Ankle sprains are common and can be a painful. In the worst-case scenario, the ankle can become weak and unstable, preventing any sporting activity, but with the right management you can soon be back on your feet.
The British Journal of Sports Medicine published a clinical guideline on the management of acute ankle sprains – Kerhoffs et al. (2012). This will form the basis of our recommendations. Lateral ankle sprains (ones that involve the outside of the ankle) are more common than medial sprains and will be the main focus of the article.
Ankle sprains are commonly caused by the inversion of the foot and ankle i.e. the foot and ankle turn in. This, accompanied with our body weight, places great stress on the structures on the outside of the foot and ankle.
Most commonly the Anterior Talofibular Ligament (AFTL) is injured – it has been estimated this ligament is affected in as much as 90% of inversion sprains. The AFTL is part of the capsule surrounding the ankle joint, as a result, when it is injured there is usually fairly immediate swelling.
General principles in managing acute ankle sprains;
Rule out serious injury
Respect the healing process
Manage pain and swelling with POLICE +/- NSAIDS
Restore range of movement, control and strength
Ruling out serious injury
Acute sprains will often result in pain and swelling around the outside of the ankle, with discomfort moving or taking weight. An important initial question is there is any fracture?
Kerhoffs et al. 2012 estimate that only around 15% of ankle sprains result in a fracture but it is important to rule this out. There are clinical signs you can use by following the Ottawa Rules. These are a series of signs and symptoms that are used to help rule out a fracture and are “strongly recommended” in the BJSM guideline;
“X-ray diagnostics is only indicated in case of pain in the malleoli or middle foot, combined with one of the following findings:
- palpation pain on the dorsal side of one or both of the malleoli
- palpation pain at the bases of the 5th metatarsal bone
- palpation pain of the navicular bone
- patient is unable to walk at least four steps.”
Another good sign is a lack of swelling within the first 24-48 hours. Most serious injuries to the ankle will swell, either fairly immediately (within the first 2-3 hours) or within the first day or so afterwards. If no swelling and patient can comfortably weight bear then may it is a minor sprain. This is sometimes called a ‘distortion’ which means the ligament may have been stretched or partially torn but as a whole remains intact. Many people with these injuries will choose not to seek medical help.
Respecting the healing process
The body has amazing abilities to heal and though we may try to speed up this process, perhaps in reality all we can really do is try to create the best environment for healing to happen. In the early stages of an ankle sprain, there is usually significant inflammation. Ligament injuries are thought to take around 12 weeks to heal and during this period may be vulnerable to excessive load. This is especially true in the first few days leading up to 3-4 weeks after injury.
The body will be trying to repair the injured tissue by forming a scar, made up largely of collagen. Up until 3-4 weeks post-injury this new tissue is fragile and will break down if too much stress is placed upon it. Bear this in mind when considering exercise and activity. stick to things that don’t increase pain or swelling. Avoid activities that involve twisting the ankle or heavy resistance. Also, even walking a long way can be painful in the early stages, don’t be tempted to do too much too soon – let the area heal!
Manage pain and swelling
RICE used to be the standard recommendation but recently this has changed to POLICE which stands for Protection Optimal Loading Ice Compression and Elevation. The BJSM gave a rather mixed message in the role of ice and compression in acute ankle sprains, they comment on the lack of research evidence but conclude,
“The use of ice and compression, in combination with rest and elevation, is an important aspect of treatment in the acute phase of LAI”. (LAI = Lateral Ankle Injury).
The aim with ice, compression etc is to reduce ankle swelling and pain. Some believe this may be counterproductive as swelling is a natural part of the healing process. It surrounds and supports the area as it heals and helps deliver a host of chemicals and specialist cells which are essential to the healing process. Unfortunately, though excessive swelling can limit the range of movement, increase pain, reduce proprioception and inhibit muscle activity. Like many things, it’s about striking a balance. Intermittent use of ice etc is likely to be helpful to prevent excessive swelling without inhibiting the healing process.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) are frequently recommended after sprains but there is some debate over their effectiveness. There has been some suggestion that they may delay healing but if they allow early movement and reduce pain they can have a beneficial effect on recovery. You may choose a simple pain relief (such as paracetamol) instead of or as well as NSAIDs. More details here on NSAIDs in sport.
Protecting the ankle from excessive movement can help the pain, the BJSM recommended the use of a brace or supportive taping to prevent relapses. They also found using a brace may speed return to work. However, they point out that these supports should be phased out over time.
Restoring range, control and strength
Swelling, pain and immobility can have dramatic effects on the foot and ankle. In many cases the ankle becomes stiff, surrounding muscles weaken and balance and control of movement is reduced. This leaves the ankle vulnerable to re-injury if not addressed. The challenge is maintaining ankle function while respecting the healing process – you may want to start exercising as early as possible but it needs to be done cautiously to allow the area to recover. The BJSM recognised the importance of rehab;
“Rehabilitation of athletes after LAI must be the result of a variety of exercises in which propriocepsis, strength, coordination and function of the extremity are maintained.”
Minor ankle sprains
Before we look into more serious ankle injuries we’ll briefly consider minor ankle sprains. These might be described as a ‘distortion’ rather than an actual ligament tear. They tend to occur with a similar mechanism of injury but have less severe pain and swelling and rapidly resolve. It isn’t unusual for someone to return to running in as little as 1-2 weeks as there is little structural damage. For a minor ankle sprain the advice would be to use POLICE in the first few days, gentle movement to restore range and then a gradual return to running when it feels comfortable to do so. Balance and strength work to prevent recurrence.
Moderate to severe ankle sprains
Severity of ankle sprains and their prognosis varies a great deal. The following is a general guideline, do consider that times will vary considerably between individuals.
The first 3 days typically involve considerable bleeding and inflammation, use POLICE and combine it with gently moving the foot up and down, just as far as comfortable, little and often. It may be sensible to avoid sideways movements which may place excessive stress on healing tissue and cause pain.
As you begin to enter the sub-acute phase pain may settle somewhat. In addition to up and down movements you may add gently moving the ankle side to side, just as far as comfortable. A little stress to healing tissue can stimulate recovery but be careful not to overdo it. Again little and often is best.
If comfortable add seated ‘proprioception’ exercises – proprioception is the body’s ability to recognise its position in space and is closely linked to balance and movement control. At this stage, something simple like placing a ball under the foot and moving it forwards and backwards and side to side with the eyes closed can stimulate proprioception.
You can also start isometric strength work, again if comfortable. This means contracting the muscles around the ankle against something that won’t move. This way the muscle works but the joint stays still. Push the foot down against the floor or a wall. Pull up against resistance from your other foot and push in and out against a wall or something sturdy that won’t move.
Start to progress to a range of movement exercises in all directions – aim to restore flexibility when moving the ankle in, out, up and down. Advice patient not to push through pain, just do what you can.
In many cases, pain may diminish significantly by 2 weeks after the injury. Much of the initial inflammation has settled and you may find you can progress your rehab. Despite this, tissue is still healing and it’s best to avoid impact or sudden twisting movements. You can start to add single leg balance to your exercises if comfortable and progress to strength work through range rather than isometrically. You can do this with a resistance band or by starting calf raises (using both legs).
From roughly day 21 scar tissue is thought to be more capable of handling loads and stresses. It is however far from ‘mature’ and re-injury and recurrent sprains are common so proceed with caution. Exercises may now be progressed with slightly more resistance, if comfortable you can try single leg calf raises and add a mini squat – this helps to restore dorsiflexion (the upward movement of the ankle).
The BJSM found that some will be able to return to ‘light work’ at between 3 and 4 weeks after partial or complete ligament rupture (or 2 weeks for ‘distortion’). This depends on how your patient is progressing.
It may be your patient is ready to start cross-training, if so make it your priority that patient stay comfortable rather than improve fitness. Straight-line activities such as low resistance cycling or swimming front crawl are often best to start with but don’t work through the pain and monitor swelling.
Week 4 onwards
Obviously the progress from week 4 onwards will depend a great deal on how things are going. To give you an idea of the variation we see in clinic, I have treated cases where people have been able to run, hop and kick a football just 2 weeks after an ankle sprain while others have still been on crutches at 6 weeks. You can appreciate how hard it is to predict your progress at this stage.
Hopefully, your exercises so far will have kept the ankle flexible and strong but before starting more advanced impact and control work it is often best to ensure you have restored range of movement and muscle power.
Restoring ankle range
All ankle movements are important but lack of dorsiflexion (the upward movement of the foot) is arguably the most vital. The ankle dorsiflexion is essential for running and impact-based activity. Check your range using Lunge Test. If it is limited you can work on it using lunges, single-leg dip, gastroc and soleus stretches. The in and out movements of the ankle (inversion and eversion) as also important, they allow the ankle to adapt its position to balance. Turn the ankle in as far as comfortable and use hands or a towel to stretch it a little. Do the same with turning the ankle out.
Improving muscle power
Strengthening around the ankle is sensible after a sprain. In particular, strengthening the peroneal muscles (on the outside of the ankle), Tibialis anterior (at the front) and the calf muscles will help to prevent re-injury. This can be done with TheraBand.
Single leg calf raises are excellent for building calf strength, To do it, stand on one leg with a little support if needed. Push up on your toes as far as comfortable, repeat until the calf fatigues.
Working basic balance
Single leg balance and single knee dip are 2 excellent exercises for improving basic balance;
Progressing control rehab
Rather than adhering closely to specific timeframes, progressive control is about gradually challenging the ankle more, without increasing pain or swelling. Bear in mind though that ligaments are thought to take around 12 weeks to heal. You may need to be cautious in your progression to prevent re-injury. follow this rough order with the direction of movements;
So this might mean starting with single leg balance and single knee dip. then jogging on tiptoes. All of these are ‘straight line’. Next, add ‘lateral’ movements – side-stepping, then sideways jogging, if this was comfortable you could progress with ‘rotational’ movements – single leg balance while rotating the body or jogging a figure of 8 around cones. ‘Rotation + lateral’ means combining these movements together – such as ‘Greek dancing’ (sideways jogging crossing one leg in front of the other) or adding cutting, or twisting movements to sideways activities. Make sure is comfortable with one type of exercise before progressing to the next. Gradually increase speed and exercise intensity, add impact (such as running, skipping etc) only when comfortable. Balance boards, BOSUs, ‘hedgehogs’, trampets, wobble cushions etc. can all be used as well to challenge control and improve proprioception.
Returning to Sport
As mentioned previously a mild sprain may see a return to sport in 1-2 weeks, a very severe sprain may need 4-6 months. In order to return to sport without risking re-injury, you need a full range of movement in the ankle, good muscle power (with equal calf strength) and good control of movement. The ankle should feel stable and not give a way. Impact should be pain-free and patient should be able to run without pain. Ideally, all swelling should also have settled but some ankle sprains can remain slightly swollen for over a year after the injury so pain and function are better signs to use.
For moderate to severe ankle sprains, you may be able to start some light treadmill jogging at around 4-6 weeks if comfortable, but it may take considerably longer in many cases. The treadmill is a good place to start as the surface is totally flat and predictable and unlikely to force the ankle into rapid sideways movements that may cause injury. When comfortable this can be progressed to road running but trail running should be approached with caution – a rabbit hole or tree root could easily re-injure the ankle.
Gradually increase distance and training intensity but remain sensible for at least 3-4 months after the injury and bear in mind that additional pain or swelling are signs that you’re overdoing it.