Rehabilitation for Ankle Sprain

Introduction

Ankle sprains are common injuries affecting all types of people, from athletes to the elderly. Any treatment of serious sprains, including surgery, must involve intense physiotherapy to return the strength and suppleness of the soft tissues around the ankle.

Rehabilitation following an ankle sprain will vary greatly depending on:

  • The severity of the injury – see Grades below
  • The activity of the patient, eg will you return to high-impact sports after your sprain

These two factors change the length, intensity and exercises used during rehabilitation. This guide is therefore meant to only provide a rough outline of what you may experience – always refer to your physiotherapist for advice.

General Principles of Rehabilitation

In the early period after injury, your ankle needs to be protected (ie non-weight-bearing, non movement), and swelling needs to be controlled with frequent elevation of the ankle and icing.

NB Rehabilitation exercises are dsigned to provoke growth and change in the injured ligaments to improve the scar. This means that some degree of swelling and inflammation may continue throughout your rehabilitation, especially after performing your exercises. This is to be expected, but you should raise any concerns with your physio.

The ankle is a moving dynamic structure, and consequently movement (‘mobilisation’) as soon as safe is necessary for good recovery. Keeping the ankle in a cast or rigid brace (immobilisation’) for long periods of time will require longer periods of rehabilitation to recover full function.

Grades of Ankle Sprain

Your surgeon or physiotherapist will decide on the severity of your ankle sprain by examining your ankle and possibly getting X-Rays (usually weight-bearing).

The ‘grade’ of ankle sprain reflects the severity of the injury, with grades 1 & 2 indicating mild-moderate injury and grade 3 indicating severe sprain.

  1. A Grade 1 sprain is defined as injury with no evidence of rupture of ligaments (and hence little, if any instability in the ankle) and limited swelling. Grade 1 sprains require the shortest period of rehabilitation and rarely require any full immobilisation.
  2. Grade 2 sprains have partial tears through the ligaments (with some degree of instability) and moderate swelling around the ankle.
    • Grade 1 and 2 sprains usually do not require full immobilisation in a plaster cast, and can instead be ‘protected’ by a removeable boot or nonrigid functional ankle brace.
  3. Grade 3 sprains are the most severe, and have similar symptoms to a mild ankle fracture. In these sprains, the ligaments have ruptured. Consequently, the ankle feels very unstable and weight-bearing is difficult or impossible. Bruising & swelling is also severe and requires a longer phase 1 of icing and elevation.
    • Unlike grades 1 and 2, grade 3 sprains usually require a period of complete immobilisation, usually in a cast. The plaster may need to remain in place for up to 4 weeks. During this time, you may require crutches to move around.

Phase 1 | 0 – 7 days

In the immediate aftermath of the sprain, the PRICE treatment method is important to control swelling and reduce further injury.

  • Protection.
    • Immobilize your ankle with an elastic wrap or splint to protect it from further injury.
    • There are a variety of designs for
    • If your sprain is severe, your doctor may place a cast or brace around your ankle to protect it and instruct you on how to use a cane or crutches.
  • Rest.
    • Avoid activities that cause pain, swelling or discomfort – but don’t avoid all physical activity.
    • With an ankle sprain, you can usually still exercise other muscles to prevent deconditioning. For example, you could use an exercise bicycle, working both your arms and the uninjured leg while resting the injured ankle on a footrest. That way you still exercise three limbs and keep up your cardiovascular conditioning.
  • Ice.
    • Even if you’re seeking medical help, ice the area immediately. Use an ice pack or slush bath for 15 to 20 minutes and repeat every two to three hours while you’re awake, for the first 48 to 72 hours.
    • Cold reduces pain, swelling and inflammation in injured muscles, joints and connective tissues. It also may slow bleeding if a tear has occurred. If the area turns white, stop treatment immediately as this could indicate cold injury.
    • NB If you have vascular disease, diabetes or decreased sensation, talk with your doctor before applying ice.
    • Your physiotherapist may supplement icing with electrical stimulation (TENS).
  • Compression.
    • To help stop swelling, compress the ankle with an elastic bandage until the swelling stops. Begin wrapping below your heel then up over and around your ankle.
    • If your toes tingle, become numb or go blue the bandage is too tight and needs to be changed.
  • Elevation.
    • To reduce swelling, elevate your ankle above the level of your heart, especially at night. Gravity helps reduce swelling by draining excess fluid.

You can only progress on the the second phase of rehabilitation when the swelling has sufficiently decreased.

When you have only a minor sprain, this may be 1 to 2 days, however more severe sprains (Grade 3) can take several days before the swelling has diminished significantly. Even with minor sprains, the continued use of braces or taping is necessary to support the ligaments.

Phase 2 | Days 3 – 12

When swelling has gone down, phase 2 of rehabilitation can begin. This period focuses on gently building the flexibility of the ankle while gradually returning to weight bearing with crutches.

You will probably need to continue elevating your foot to keep swelling minimal. You may also need ice, but the use of both of these methods should be decreasing. If you find swelling is still problematic talk to your physiotherpist or doctor.

Braces & Orthotics

Usually, your orthotist and physio will recommend you continue wearing the supportive brace or tape throughout this phase.

Weight Bearing

Less severe sprains (grade 1 and 2) can begin to progress to careful partial weight-bearing. You should not force your ankle to carry your full weight, instead transfer your weight to your injured ankle gently.

Physiotherapy Exercises

Your physiotherapist will show you the specific exercises you need to perform. These will usually include:

  1. Active range of movement – this means flexing and extending your ankle and foot. You should avoid tilting your foot inwards and outwards (inversion and eversion) unless directed by your phyiostherapist as this can re-injure damaged ligaments.
  2. Passive range of movement – these exercises involve someone else holding your foot and moving it for you. At this stage of rehabilitation, you can only perform passive exercises that flex and extend your ankle but do not tilt it to the sides.
  3. Strengthening exercises – your physio will get you to stretch and flex your toes and pick up objects (usually a towel) with your toes.
  4. Proprioception – Your physiotherapist will get you to stand on an unstable platform called a ‘wobble board’. This helps to retrain nerves, ligaments and muscles around your ankle to coordinate reflexes.

Exercises should be performed frequently, usually in sets twice a day.

At this point you may experience some pain with the stretches. This is normal, but should not be a sudden or severe pain. If you have concerns, discuss these with your physiotherapist.

Phase 3 | Weeks 3 – 6

Phase 3 of rehabilitaion focuses on rebuilding strength around the ankle and moving in all directions.

During this period of rehabilition, you should start to perform many of your normal activities (excluding high stress exercise and running) with minimal pain.

Weight-bearing

You should be either fully weight-bearing or progressing to full weight-bearing as tolerated. You may find this difficult, even painful at first, however this is a normal consequence of disused muscles.

Support

You may still need orthotics, braces or taping during this time to support the still healing ligaments.

Physiotherapy Exercises

Again, you will need to perform exercises regularly, usually sets of repetitions twice a day. Exercises may include:

  • Passive range of movement and stretching:
    • You should now be able to move your joint in all directions, including inward and outward tilting (inversion/eversion).
    • Continue to stretch the muscles around your ankle, in particular the calf muscles (gastrocnemius). You can do this by flexing you foot
  • Strengthening exercises:
    • Toe & heel raises – your physiotherapist may ask you to perform a series of ‘heel raises’, where you come up to stand on your toes with your heel off the ground, then gradually go back down again. You may need to do these with your toes point inwards (inverted), straight (neutral) and outwards (everted).
    • Squats
  • Proprioceptive training with a wobble board

Phase 4 | Weeks 5 – 12

This is the final phase of formal physiotherapy for ankle sprains and focuses on returning you to all your previous activities without risk to you ankle.

Throughout this period, you should continue to wear tapes or braces during sports to reduce the risk of reinjury. Your physiotherapist will be able to recommend when supports need to be worn.

Physiotherapy Exercises

  1. Range of Movement, Strengthening and Proprioceptive exercises
    • Your physiotherapist will encourage you to begin performing more advanced exercises in these fields.
  2. Agility Exercises – change of position and direction.
  3. Specific exercises for sports.

Prevention of Further Injury | Ongoing

Even after formal physiotherapy has ceased, your scarred ligaments will continue to grow and change over time. Long-term exercises are consequently important to maintain the suppleness of strength of the soft tissues supporting your ankle.

Preventative exercises may include:

  • Prophylactic strengthening of muscles around the ankle, especially the peroneal muscles that run along the outside of your ankle.
  • Using braces, tapes or supports as required.
  • Performing exercises pre-season that focus on:
    • Proprioception
    • Balance
    • Coordination

Remember that many of the exercises used in rehabilitation can be used to maintain the strength of the ankle. You should discuss this with your physio before being discharged from rehabilitation.

It’s important to remember that you should only return to full activities when:

  • Swelling has disappeared
  • Your ankle can move through all its positions without pain
  • Strength, proprioception, balance and coordination have demonstrably improved and are sufficient for activities

F.A.Q.s | Frequently Asked Questions

Will my ankle always be weak after a sprain?

This depends on the severity of your sprain and your rehabilitation program, however many people only suffer one ankle sprain.

Using preventative exercises will help protect your ankle from further sparins.

For more information, see Chronic Ankle Instability.

References

Atkinson, K., Coutts, F., Hassenkamp, A., ‘Physiotherapy in Orthopaedics: A Problem Solving Approach’, 2nd Ed., Elsevier Churchill Livingstone, London, 2005.

Brotzman, S. B., Wilk, K. E., ‘Clinical Orthopaedic Rehabilitation’, 2 ed., Mosby, 2003, Philadelphia, USA. pp 371-389.

Delee, J. C., Drez, D., Miller, M. D., ‘Delee & Drez’s Orthopaedic Sports Medicine’, 3rd Ed., Saunders Elsevier, Philadelphia, USA, 2010, pp 1914-1924.