Ankle Sprain Rehabilitation

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Cold pack on footOur step by step ankle rehabilitation program outlines how to reduce pain and inflammation, restore mobility, strength and prevent future injuries.

The following guide is intended for information purposes only. We recommend seeking professional advice before attempting any rehabilitation. Rehabilitation of an ankle sprain can be broken down into separate phases; decreasing pain and swelling, improving mobility and flexibility, improving ankle strength and co-ordination and returning to full fitness.

Reducing pain and swelling

The acute phase of ankle rehabilitation should start immediately after injury with the aim of decreasing pain and swelling. It can last from 2 days to 2 weeks or more depending on how bad the injury is. The PRICE principles apply of protection, rest, ice, compression and elevation.

Protect the ankle from further injury by resting. Avoid weight bearing by using crutches if necessary and wear an air or stirrup type ankle brace which allows forwards and backwards movement but not lateral or sideways movement. An ankle support or ankle taping also accomplishes early medial and lateral protection while allowing up and down movements.

Rest is essential. A healing ligament needs a certain amount of stress to heal properly but overdoing it early on in the rehabilitation process can prevent healing. Full weight bearing should be introduced as soon as pain allows but not before. Isometric exercises are static exercises or those which involve no movement. They can be done in the early stages but only in the up and down plane or plantar flexion and dorsi flexion to use the technical terms. Avoid sideways ankle movements which are likely to stress the injured ligaments.

Stirrup ankle braceIce or cold therapy should be applied throughout the rehabilitation process. Apply ice for 15 minutes every hour initially for the first day then reduce this to 4 to 5 times a day from then on as required. Do not apply directly to the skin as this may cause ice burns. Using ice wrapped in a wet tea towel or commercially available cold pack can avoid this. In the acute stage ice will constrict blood vessels and prevent further bleeding. Longer term benefits include reduction of pain and muscle spasm. Ice should not be used for longer than 15 minutes as prolonged cooling has the reverse effect of increasing blood flow. Long periods of cooling can also cause nerve injury. Ice should be used for as long as it is beneficial. As soon as the rehabilitation process plateaus the therapist may decide to alternate hot and cold to progress further.

Ankle tapingCompression will help reduce and prevent swelling and can be applied immediately after injury at pitch side but only for 10 minutes at a time to avoid stopping the circulation. A tube grip or elastic ankle support can provide mild compression throughout the healing process to help reduce swelling.

Elevation by raising the leg will help swelling drain away from the site of the injury. Elevate the leg while icing and for 10 minutes after.

Improving ankle mobility

Ankle mobilityThe next phase of ankle rehabilitation begins when swelling starts to decrease and pain lessens. This means the ligaments have reached the point in the healing process where they are not in danger of being re-injured from mild stress.

For the first 2 to 7 days after injury the patient can start to move the ankle straight up and down but do not turn it in or out. This will help maintain and increase ankle mobility and begin to strengthen it up. Do as much as pain will allow. Try 2 sets of 40 reps whilst the ankle is being iced and elevated and build on that over the next few days.

Seated wobble board exercises may be beneficial for an ankle that has reduced mobility. Initially plantar flexion and dorsi flexion only so as not to stress the ligaments on the outside of the ankle and then progress to inversion eversion as pain allows.

As swelling and pain lessen you can start to invert and evert the ankle (move the soles of you feet inwards and upwards and the outwards and upwards). This will start to put more stress on the damaged structures so be careful not to do too much. See ankle mobility exercises. Stretching the calf muscles and achilles tendon several times a day is important. There are a number of methods which can be used for stretching the calf and achilles, including using a slant board.

Strengthening and co-ordination

Ankle strengtheningWhen pain allows strengthening exercises in the up and down plane only can begin. For example pulling the foot and toes up and hold for 10 sec's and then push down and hold for 10 sec's. Try 3 sets of 10 reps twice a day and build on that. Later these isometric type exercises can also be done for inversion and eversion as pain allows.

If no further improvements are seen with ice alone then alternating with hot and cold can be tried. Apply a warm pack or 3 minutes, followed by a cold pack for 5 minutes. Repeat this again so that the whole process last 20 minutes.

Strapping and taping may still be beneficial here to provide compression and support the ankle as you return to full weight bearing. By now it may be possible to maintain fitness by swimming or cycling if these activities are not painful.

Proprioception exercises are thought to be important in avoiding recurrent ankle sprains. The neuromuscular control you have over your muscles will have been damaged when you injured the ankle as these small sensors are located in ligaments and tendons. Balance type exercises can be used to improve this function and help avoid future ankle injuries. An ankle wobble board can be used, intially in a sitting position, followed by standing on both legs and progressing to single leg balancing. Wobble board exercises.

If you don't have a wobble board, simply balancing on one leg can be effective. Once you can manage this, you can challenge your balance by moving your arms, twisting your body and bending the knee. For a real challenge, try to balance with your eyes closed!

Returning to full fitness

In order to start the functional rehabilitation phase (activity and sports specific training) it is important the athlete has full range of motion and 80 to 90% of pre-injury strength. When you can comfortably do all of the above then you are ready to start phase 3 and begin your return to activity.

Cardiovascular exercise is important and should begin as soon as possible after injury depending on what pain will allow. It is important that the athlete maintain some kind of CV exercise not just for the physical benefits but for psychological well being as well. Stationary cycling, hand cycle ergometer, running in water and swimming are all possibilities depending on severity of injury and what pain will allow.

Running may begin as soon as walking is pain free. Ankle taping can be very beneficial when starting running training particularly during early sessions until confidence, proprioception and strength has returned. A laced ankle brace can also provide support and is less expensive in the long run, particularly if laxity in the ligaments means a support needs to be worn permanently.

Running should begin on a clear flat surface such as a running track. Grass or bumpy surfaces will increase the risk of re-injury. Jog the straights and walk the curves. Speed should be gradually increased over time to a sprint. Sports specific drills using cones can be introduced. Changing direction, running in a figure of 8 pattern and zig zagging between cones.