by Matthew Anderson
Lateral ankle sprains are not only a common injury in sport but can also occur in daily life. With research indicating up to 43% of individuals can re-sprain their ankle it’s important to ensure a proper rehabilitation program is completed. Following the rehabilitation guide-frame below will give you the best opportunity for a full recovery.
EARLY PHASE REHAB
Once a lateral ankle sprain is diagnosed and other foot and ankle injuries are ruled out, early mobilisation is recommended. Early mobilisation involves moving the ankle through comfortable ranges of motion while there is no weight on the foot. This is as simple as drawing out the “ABC” with the ankle. Standing and walking, as much as is comfortable, is also recommended. This can be helped by using ankle braces and crutches in the very early phases of recovery.
If pain levels are high, tablet or gel-based anti-inflammatory medication may assist in reducing the pain. It’s best to speak to your pharmacist or GP before starting these medications to ensure no side effects occur.
Early physiotherapy treatment involves mobilisation the ankle joints to ensure ankle dorsiflexion range is achieved and any swelling is reduced as quickly as possible. Surgery is typically not required as research has shown surgery is no better compared to physiotherapy management for simple ankle sprains.
Early phase exercises can be completed frequently in short durations in the days following the ankle sprain. Typical exercises include seated heel raises, double leg heel raises that are progressed to single leg heel raises, ankle dorsiflexion stretches, early balance exercises and exercises to help strengthen the smaller muscles of the foot and ankle.
As guide, you should be able to complete the following exercises before progressing to more high load exercises:
- Walking normally without any external support such as crutches.
- Isometric seated heel raise with 1.5x body weight or as much weight as you have available. 30 repetitions is the aim.
- Bilateral heel raises up to 20 repetitions.
- A knee to wall distance of greater than 2cm.
MID-PHASE REHAB
The key areas for mid-phase rehabilitation are strength and stability of the ankle.
Achieving comfortable single leg heel raises is the main goal of strength training. The aim is to be able to achieve 20 reps of a single leg heel raise, or at least 80% of the repetitions of the uninjured side.
Ankle dorsiflexion range should be greater than 8cm, or within 3cm of the uninjured side, when assessing with a knee-to-wall test. Whilst ankle and calf stretches can help this out, physiotherapists are able to perform mobilisation techniques and soft tissue release of the foot, ankle and calf to ensure the joints are moving efficiently.
Challenging your balance is important for when you return to higher levels of impact and agility. Progressing your balance can be done by standing on one foot on unstable or soft surfaces such as a foam mat. Further challenge can be added by standing on one leg, eyes open, and trying to throw and catch a ball. Aim to be able to balance on one leg, eyes closed, on a firm surface for at least 10 seconds.
Completing dynamic balance exercise such as the Y-Balance test is a great way to assess your balance and stability. Balancing on one leg, attempt to tap the other foot as far out in a front, backwards-left and backwards-right direction as possible. Having a difference greater than 4cm between both sides when reaching forwards is predictive of ankle joint sprains.
LATE PHASE REHAB
In the later phases of recovery you can introduce running. To be sure the ankle will handle this transition the ability to perform 20 hops on the spot with good power and stability is crucial. You should also aim for a single forward hop distance that is 75% of the uninjured side. To really challenge your rehabilitation add in drop jumps where you jump off a step, land on both feet and then jump upwards or sideways. Progress these to single leg versions where you land off a step onto one foot, then hop upwards or sideways. You can also introduce vertical hops aiming to achieve a maximum vertical height.
A simple way to return to straight line running is to introduce block running where you walk for 200 metres, jog for 200 metres and repeat this block 5 times. To progress, increase the jogging time as you reduce the walking time with the aim of completing a continuous 2km of jogging at a comfortable pace.
RETURN TO SPEED RUNNING AND AGILITY
Once you have returned to straight line running the next aim is to progress to faster paced running and agility based motions.
In this phase the aim is for the injured ankle to achieve at least 95% compared to the uninjured side when performing any test.
The following are a range of exercises that can be performed to help return you to agility based training.
- Single hop forwards for distance
- Triple hop forwards for distance
- Triple cross over hops for distance
- Maximal side hop test
- Diagonal hops
- Maximum number of side hops in 30secs, over lines 40cm apart. Females aim for 50+ and males 55+
Once you can achieve 95% in the above exercises compared to the uninjured side, as well as a knee to wall range that is less than 2cm different to the uninjured ankle, it’s time to return to contact training.
RETURN TO CONTACT
Return to contact sport is great to be able to achieve and means the ankle should be feeling really good. This is the time where you can start to utilise the ankle brace or ankle tape to provide additional support.
During this phase it’s all about adding in reactive agility drills where you react to an external cue to decide which direction to cut. This can be as simple as running in a straight line and a partner calling left or right to indicate which direction to go. Progressively build up the speed of the cuts so you feel you are running 100% speed prior to making the cutting motion.
RETURN TO PLAY
To make sure the ankle is ready for a return to full sport no episodes of ankle instability should be experienced, all strength and hopping tests should be at least 95% of the uninjured side. To maximise the strength of the ankle, the ankle muscle invertors and evertors should have a ratio of 1:1, a seated heel raises 1.5x body weight and standing heel raises of 3x bodyweight should be able to be achieved.