
• Restores gastrocnemius/soleus strength for push-off stability.

C. Hip/Core Stability

• Clamshells (3x15 reps): Side-lying, resist band at knees to strengthen gluteus medius.
• Dead Bugs (3x10 reps/side): Core activation with controlled limb movements.

2. Balance & Proprioception

• Single-Leg Stance (30 sec → 1 min): Progress to unstable surfaces (foam pad).
• Tandem Stance Heel Raises: Improves dynamic control.

3. Controlled Weight-Bearing

• Mini Squats (3x12 reps): Partial range, ensuring knee tracks over toes.
• Step-Ups (2x10 reps/side): Low height (4–6"), controlled eccentric phase.

Things to Avoid in Phase 2:

• Aggressive jumping/running.
• Sudden direction changes.
• Overstretching into eversion.

Progression Criteria to Phase 3:

✔ Full pain-free weight-bearing.

✔ Single-leg stance >30 sec without wobbling.

✔ No swelling after exercise.

Phase 3: Functional Training (Weeks 6–12+)

Goals:

• Restore dynamic stability for sports/ADLs.
• Rebuild power, agility, and endurance.
• Prepare for full return to activity.

1. Advanced Balance & Proprioception

A. Wobble Board/BOSU Drills

• Single-Leg Balance (30–60 sec) → Add arm motions or ball tosses.
• Tilt-to-Catch: Partner tosses ball while you balance on uneven surface.

B. Dynamic Stability Drills

• Single-Leg Squat to Mini-Hop (3x8 reps/side): Small hops landing with control.
• Star Excursion Balance Test (SEBT): Reach drills to improve neuromuscular control.

2. Agility & Plyometrics

A. Lateral Movements

• Lateral Shuffles (3x30 sec): Low-impact → progress to resisted bands.
• Carioca Drills (3x20 yards): Cross-step agility for multidirectional stability.

B. Controlled Plyos

• Box Step-Ups → Depth Drops (2x6 reps): Start low (6–12"), focus on soft landing.
• Single-Leg Hops (3x5 reps/side): Forward/backward → progress to lateral hops.

3. Sport-Specific Drills

• Cutting Drills (45°→90° turns): Mimic game-direction changes.
• Throwing/Kicking Progressions: Gradually increase distance/intensity.
• Endurance: Interval runs (e.g., jog/sprint ratios) if needed for sport.

Taping and bracing may also be helpful for additional external support.

Avoid in Phase 3:

• Full-speed pivots/cutting without control.
• Max-effort jumps until cleared.

Progression Criteria to Phase 4 (Return to Sport):

✔ No pain/swelling after high-impact drills.

✔ 90% strength/balance vs. uninjured side.

✔ Passes sport-specific tests (e.g., hop tests, agility benchmarks).

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Why Eversion Sprains Need Specialized Care

Eversion ankle sprains (medial/deltoid ligament injuries) require careful rehab due to:

1. Higher Complication Risk - Greater likelihood of associated injuries (syndesmotic sprains, medial malleolus fractures)
2. Severity - Results from high-force trauma that often damages multiple structures
3. Healing Challenges - Poor blood supply to deep deltoid fibers leads to slower recovery (6-12+ weeks vs 2-6 weeks for lateral sprains)
4. Unique Demands - Requires:
   • Tibialis posterior strengthening
   • Controlled pronation stability
   • Hip/core integration

Unlike lateral sprains (focus on peroneals), eversion sprains need medial protection. Extended bracing (8-12 weeks) is often necessary during return to sport.

It is important to consider the combination of higher complication risk and slower healing for eversion sprains, as this means rushed rehab often leads to chronic instability.

Prognosis and Return to Activity

Recovery Timeline

• Grade I (Mild): 4–6 weeks
  • Minimal ligament stretching
  • Focus on early mobility and progressive strengthening
• Grade II (Moderate): 6–12 weeks
  • Partial tearing of deltoid ligament
  • Requires bracing and structured rehab
• Grade III (Severe): 3–6+ months
  • Complete tear ± associated injuries (fractures/syndesmosis)
  • May need surgery if unstable

Return to Sports

• Non-contact activities: 6–12 weeks (when strength/balance reaches 90% of uninjured side)
• Overhead/cutting sports: 3–6 months
  • Requires sport-specific drills and gradual exposure to pivoting/impact

Key Factors Affecting Prognosis:

✔ Early protection (avoid premature eversion stress)

✔ Proper progression of strength/balance drills

✔ Addressing kinetic chain deficits (hip/core/arch control)

Warning Signs of Poor Recovery:

✖ Persistent medial pain

✖ Feeling of "giving way"

✖ Swelling after activity

Preventing Medial Ankle Injuries

1. Proprioception Training
   • Single-leg balance drills (progress to unstable surfaces)
   • Wobble board/BOSU exercises 2-3x/week
2. Targeted Strengthening
   • Tibialis posterior focus: Banded inversions, heel raises on incline
   • Peroneal balance: Resisted eversion to prevent overcompensation
3. Footwear & Bracing
   • Motion-control shoes for overpronators
   • Prophylactic taping/bracing during high-risk activities
4. Biomechanical Corrections
   • Address overpronation with:
     • Custom orthotics if needed
     • Arch strengthening (towel scrunches, marble pickups)
   • Improve hip/core stability (clamshells, dead bugs)

For Athletes:

✔ Pre-season ankle strengthening program

✔ Sport-specific agility drills (gradual exposure to cutting motions)

✔ Taping for competition if history of sprains

Most Overlooked Factor:

Poor landing mechanics → Focus on soft, controlled landings during jump training

FAQs About Eversion Sprains

Can eversion sprains cause chronic instability?

Yes, if improperly rehabbed. The deltoid ligament’s poor blood supply slows healing, leading to:

• Persistent medial joint laxity
• Recurrent sprains or "giving way" sensations
• Increased risk of post-traumatic arthritis
• Prevention: 6+ weeks of bracing and eccentric tibialis posterior strengthening.

Eversion sprain vs. high ankle sprain

• Eversion sprain: Stretches/tears the deltoid ligament (medial side).
• High ankle sprain: Injures the syndesmotic ligaments (between tibia/fibula).
• Key distinction: High ankle sprains cause pain above the ankle and worsen with calf squeezes.

How is this different from a syndesmosis injury?

• Deltoid injury: Medial pain, swelling, eversion weakness.
• Syndesmosis injury:
  • Pain with external rotation/dorsiflexion (e.g., squatting)
  • Positive "squeeze test" (compressing calf elicits pain)
  • Often requires longer rehab (3–6+ months).

When is surgery needed for a deltoid ligament tear?

Surgery is rare (10–15% of cases) but considered when:

• Grade III tear + ankle instability (failed 3+ months of rehab)
• Associated fractures (medial malleolus, syndesmotic disruption)
• Persistent pain/mechanical symptoms (e.g., catching, locking)

Post-op: 6–12 weeks non-weightbearing in a boot, then phased rehab.

Start Your Eversion Sprain Recovery Journey Today

Book a specialist assessment at Vaughan Physiotherapy Clinic to regain your strength and function!

Book Your Specialized Assessment Today:

• Phone: 905-669-1221
• Location: 398 Steeles Ave W #201, Thornhill, ON L4J 6X3
• Online Booking: www.vaughanphysiotherapy.com

Serving Thornhill, Langstaff, Newtonbrook, Willowdale, North York, Markham, Richmond Hill, Concord, and North Toronto.

Convenient Thornhill location with evening/weekend appointments available.

By: Tiffany Corpus

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