The Ankle Sprain Return-to-Play Framework Nobody Told You About

The SparkNotes

• 155 sports medicine experts across 19 countries spent three rounds agreeing on what should be checked before you go back to sport after an ankle sprain.

• Sixteen criteria made the cut, in five categories: pain, ankle impairments, athlete perception, sensorimotor control, and sport performance.

• Your own confidence in the ankle is one of them. Formally.

• Imaging of the ligaments was deliberately left out.

• Two questions split the panel down the middle and were never resolved.

The Whole Story

Ankle sprains are the most common injury in sport. They are also the most casually dismissed.

More than half of people who sprain an ankle never see a medical professional about it at all. Among American high school athletes, most were back playing within three days.

Three days.

For a long time that was hard to argue with, because nobody had agreed what a proper recovery should even involve. Two clinicians could look at the same ankle and set completely different bars, and neither had anything to point at.

What changed

A research team ran a three-round Delphi consensus process — a structured way of getting experts to converge — with 155 sports medicine professionals across 19 countries and 15 sports. Physiotherapists, athletic trainers, sports medicine physicians.

They were handed 35 possible criteria and asked, round after round, which ones actually belong in the decision to send someone back.

Sixteen survived. They sort into five categories, and the categories spell PAASS.

• PAIN — not whether it hurts sitting still, but pain during actual sport, and over the previous day.

• ANKLE IMPAIRMENTS — range of motion, strength, endurance, power. Measured against the other side, not eyeballed.

• ATHLETE PERCEPTION — whether you trust the ankle, and whether you feel ready.

• SENSORIMOTOR CONTROL — proprioception and dynamic balance. Your ankle's ability to sense and react, not just move.

• SPORT AND FUNCTIONAL PERFORMANCE — hopping, jumping, cutting, sport-specific drills, and getting through a full session.

The part that surprises people

Athlete perception is on that list. Not as a footnote — as one of five core categories.

If you have ever said "it feels fine, I just don't trust it yet" and had that treated as nerves to push through, a panel of 155 experts disagrees with whoever told you that. Your confidence in the joint is data.

Something else is missing from the list, and its absence is deliberate. Structural imaging of the ligaments was specifically excluded. Not because imaging is useless — it matters for ruling out a fracture — but because the panel did not consider a picture of the ligament a reliable guide to whether the ankle is ready to perform. General quality-of-life questionnaires were dropped too, as too blunt to say anything about sport.

Where the experts could not agree

Two items never reached consensus at all, after three full rounds.

Whether ongoing joint swelling should hold someone back. And whether balancing on one leg standing still still tells you anything once you have tested balance during movement.

On static balance the panel split exactly down the middle — 48% for including it, 48% against. On swelling it leaned toward including it, 67% to 26%, but never reached the 70% bar the study had set in advance.

That is worth knowing rather than hiding. It marks the point where the evidence runs out and somebody has to make a judgment call — which is a different thing from following a protocol, and it is worth asking whoever is treating you which one they think they are doing.

One honest limitation

This is a consensus on WHAT should be assessed. It is not a set of tested pass-or-fail numbers.

The authors say so directly: the specific tests, and the thresholds you would need to clear, still have to be developed and validated. So this framework tells you which questions a good assessment asks. It does not yet tell you what score means ready.

That is still a long way ahead of "does it hurt?"

The sentence I hear most

Ask someone with a long-standing ankle problem how many times they have rolled it, and the answer comes back in one of two forms. “I’ve rolled it so many times I can’t even count.” Or “I lost count after three or four.”

That is not somebody who had one bad sprain. That is somebody whose first sprain was never finished.

Finish the course

Think about how a doctor talks to you about antibiotics. You start feeling better after a few days, because the medicine is doing its job — and what do they always say? Keep taking it until it is finished, not until you start to feel better.

Ankle sprains work the same way. A low-grade first or second sprain can feel better quickly, and that is exactly the moment people stop. Seeing the rehab through is what makes sure no deficits are left behind.

This does not mean you cannot go back to sport until rehab is over. You can, and usually should. It means the rehab keeps going while you do — as you get better, as you return to training, as you go back to playing.

What to do with it

If you have sprained an ankle — last month or nine years ago — you can hold your own recovery up against this.

• Has pain been checked during real sport movement, or only at rest?

• Has strength, range and endurance actually been measured against your other side?

• Do you trust it, honestly, or have you quietly stopped doing one or two things?

• Has anyone tested your balance while you were moving, not just standing?

• Have you been tested at sport intensity — cutting, landing, a full practice — rather than walking around pain-free?

If most of your recovery was pain and basic movement, some of those categories were probably never looked at. That gap is one of the better-documented routes into chronic ankle instability: the ankle that keeps rolling, keeps feeling untrustworthy, and keeps quietly shrinking what you are willing to do on it.

And that is not a permanent condition you are stuck with. Often it is an assessment that never happened.

Follow along as Resurgo comes together.

Read next: Cleared to Play Isn't the Same as Ready to Compete · What Happens After You're Discharged?

SOURCE: Smith MD, Vicenzino B, Bahr R, Bandholm T, Cooke R, Mendonça LM, Fourchet F, Glasgow P, Gribble PA, Herrington L, Hiller CE, Lee SY, Macaluso A, Meeusen R, Owoeye OBA, Reid D, Tassignon B, Terada M, Thorborg K, Verhagen E, Verschueren J, Wang D, Whiteley R, Wikstrom EA, Delahunt E. Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework — an international multidisciplinary consensus. British Journal of Sports Medicine. 2021 Nov;55(22):1270–1276. doi:10.1136/bjsports-2021-104087. PMID 34158354.