Rehabilitation for Ankle Sprain

Introduction

Ankle sprains are common and happen to all kinds of people, from athletes to older adults. A serious sprain, including one treated with surgery, needs a lot of physiotherapy to get strength and flexibility back in the soft tissues around the ankle.

Rehabilitation after an ankle sprain depends on:

• The severity of the injury – see Grades below
• Your activity level, for example whether you will go back to high impact sport

These two things change how long rehabilitation lasts, how hard it is and which exercises you do. This guide is only a rough outline of what to expect. Always ask your physiotherapist for advice.

General Principles of Rehabilitation

Early on, your ankle needs to be protected. This means no weight and no movement. Control the swelling by raising the ankle often and using ice.

Rehabilitation exercises are meant to make the injured ligaments grow and heal into stronger scar tissue. Some swelling and soreness may continue during rehabilitation, especially after exercises. This is expected, but tell your physio if you are worried.

The ankle is a moving joint, so it needs movement (mobilisation) as soon as it is safe. Keeping it in a cast or rigid brace (immobilisation) for a long time means a longer rehabilitation.

Grades of Ankle Sprain

Your surgeon or physiotherapist will decide how severe your sprain is by examining your ankle. You may also have X-rays, usually while standing.

The grade shows how severe the sprain is. Grades 1 and 2 are mild to moderate. Grade 3 is severe.

1. A Grade 1 sprain has no tear in the ligaments, so the ankle is stable or nearly so, and there is little swelling. It needs the shortest rehabilitation and rarely needs full immobilisation.
2. Grade 2 sprains have partial tears in the ligaments, so the ankle is a little unstable, and there is moderate swelling around the ankle.
   • Grade 1 and 2 sprains do not usually need a plaster cast. A removable boot or a soft ankle brace can protect the ankle instead.
3. Grade 3 sprains are the most severe. Their symptoms are like a mild ankle fracture. The ligaments are torn right through, so the ankle feels very unstable and standing on it is hard or impossible. Bruising and swelling are also severe, so the first phase of ice and elevation lasts longer.
   • Grade 3 sprains usually need a period of complete immobilisation, normally in a cast. The plaster may stay on for up to 4 weeks, and you may need crutches to get around.

Phase 1 | 0–7 days

Straight after the sprain, the PRICE method helps control swelling and limit more injury.

• Protection.
  • Support your ankle with an elastic wrap or splint to protect it from more injury.
  • There are several designs available.
  • If your sprain is severe, your doctor may put a cast or brace on your ankle and show you how to use a stick or crutches.
• Rest.
  • Avoid activities that cause pain or swelling, but do not stop all physical activity.
  • You can usually still exercise other muscles so you do not lose fitness. For example, you could use an exercise bike with your arms and your good leg, while the injured ankle rests on a footrest. That way three limbs keep working and your heart and lungs stay fit.
• Ice.
  • Ice the ankle straight away, even if you are going to see a doctor. Use an ice pack or slush bath for 15 to 20 minutes. Repeat every 2 to 3 hours while you are awake, for the first 48 to 72 hours.
  • Cold eases pain, swelling and inflammation in injured muscles, joints and ligaments. It may also slow bleeding from a tear. If the skin turns white, stop at once, as this can mean a cold injury.
  • If you have vascular disease, diabetes or reduced feeling in your foot, talk to your doctor before using ice.
  • Your physiotherapist may also use electrical stimulation (TENS) as well as ice.
• Compression.
  • Wrap the ankle in an elastic bandage to stop swelling, and keep it on until the swelling stops. Start below the heel, then wrap up and around the ankle.
  • If your toes tingle, go numb or turn blue, the bandage is too tight. Take it off and wrap it again more loosely.
• Elevation.
  • Raise your ankle above the level of your heart, especially at night. Gravity helps drain extra fluid and reduces swelling.

You can move on to phase 2 only when the swelling has gone down enough.

For a minor sprain this may take 1 to 2 days. A more severe (grade 3) sprain can take several days. Even with a minor sprain, you still need a brace or tape to support the ligaments.

Phase 2 | Days 3 – 12

When the swelling has gone down, phase 2 can begin. This phase gently builds flexibility in the ankle and slowly returns you to putting weight on it with crutches.

You will probably still need to raise your foot to keep swelling low. You may also need ice, but you should need both less and less. If swelling is still a problem, talk to your physiotherapist or doctor.

Braces & Orthotics

Your orthotist or physio will usually ask you to keep wearing a supportive brace or tape through this phase.

Weight-bearing

With grade 1 and 2 sprains you can start to put some weight on the ankle, carefully. Do not force the ankle to take your full weight. Shift your weight onto it gently.

Physiotherapy Exercises

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

1. Active range of movement. This means bending and straightening your ankle and foot. Do not tilt your foot in or out (inversion and eversion) unless your physiotherapist says so, as this can injure the ligaments again
2. Passive range of movement. Someone else holds your foot and moves it for you. At this stage you can only do passive movements that bend and straighten the ankle, not tilt it to the sides
3. Strengthening exercises. Your physio will have you stretch and bend your toes and pick up objects, usually a towel, with your toes
4. Proprioception. You stand on an unstable platform called a wobble board. This retrains the nerves, ligaments and muscles around the ankle to work together

Do your exercises often, usually in sets twice a day.

You may feel some pain with the stretches at this stage. This is normal, but the pain should not be sudden or severe. If you are worried, talk to your physiotherapist.

Phase 3 | Weeks 3–6

Phase 3 rebuilds strength around the ankle and gets it moving in all directions.

In this phase you should start doing many of your normal activities with little pain. Leave out running and other high stress exercise for now.

Weight-bearing

You should be putting full weight on the ankle, or nearly. It may be hard, even painful, at first. This is normal after the muscles have not been used.

Support

You may still need orthotics, a brace or tape to support the ligaments while they heal.

Physiotherapy Exercises

Keep doing your exercises regularly, usually sets of repetitions twice a day. They may include:

• Passive range of movement and stretching:
  • You should now be able to move the ankle in all directions, including tilting in and out (inversion and eversion).
  • Keep stretching the muscles around your ankle, especially the calf muscles (gastrocnemius), by bending your foot up
• Strengthening exercises:
  • Toe and heel raises. Your physiotherapist may ask you to rise up onto your toes with your heels off the ground, then lower slowly. You may do these with your toes pointing in, straight and out.
  • Squats
• Proprioceptive training with a wobble board

Phase 4 | Weeks 5 – 12

This is the last phase of formal physiotherapy. It gets you back to all your usual activities safely.

Keep wearing tape or a brace during sport to lower the risk of another injury. Your physiotherapist will tell you when you can stop.

Physiotherapy Exercises

1. Range of Movement, Strengthening and Proprioceptive exercises
   • Your physiotherapist will start you on harder exercises for movement, strength and proprioception.
2. Agility Exercises – change of position and direction.
3. Specific exercises for sports.

Prevention of Further Injury | Ongoing

Even after physiotherapy ends, the scarred ligaments keep growing and changing. Long term exercises help keep the soft tissues around the ankle flexible and strong.

Preventative exercises may include:

• Strengthening the muscles around the ankle, especially the peroneal muscles along the outside of the ankle
• Using braces, tapes or supports as required.
• Doing pre-season exercises that train:
• Balance
• Coordination

Many rehabilitation exercises can also be used to keep the ankle strong. Talk to your physio about this before you finish rehabilitation.

Only go back to full activities when:

• Swelling has disappeared
• Your ankle can move through all its positions without pain
• Your strength, proprioception, balance and coordination are good enough for the activity

F.A.Q.s | Frequently Asked Questions

Will my ankle always be weak after a sprain?

It depends on how severe the sprain was and how well you do your rehabilitation. Many people have only one ankle sprain.

Preventative exercises help protect your ankle from more sprains.

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.