Sprained Ligaments in Children: What They Are and How They Manifest

A sprained ligament in children is an injury to the ligament fibers and surrounding soft tissues without a complete rupture or necessarily involving bone. In children and adolescents, such injuries most often occur during sports and active games, with the ankle joint (inversion injuries) being the most common. It's important to remember that in children, the growth plate (physeal plate) is weaker than the ligaments: the clinical picture of a sprained ligament often masks a Salter-Harris fracture, so diagnosis and treatment differ from those for adults. [1]

In the first 24 hours after injury, pain, swelling, and limited function predominate; after 24-72 hours, decisions about early mobilization, orthosis selection, load volume, and return to sports become crucial. Modern rehabilitation shifts the emphasis from prolonged rest to early functional mobilization and neuromuscular training, which reduces the risk of chronic instability and recurrent injuries. [2]

A separate task is judicious visualization. In many children with typical clinical presentations and negative Ottawa guidelines, radiography is not required; in cases of prolonged pain (more than a week) and "red flags," additional examinations according to ACR criteria are indicated. The wrong approach is to "X-ray everyone" or, conversely, to continue inactive if function fails to recover. [3]

A comprehensive approach includes family formation (which should be avoided in the first 48-72 hours), adequate analgesia, well-thought-out immobilization, and a gradual return to activity. Properly managed initial days determine the prognosis for months. [4]

Epidemiology

Soft tissue injuries are one of the most common reasons children visit emergency departments; millions of sports-related injuries are recorded in children and adolescents in the United States each year, and a significant proportion are strains and contusions. According to pediatric centers, nearly a third of all childhood injuries are sports-related, and strains are among the top diagnoses. [5]

The ankle is the most common segment: in population estimates, the incidence of acute ankle sprains reaches ~2-3 per 1000 person-years, with a peak in adolescence and in children actively involved in sports. In girls, the peak often occurs at 10-14 years of age, and in boys, at 15-19 years of age. [6]

In team sports (football, basketball), up to three-quarters of ankle injuries are sprains; this is critically important because untreated cases develop into chronic instability and limit participation in sports. The epidemic of recurrent injuries perpetuates the cycle of "pain - fear of movement - deconditioning - new risk." [7]

During the pandemic years, a shift in injury profile was observed (more domestic, fewer competitive), but after returning to training, the incidence of ligament injuries increased again. This highlights the importance of gradually increasing loads and preventative programs. [8]

Reasons

A typical mechanism is inversion of the foot upon landing, changing direction, or contact with an opponent; less common is eversion with damage to the medial ligaments. Sudden braking/turning (valgus, twisting), which can cause strain of the MCL/PCL, is dangerous for the knee in adolescents; in sports with throwing/weight-bearing loads, the wrist complex is affected. [9]

Extra-articular causes include poor footwear, uneven surfaces, fatigue, inadequate warm-up, sleep deprivation, and micro-loads associated with growth. Poor technique (landing on the toes with an inward roll, knee valgus) increases the risk. [10]

Recurrent episodes are associated with a previous sprain without rehabilitation: proprioception and stabilization strategy are impaired, the peroneals/flexors weaken, and even a slight shift in the center of gravity causes a new "twist." This explains why balance exercises reduce the risk of recurrence. [11]

In childhood injuries, the physis is particularly important: the same force in an adult can damage a ligament, but in a child, it can "stunt" part of the growth—a Salter-Harris fracture. Therefore, a clinical "sprain" in a child is not a diagnosis, but a hypothesis that must be confirmed to ensure a fracture is not missed. [12]

Risk factors

The greatest contributors are: a previous sprain of the same joint, inadequate rehabilitation, female gender in prepuberty/early puberty (for some sports), high body mass index, and growth spurts (strength/coordination imbalance). In football and basketball players, recurrent injuries are particularly common without preventive programs. [13]

Training errors include a sudden increase in volume/intensity, lack of warm-up, monotonous training surfaces, and overfatigue. Poor footwear, worn out spikes/soles, and lack of arch supports for those with hallux valgus all increase stress on the lateral ankle complex. [14]

Neuromuscular deficits (balance, reaction time, knee control during landing) are predictors of ankle and knee problems. Finally, sleep deprivation and prolonged, monotonous loads increase the incidence of overuse injuries, which "set the stage" for acute strains. [15]

In children under 10 years of age and in early puberty, the risks are not so much due to “weak ligaments” as to unstable motor control and growth phases: bone grows faster than muscles and tendons - temporary incoordination increases the likelihood of unsuccessful landings. [16]

Pathogenesis

In inversion foot trauma, the anterior talofibular ligament (ATFL) is primarily affected, followed by the calcaneofibular ligament (CFL); in more severe cases, the posterior talofibular ligament (PTFL) is affected. Microtears in collagen fibers cause hemorrhage, swelling, pain sensitization, and temporary loss of proprioception. [17]

In childhood, fibrous tissue is highly flexible, but the physis is more vulnerable: some "stretches" are actually subperiosteal or physeal injuries. Therefore, if persistent pain in the growth plate area occurs, the diagnosis should be reconsidered. [18]

Prolonged immobilization leads to deconditioning and delays the recovery of mechanoreception, which increases the risk of recurrent sprains. Therefore, modern protocols favor early functional mobilization combined with compression and progressive exercises. [19]

Incomplete recovery creates a cascade: pain → avoidance of exercise → strength/balance deficit → chronic instability and further injury. Early neuromuscular training breaks this cycle. [20]

Symptoms

Acute presentation: pain at the time of injury, increasing swelling, localized tenderness along the damaged ligament, and functional limitation (limping, refusal to bear weight). A hematoma appears within a few hours. With a lateral sprain, pain is present in front of and below the lateral malleolus. [21]

Red flags: inability to take four steps immediately after injury and in the emergency room, deformity, severe instability, pain in the area of the medial malleolus or base of the 5th metatarsal, severe pain in the physeal area - these are reasons for immediate imaging. [22]

In case of knee sprain of the MCL/PCL - local medial/lateral pain, swelling, tenderness during valgus/varus tests; in case of wrist - pain during abduction/flexion, local point along the scaphoid bone (rule out fracture). Persistent nocturnal pain, worsening of symptoms after 7-10 days - indication for reconsideration of the diagnosis. [23]

It's important to ask children about the "second impact"—a fall with repeated twisting often aggravates the injury and masks the underlying mechanism. The presence of a "crunch," acute deformity, or unstable support requires careful immobilization and transportation. [24]

Forms and stages

Clinically, grades of sprain are distinguished: I (tear of several fibers, minimal swelling), II (partial rupture, moderate swelling/hematoma, lameness), III (almost complete/complete rupture, severe instability, inability to support). In pediatrics, suspected physeal injury with localized pain along the growth plate is added to these. [25]

By phase: acute (0-72 h) - pain/swelling control, protection, early activation; subacute (3-14 days) - restoration of range of motion, isometrics, balance; functional (2-6 weeks) - strength, plyometrics, running/turning; return to sport - upon performing functional tests without pain. [26]

For the ankle, it's important to differentiate between lateral and medial instability, as well as high (syndesmosis) sprains—the latter require different loading timing and often longer-term protection. Incorrect classification leads to disruption of rehabilitation. [27]

Finally, some children may experience overstretching with hypermobility (benign) - then the need for stabilization exercises and training in landing technique is more pronounced. [28]

Complications and consequences

The main risks of an untreated sprain are chronic instability (a feeling of "twisting," a fear of supporting oneself), recurrent injuries, pain during exercise, and decreased athletic activity. This impacts quality of life and creates a "corridor" for post-traumatic osteoarthritis in adulthood. [29]

For the knee, this includes persistent medial pain, limited range of motion, and compensatory movement patterns (dynamic valgus), which increases stress on the anterior cruciate complex. For the wrist, this includes persistent pain when bearing weight and the risk of missing a scaphoid fracture. [30]

Incorrect immobilization, especially rigid and prolonged immobilization, leads to deconditioning and prolonged recovery times; conversely, too early "full" loading without stabilization leads to relapse. Therefore, measured activity and scheduled functional testing are necessary. [31]

Rare complications include pain dysfunction syndrome, reactive synovitis, and chronic avulsions. Physeal injuries can lead to growth disturbances, hence the low threshold for observation and re-evaluation if symptoms persist. [32]

Diagnostics

The basis is anamnesis and physical examination with targeted stress tests (anterior drawer, talar-tilt for the ankle; valgus/varus for the knee), assessment of support, and the "Ottawa rules" for deciding on an X-ray. If the Ottawa rules are negative and the clinical picture is typical in children, an X-ray is not necessary. [33]

If pain and function do not improve within 7-10 days, the ACR recommends considering MRI without contrast or CT (if bone pathology is suspected), especially in children over 5 years of age. Ultrasound is useful for dynamic evaluation of ligaments and effusions by an experienced operator. [34]

Laboratory tests are not indicated for uncomplicated sprains; they are required if systemic inflammatory/infectious processes are suspected, as well as before interventions. In questionable cases (local pain along the fibula/metatarsus, physis), there is a low threshold for repeat imaging. [35]

Document baseline function: one-legged standing test, jumping in place, line walking - this is useful for assessing readiness for return and preventing relapse. [36]

Differential diagnosis

Fractures (including avulsion and Salter-Harris fractures), syndesmotic injuries (high sprains), intra-articular lesions (meniscus, osteochondral lesions), tendinopathies (peroneal, Achilles), and compression syndromes (rare) should be excluded. The clinical picture, the location of maximum pain, and stress testing guide the choice of imaging. [37]

For pain at the base of the 5th metatarsal, rule out an avulsion fracture and a Jones stress fracture; for medial ankle pain, evaluate the deltoid ligament and talus; for persistent dorsal wrist pain, rule out a scaphoid fracture. [38]

Pain without trauma or with minimal mechanism requires searching for overload causes (apophysitis, stress fractures, synoviopathy). In hypermobile patients, systemic causes of pain should be excluded and a stabilization program should be selected. [39]

In preschoolers, “subluxations” (for example, “nanny elbow”) have a different mechanism and require different manipulations - this is a different clinical scenario. [40]

Treatment

Acute phase (0-72 hours): "PEACE" instead of "aggressive RICE." Protect the joint from further trauma, elevate, avoid NSAIDs and cryoexcesses during the first 24 hours for minor injuries (they can slow collagen regeneration), compression (elastic bandage/semi-soft orthosis), educate the family about the hardships of immobilization ("do no harm"). Ice - briefly for pain relief. [41]

Subacute stage (3-14 days): "LOVE." Loads - dosed and early (walking in a partial-support orthosis), optimism - reduction of fear-avoidance, vascular stimuli (Vascularization) - exercise bike/easy jogging in place without pain, exercises (Exercise) - isometrics/active movements, balance on an unstable surface. This restores proprioception faster than prolonged "rest." [42]

Orthoses and bracing. For grades I-II ankle bracing, semi-rigid braces/tapes and early mobilization are preferred; for grade III, a short period of immobilization (boot/splint) followed by a transition to a functional regimen. New data in children show that minimal restrictions are as effective as bandaging and are sometimes even better tolerated. [43]

NSAIDs and analgesia. Paracetamol as a basic analgesic; NSAIDs – for pain and short-term relief. Opioids are not required. In case of severe swelling, compression and elevation are recommended. Physiotherapy with an emphasis on neuromuscular control (peroneals, gluteals) and landing disorders is key to preventing relapse. [44]

Return to sport. Criteria: pain-free support, symmetrical range of motion, strength ≥90% of the healthy side, passing functional tests (jumps, Y-Balance). Prophylactic taping/orthesis in the first weeks after return reduces the risk of re-injury. [45]

Table 1. “PEACE & LOVE” for soft tissue injuries in children (adapted)

Stage	Transcript	What to do in practice
PEACE (0-72 h)	Protect, Elevate, Avoid anti-inflammatories, Compress, Educate	Brace/crutches for pain, elevation, short-term ice for pain, elastic bandage, explain plan to family. [46]
LOVE (3-14 days)	Load, Optimism, Vascularisation, Exercise	Dosed walking, positive attitude, cycling/swimming, ROM+isometrics+balance. [47]

Table 2. When to take x-rays for an ankle injury in a child

Situation	Tactics
Ottawa's Positive Rules (Local pain in bone points + inability to walk 4 steps)	Radiography in 2-3 projections. [48]
Pain > 1 week, persistent lameness	Consider MRI without contrast (≥5 years) or CT.[49]
Local pain in the physis area	Low threshold for imaging/re-evaluation at 5-7 days. [50]
Suspected syndesmosis/high strain	X-ray ± stress images; MRI as indicated. [51]

Table 3. Classification of the severity of sprains (summary)

Degree	Clinic	Tactics for the first 2 weeks
I	Localized pain, minimal swelling, support possible	Orthosis/compression, early walking, LOVE. [52]
II	Moderate swelling/hematoma, lameness, limited ROM	Semi-rigid orthosis, crutches for 2-4 days, early mobilization. [53]
III	Severe pain/swelling, instability, no support possible	Short immobilization (boot), then functional rehabilitation; MRI control if in doubt. [54]

Table 4. Red flags for sprains in children

Sign	What to exclude	Actions
Inability to complete 4 steps	Fracture/serious injury	Ottawa X-ray. [55]
Localized pain along the fibula at the top of the ankle/base of the 5th metatarsal	Tearaway/Jones	Targeted radiography/MRI. [56]
Pain along the frieze (growth zone)	Salter-Harris	Visualization, gentle tactics. [57]
Pain >10 days, instability	Syndesmosis/intra-articular injury	MRI, change in treatment plan. [58]

Table 5. Relapse prevention: what really works

Measure	Effect/comments
Neuromuscular training (balance, peronei, landing)	Reduces the risk of recurrent strains and chronic instability. [59]
Semi-rigid orthosis/tape for return to sports	Reduces relapses in the first 6-12 weeks. [60]
Gradually increasing the load, sleep, a variety of surfaces	Reduces overuse and acute injuries. [61]
Checking shoes/insoles, correcting technique	Important for valgus/pronation; work with a trainer/PL. [62]

Table 6. Differences between "sprain vs. physeal injury" (suspected)

Sign	Stretching	Physeal damage
Localization of pain	By ligament/capsule	Exactly along the growth line
Edema	Periarticular	Local to the growth zone
X-ray	Often unchanged	It may be normal for the first day.
Tactics	Functional	Gentle, re-evaluation/MRI if in doubt [63]

Table 7. Minimum set of exercises (2-6 weeks)

Target	Examples
Proprioception	Standing on one leg, balance platform, touch star
Strength	Isometric/isolation peronei resistance, monster steps, squats
Motion control	Jumping in place, landing with emphasis on the knee over the foot
Non-impact cardio	Exercise bike, elliptical, swimming

Prevention

At the child and family level. Regular balance and strength exercises to stabilize the ankle/knee, teach proper landing and direction changes. Shoes should fit properly, with adequate heel support; check sole wear. Increase the load gradually, allow for recovery days, and monitor sleep and hydration. When returning to sports after a sprain, use a brace/tape for 6-12 weeks and follow a home program. [64]

At the school/club level. Include neuromuscular programs in the warm-up (5-10 minutes), monitor training volume and periodization, ensure a safe surface and an ice removal/inspection plan. For coaches, provide "return to play" checklists with functional testing; for medical staff, provide selection algorithms for Ottawa-compliant imaging and access to early rehabilitation. [65]

Forecast

With proper early management (PEACE & LOVE, functional bracing, neuromuscular rehabilitation), most children with grade I-II sprains return to normal activity within 2-6 weeks without long-term consequences. Recurrence is rare with adherence to a strengthening program and the use of a preventative brace at the outset. [66]

Risks for a worse outcome include grade III, missed physeal injuries, premature return without readiness criteria, and lack of a preventive program. These factors prolong recovery time and increase the likelihood of chronic instability. Early revision of the plan when progress is lacking is key to a good outcome. [67]

FAQ

• Does everyone need to have an x-ray when they get a 'turned'?

No. Follow the Ottawa guidelines; if they are negative and the clinical picture is typical, many children do not require an X-ray. If pain persists for >7-10 days, re-evaluate and MRI may be necessary. [68]

• Are ice and NSAIDs harmful?

Ice is acceptable for short sessions for pain relief. NSAIDs are used briefly for pain relief. The PEACE & LOVE concept recommends avoiding "aggressive" anti-inflammatory strategies in the first 24 hours for minor injuries, prioritizing protection and early mobilization. [69]

• How long should I wear the orthosis?

Typically 2-4 weeks for grades I-II, then another 4-6 weeks for sports only. For grade III, short-term immobilization (boot) with a transition to a functional regimen. [70]

• When can I return to training?

When the criteria are met: no pain/swelling at rest and during running tests, range of motion and strength ~90% of the healthy side, functional jumping/balance tests passed. [71]

• How to prevent a recurrence?

Balance and strength training 2-3 times a week, proper landing technique, brace/tape in the first weeks of the “comeback”, sufficient sleep and a gradual increase in loads. [72]