1 · SNAPSHOT
Who: Eversion mechanism, external rotation, or high-energy trauma. Less common than lateral sprain.
What: Injury to the superficial and/or deep deltoid complex. The deltoid resists eversion, talar tilt and external rotation [1] — which is exactly why it rarely gets injured alone.
How it behaves: Medial pain, swelling and bruising after the mechanism. Sometimes instability or catching. Eased by rest and compression.
The one thing to take from this page:
A medial ankle sprain is a screening obligation before it is a diagnosis. The same mechanism loads the deltoid, the syndesmosis and the bones — so screening one is screening none.
| Before you call it a sprain | Why |
|---|---|
| Screen the lateral ligaments | Medial injuries frequently coexist with lateral ones |
| Screen the syndesmosis | The deltoid resists external rotation — so does the syndesmosis |
| Apply the fracture rules | Deltoid rupture can make an ankle fracture unstable |
| Ask about weight-bearing and catching | Both push toward imaging |
⚠️ No Australian management guideline exists, and no guideline anywhere covers the medial injury specifically; for the X-ray decision, NSW's emergency care protocol uses the Ottawa Ankle Rules. Anchored to the JOSPT ankle stability clinical practice guideline [2] and the international ankle sprain guideline [3]. Both are built on lateral ankle sprain evidence. The rehabilitation principles transfer; the timeframes and the screening do not.
2 · SE — THE SUBJECTIVE PATTERN (the 70%)
Acute trauma, so your course reorders it: MAIN PROBLEM → BODY CHART → HISTORY → BEHAVIOUR.
MAIN PROBLEM
"I rolled it — but outwards, not inwards."
"It's swollen on the inside of my ankle."
"It feels like it's going to give way when I turn."
BODY CHART
- Mark the medial malleolus and the deltoid course — and separate superficial from deep if you can. Pain location maps to structure (Obionu et al. 2024).
- Draw the lateral side and the syndesmosis too. If you have not drawn them, you have not screened them.
- Mark the Ottawa sites — malleoli, base of the fifth metatarsal, navicular.
HISTORY
- The mechanism, in detail. Eversion? External rotation? A direct high-energy blow? Foot position at the time?
- Could they weight-bear immediately, and can they take four steps now?
- Any pop, crack, or immediate swelling?
- Previous ankle injuries — including "just sprains". Chronic instability is not always lateral (Anderson et al. 2025).
BEHAVIOUR
- Eased by rest and compression, as any acute ligament injury is.
- Severity: VAS 0–10 at best / at worst / right now.
- Instability, giving way, or catching — all three push toward imaging rather than rehabilitation.
- Symptoms on rotation rather than on inversion is a medial and syndesmotic pattern.
SPECIAL / SCREENING QUESTIONS
- Anything suggesting fracture — see the red flags section, which is free.
- Occupation and sport, specifically whether it involves cutting, pivoting or external rotation loads. These come back later than a lateral sprain would suggest.
Assessing this region? Download the Ankle & Foot assessment template →
3 · HYPOTHESIS RANKING
| Competing pattern | The one discriminating feature |
|---|---|
| Tibialis posterior tendinopathy | Gradual medial arch ache with a collapsing foot and a failed single-leg heel raise. A deltoid sprain is traumatic and eversion-loaded. |
| Tarsal tunnel syndrome | Burning, tingling or numbness into the plantar foot, positive Tinel's, symptoms on dorsiflexion-eversion. Neural, not ligamentous. |
| Syndesmosis injury | Frequently coexists rather than competes. External rotation pain, squeeze test, pain above the joint line. Assess all three. |
And the two that outrank all of them
Fracture, and an unstable ankle. Deltoid injury often enters clinical decision-making through fracture stability (James & Dodd 2022), and stress testing matters most exactly when fracture or instability is in the differential (Cao et al. 2023). Medial pain after a high-energy injury is not a benign sprain until bony injury has been excluded (van Leeuwen et al. 2022).
4 · RED FLAGS — DON'T MISS THIS
This section is free, on every pattern, forever. Safety is never gated.
| Finding | What it suggests | What you do |
|---|---|---|
| Bony tenderness — malleoli, base of 5th MT, navicular | Fracture | Image before you treat |
| Unable to take four steps — then or now | Fracture | Image before you treat |
| Deformity, crepitus, open wound, neurovascular compromise | Fracture | 🚑 Emergency department |
| Proximal fibular tenderness — palpate to the fibular head | Maisonneuve fracture | Urgent assessment |
| Marked valgus laxity or a sense of the ankle shifting | Instability, possible deltoid rupture | Orthopaedic review |
| Catching or locking | Osteochondral lesion | Imaging, orthopaedic review |
| High-energy mechanism + medial pain | Fracture or unstable ankle | Image. Do not call it a sprain |
| Not settling on standard rehabilitation | Medial instability, or a missed associated injury | Reassess, then re-image |
The rule: a medial ankle sprain earns its diagnosis only after the lateral ligaments, the syndesmosis and the bones have been screened.
Cross-links: Lateral ankle sprain · Syndesmotic / high ankle sprain · Fracture / OLT / infection
5 · OE — THE OBJECTIVE (the 30%)
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The objective exam, management and pearls, plus the six-minute lesson and the debrief. Free with an account.
Sign in or join free6 · MX — MANAGEMENT ESSENTIALS
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The objective exam, management and pearls, plus the six-minute lesson and the debrief. Free with an account.
Sign in or join free7 · CLINICAL PEARLS + RETRIEVAL CHECK
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The objective exam, management and pearls, plus the six-minute lesson and the debrief. Free with an account.
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Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.
Sign in or join freeGuideline anchor
No Australian guideline covers ankle sprain management; for the X-ray decision, NSW's emergency care protocol (Agency for Clinical Innovation) uses the Ottawa Ankle Rules, including medial malleolar tenderness.
More
Anchored to the JOSPT clinical practice guideline on ankle stability and movement coordination impairments (Martin et al. 2021, PMID 33789434) and the international evidence-based guideline on the diagnosis, treatment and prevention of ankle sprains (Vuurberg et al. 2018, PMID 29514819). Both are lateral-dominant and neither is Australian — the page says so, and says which principles transfer.
Both guidelines are built on LATERAL ankle sprain evidence. There is no guideline anywhere for the medial-sided injury specifically. The rehabilitation principles transfer — protected early motion, balance and proprioception, strength, functional criteria for return — but the timeframes and the associated-injury screening do not, and this page treats the medial injury as slower and higher-suspicion for that reason.
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Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.
Sign in or join freeSources · 20
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Every source on this page resolves and title-verifies against PubMed. Newest first.
- 2013Savage-Elliott et al. (2013). The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 21(6), 1316-27. https://doi.org/10.1007/s00167-012-2159-3
- 2021Martin et al. (2021). Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. The Journal of orthopaedic and sports physical therapy, 51(4), CPG1-CPG80. https://doi.org/10.2519/jospt.2021.0302
- 2018Vuurberg et al. (2018). Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine, 52(15), 956. https://doi.org/10.1136/bjsports-2017-098106
- 2010Chinn & Hertel (2010). Rehabilitation of ankle and foot injuries in athletes. Clinics in sports medicine, 29(1), 157-67, table of contents. https://doi.org/10.1016/j.csm.2009.09.006
- 2013McCollum et al. (2013). Syndesmosis and deltoid ligament injuries in the athlete. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 21(6), 1328-37. https://doi.org/10.1007/s00167-012-2205-1
- 2015Crim & Longenecker (2015). MRI and surgical findings in deltoid ligament tears. AJR. American journal of roentgenology, 204(1), W63-9. https://doi.org/10.2214/AJR.13.11702
- 2020Halabchi & Hassabi (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World journal of orthopedics, 11(12), 534-558. https://doi.org/10.5312/wjo.v11.i12.534
- 2022van Leeuwen et al. (2022). The value of radiologic diagnostics in evaluating deltoid integrity in isolated type B ankle fractures: a systematic review of the literature. Archives of orthopaedic and trauma surgery, 142(7), 1523-1530. https://doi.org/10.1007/s00402-021-03850-y
- 2022de Krom et al. (2022). Diagnostic tools to evaluate ankle instability caused by a deltoid ligament rupture in patients with supination-external rotation ankle fractures: A systematic review and meta-analysis. Injury, 53(2), 724-731. https://doi.org/10.1016/j.injury.2021.09.034
- 2022James & Dodd (2022). Management of deltoid ligament injuries in acute ankle fracture: a systematic review. Canadian journal of surgery. Journal canadien de chirurgie, 65(1), E9-E15. https://doi.org/10.1503/cjs.020320
- 2019Sridharan & Dodd (2019). Diagnosis and Management of Deltoid Ligament Insufficiency. Foot & ankle orthopaedics, 4(3), 2473011419860073. https://doi.org/10.1177/2473011419860073
- 2022Black et al. (2022). Ultrasonography for the diagnosis of deltoid injury in supination external rotation ankle fractures - A scoping review. Foot (Edinburgh, Scotland), 51, 101897. https://doi.org/10.1016/j.foot.2021.101897
- 2022Gaddi et al. (2022). Acute Ankle Sprain Management: An Umbrella Review of Systematic Reviews. Frontiers in medicine, 9, 868474. https://doi.org/10.3389/fmed.2022.868474
- 2022Gopinath et al. (2022). Medial Ankle Instability: Review of Anatomy, Evaluation, and Treatment. Foot & ankle specialist, 15(6), 573-578. https://doi.org/10.1177/1938640021992915
- 2023Cao et al. (2023). Stress Tests for Deltoid Ligament and Syndesmosis Injury in Patients With Ankle Fracture: A Systemic Review With Meta-Analysis. Journal of orthopaedic trauma, 37(11), e441-e446. https://doi.org/10.1097/BOT.0000000000002651
- 2024Tong et al. (2024). Bone marrow edema at ligament insertion is an accurate MRI sign of deltoid ligament injury. Acta radiologica (Stockholm, Sweden : 1987), 65(1), 91-98. https://doi.org/10.1177/02841851231197508
- 2024Obionu et al. (2024). A clinical guide to the medial ligaments of the ankle: Anatomy, function, diagnosis of injuries and treatment of instability-a narrative review. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons, 30(2), 85-91. https://doi.org/10.1016/j.fas.2023.10.010
- 2024Koris et al. (2024). Deltoid ligament injuries: A review of the anatomy, diagnosis and treatments. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 32(12), 3052-3064. https://doi.org/10.1002/ksa.12274
- 2024Schrempf et al. (2024). A systematic review on how to diagnose deltoid ligament injuries-are we missing a uniform standard?. BMC musculoskeletal disorders, 25(1), 782. https://doi.org/10.1186/s12891-024-07869-1
- 2025Anderson et al. (2025). Diagnosis and Management of Deltoid Ligament Injuries in Chronic Ankle Instability: A Systematic Review. Foot & ankle orthopaedics, 10(1), 24730114251323903. https://doi.org/10.1177/24730114251323903
Mapped to this pattern
Generic measures that also apply
- Borg RPE
Borg Rating of Perceived Exertion Scale (6-20)
perceived exertion · 1 items · 1 min
- GROC
Global Rating of Change Scale
perceived change since baseline · 1 items · 1 min
- NPRS
Numeric Pain Rating Scale
pain intensity · 1 items · 1 min
- PGIC
Patient Global Impression of Change
perceived change since baseline · 1 items · 1 min
- PSFS
Patient-Specific Functional Scale
patient-generated function · 3 items · 2 min
- SANE
Single Assessment Numeric Evaluation
patient-rated function as a percentage of normal · 1 items · 1 min
- VAS
Visual Analogue Scale
pain intensity · 1 items · 1 min
- Borg CR10
Borg Category Ratio 10 Scale
perceived exertion or symptom intensity, ratio scale · 1 items · 1 min
- GAS
Goal Attainment Scaling
individualised goal achievement · 10 min
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