Cleared to Play: What Should Drive the Return-to-Sport Decision After LAS
Nine months after tearing the ACL and LCL in his left knee, Patrick Mahomes was cleared for full practice. He took 11-on-11 reps with the first team. Andy Reid said he was doing everything he normally does. The Chiefs still declined to play him a single preseason game snap, which makes this the first preseason he has missed in ten years.
A repaired knee is not an ankle sprain, and a franchise quarterback is not a typical case. Nevertheless, the Chiefs had a well-established path to follow. Knee reconstruction comes with staged rehabilitation milestones, functional test batteries, and a body of outcome research on what happens to athletes who go back too early. Holding Mahomes out until the regular season is a judgment call, but it’s a call informed by validated criteria.
This is what a well-managed gap between clearance and readiness looks like: an organization deciding that medically cleared and competitively ready mean different things, and choosing to exercise caution now rather than risk a repeat of last year.
Ankle sprains often do not get that level of consideration. The reason is not that training staff and clinicians are careless with them. It is that there is remarkably little guidance to show them what readiness should look like.
How fast athletes actually go back
Among NCAA athletes treated for a lateral ligament complex sprain, 44.4% returned to play in under 24 hours.¹ Only 3.6% took more than 21 days. When the sprain is a recurrence rather than a first injury, athletes go back faster still — the average return after an initial sprain in high school athletes was about three days, and after a recurrent one, less than a day.²
The pattern holds further down the competitive ladder, and it starts early. A survey of 2,747 youth basketball players in Niigata, Japan found that 54.7% of under-12 players and 53.5% of under-15 players had returned to competition while still in pain in the injured ankle. Among the under-15 players, 26.3% sought no professional care of any kind after their sprain. And 12.4% of players in both groups met the International Ankle Consortium's criteria for chronic ankle instability, or CAI, though the authors note those criteria were developed for adults and treat the figure as descriptive rather than diagnostic.³
As we can see, there doesn’t appear to be any consistency in medically-informed return-to-sport decisions being made in these cases. Clearance is determined by the schedule and an athlete’s willingness to play through pain, rather than meeting any established clinical criteria, and they are made that way because such criteria do not exist in a practicable form.
There is no test to pass
In 2019, a systematic review looked for prospectively determined, evidence-based criteria to inform the return-to-sport decision after a lateral ankle sprain (LAS). It found none.⁴ The following year, a second review took a different approach and asked what expert clinicians themselves used. It found no consensus among them either.⁵
The International Ankle Consortium responded in 2021 with the PAASS framework, integrating the input of 155 health professionals working in elite field and court sports. The consensus identified five domains that should inform the decision: pain severity, ankle impairments, athlete perception, sensorimotor control, and sport-specific functional performance.⁶ It is a genuine advance, and it is worth saying plainly what it is: a structured record of what experienced clinicians believe, assembled because the outcome data to build something firmer did not exist.
This is an evidence gap, not a competence gap, and the distinction matters because it changes what needs to be done about it. It is also not yet a solved problem in practice. A nationwide survey of Swedish physiotherapists managing LAS, published in January 2026, found adherence to the international assessment and return-to-sport frameworks was generally low, although slightly higher when clinicians used locally modified versions rather than the originals. Years of experience and education level made little difference to adherence. Clinicians were more confident in their own experience than in the frameworks.⁷
What two months after an ankle sprain actually looks like
The most useful data on this comes from a two-year prospective cohort that followed 64 patients after an acute LAS — albeit mostly recreational athletes in their mid-thirties, only two professionals — and scored them at two months using the Ankle-GO, a composite of four functional tests and two patient-reported questionnaires built on the PAASS domains.⁸
Fifty-four patients completed follow-up. Eighteen of them — a third — sustained a recurrent sprain within two years. Every one of those eighteen reinjuries was non-contact. Patients scoring below 8 points out of 25 at the two-month mark had close to nine times the odds of reinjury over the following two years.
The finding that deserves more attention is buried in the results table. At two months, both the reinjured (18 patients) and non-reinjured (36 patients) groups sat on the impaired side of nearly every threshold used to define CAI. Foot and Ankle Ability Measure scores within the CAI range, on both the daily-living and sport subscales. Single-leg stance error counts in the poor-balance range. Star Excursion Balance Test composite scores under the 89.6% reference. Side hop and figure-of-eight times slower than their cutoffs — 25 seconds against a 12.8-second reference in the reinjured group, 20 in the group that stayed healthy. Only one measure in the group that avoided reinjury came out clean: posteromedial reach at 93.7% against a 91% threshold. The difference between groups on that measure was not statistically significant.
TL;DR: Two months after a single LAS, the entire study cohort looked chronically unstable by the field’s own standards.
That is worth sitting with alongside the return-to-play numbers. Athletes are going back in under a day. The measurable deficits are still present at two months.
What is still missing when the athlete goes back
The deficits are not only structural. A 2026 meta-analysis of 17 electromyography studies covering 757 participants found that people with CAI activate the peroneus longus significantly less than healthy controls after initial contact during single-leg landings, with reduced gluteus medius and biceps femoris activation alongside it.⁹
The peroneals are the ankle's own active defense against inversion. They are the muscles that fire, too slowly even in a healthy ankle, when the joint starts to roll. What the EMG data describes is a defense that was already outpaced by the injury mechanism becoming measurably weaker after the first injury.
Rehabilitation addresses some of this. Balance and proprioceptive training show consistent benefit for CAI, though a systematic review published in late 2025 found the evidence base for many widely used protocols thinner than practitioners might assume, with recurrence still reaching as high as 80% in high-risk sports.¹⁰ Reinjury risk is roughly doubled in the year following an initial sprain, and around 40% of first-time sprains progress to chronic instability.¹¹
What to do with this
A few things follow directly.
The return decision should not be made on time alone, and there is now at least one objective tool that predicts something. The Ankle-GO takes under 20 minutes, requires no equipment beyond tape and a stopwatch, and has a published cut-off. A score under 8 at two months is a signal worth acting on. It is not a complete answer and its authors do not claim it is, but it is better than a calendar.
The severity of the initial injury is a poor predictor of reinjury. A Grade I sprain that lets an athlete walk off the field is not measurably safer, over the following two years, than the Grade II that put them in a boot.
Diagnostic testing right after injury or at the moment of return tells you less than testing several weeks later. The two-month score was predictive across two years. Most athletes in these cohorts were back long before anyone measured anything.
The final point follows from the other three. Even a well-run, criterion-based return puts an athlete back onto the field with a joint whose own protective response is measurably slower than it was before. That deficit is what the reinjury statistics are describing. Better testing identifies who carries it. Better rehabilitation reduces how much of it there is. Neither closes it entirely, and the athlete continues to play in the meantime.
LigaSys is developing Smart Ligament™ systems — reactive wearable hardware designed to sense dangerous joint motion and respond mechanically in real time. If you're working on athlete availability and performance outcomes, we'd like to hear from you.
References
Roos KG, Kerr ZY, Mauntel TC, Djoko A, Dompier TP, Wikstrom EA. The epidemiology of lateral ligament complex ankle sprains in National Collegiate Athletic Association sports. American Journal of Sports Medicine. 2017;45(1):201–209. https://pubmed.ncbi.nlm.nih.gov/27573356/
Medina McKeon JM, Bush HM, Reed A, Whittington A, Uhl TL, McKeon PO. Return-to-play probabilities following new versus recurrent ankle sprains in high school athletes. Journal of Science and Medicine in Sport. 2014;17(1):23–28. https://pubmed.ncbi.nlm.nih.gov/23689105/
Kikumoto T, Mizutani J, Tsuchida A, Takabayashi T, Kubo M, Okada H, Kon Y. Epidemiology of ankle sprains and anterior cruciate ligament injuries in youth basketball athletes in Niigata, Japan: a regional survey on injury management and healthcare professional involvement. PLOS One. 2026;21(3):e0344196. https://pubmed.ncbi.nlm.nih.gov/41818204/
Tassignon B, Verschueren J, Delahunt E, Smith M, Vicenzino B, Verhagen E, et al. Criteria-based return to sport decision-making following lateral ankle sprain injury: a systematic review and narrative synthesis. Sports Medicine. 2019;49:601–619. https://pubmed.ncbi.nlm.nih.gov/30747379/
Wikstrom EA, Mueller C, Cain MS. Lack of consensus on return-to-sport criteria following lateral ankle sprain: a systematic review of expert opinions. Journal of Sport Rehabilitation. 2020;29(2):231–237. https://pubmed.ncbi.nlm.nih.gov/31141438/
Smith MD, Vicenzino B, Bahr R, Bandholm T, Cooke R, Mendonça LDM, et al. 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. https://pubmed.ncbi.nlm.nih.gov/34158354/
Lööf I, Ashnai F, Nygren D, Beischer S. Clinical assessment of lateral ankle sprains among Swedish physiotherapists: a nationwide survey comparing practice to international and locally modified frameworks. BMC Sports Science, Medicine and Rehabilitation. 2026. https://pubmed.ncbi.nlm.nih.gov/41508095/
Picot B, Fourchet F, Lopes R, Rauline G, Freiha K, D'hooghe P, Valentin E, Hardy A. Low Ankle-GO score while returning to sport after lateral ankle sprain leads to a 9-fold increased risk of recurrence: a two-year prospective cohort study. Sports Medicine – Open. 2024;10:23. https://pubmed.ncbi.nlm.nih.gov/38453775/
Hakimi Poor et al. Neuromuscular characteristics of individuals with chronic ankle instability during unilateral landing tasks: a meta-analysis of electromyographic studies. Journal of Orthopaedic Surgery and Research. 2026. https://doi.org/10.1186/s13018-026-07106-6
Skwiot M. A Systematic Review of Rehabilitation Interventions Athletes with Chronic Ankle Instability. Journal of Clinical Medicine. 2025. https://www.mdpi.com/2077-0383/15/1/220
Wikstrom EA, Cain MS, Chandran A, Song K, Regan T, Migel K, et al. Lateral ankle sprain and subsequent ankle sprain risk: a systematic review. Journal of Athletic Training. 2021;56:578–585. https://pubmed.ncbi.nlm.nih.gov/34375983/
