Return-to-sport following lateral ankle sprain: Connecting scientific frameworks and real-world protocols of elite sports teams

Abstract

Lateral ankle sprains (LAS) are the most common lower-limb sports injuries and demonstrate high recurrence rates. Although several return-to-sport (RTS) frameworks exist, empirical, sport-specific criteria remain limited. Clinicians rely on heterogeneous or incomplete assessment strategies. This paper aims to answer how current RTS guidelines for LAS compare to RTS protocols in elite sports teams; and how RTS decision-making after LAS can be optimised by connecting conceptual frameworks and real-life protocols. Elite teams’ protocols (n = 6) demonstrated large variability in RTS-phases, progression, and assessment strategies. Only one StARRT domain (specific tests) was universally assessed. All teams evaluated ankle range of motion, muscle function, jumping/hopping, and agility (PAASS framework). Psychological readiness, proprioception, contextual modifiers and ability to complete a full training were deficient in the protocols. Most protocols approached RTS with phases. Both literature and practice relied heavily on isolated tests, with minimal integration of sport-specific, continuous RTS assessments. Optimising RTS after LAS requires shifting from reductionist, single-time-point testing toward a complex-systems approach embedded across the RTS continuum. Clinicians should integrate progressive on-field rehabilitation, continuous monitoring across a broader range of factors influencing risk and readiness. Aligning frameworks with practical, phase-based protocols may enhance decision-making, reduce recurrence risk and facilitate return to performance.