Ankle strains most commonly occur indirectly through rapid directional change. It is for this reason that most individuals participating in team sport, or an active lifestyle have experienced a rolled ankle throughout the life stages.
The ankle joint is comprised of the tibia, fibula, calcaneus, and talus. Due to the intricacies of the bony structures, we rely heavily on the surrounding ligaments for stability. The Anterior and Posterior Talofibular and Calcaneofibular ligament on the outer aspect of the ankle prevent ‘rolling’ over the ankle. On the inside aspect of the ankle is the Deltoid ligament which prevents the much less common inward rolling motion of the ankle.
Mechanical symptoms, pain levels, rehabilitation protocols and duration of recovery varies with the location of the ligament and the degree of damage. Classification for strain is from grade 1-3 which can be assessed via Physiotherapy, MRI, or Ultrasound.
Ankle strains may present with the following symptoms:
- Tenderness to touch
- Difficulty weight bearing
- Pain with ankle movement
- Reduced balance and stability
For further information regarding Physiotherapy assessment of Ankle Sprains and why Physiotherapy involvement is vital, check out our blog post here.
Within 24 hours
Prior management of acute ankle injuries has primarily been driven by RICE- rest, ice, compression, and elevation. An evaluation of these guidelines was conducted in 2019 whereby a shift towards PEACE and LOVE emerged.
- Protect: limit aggravating movement for day 1-3.
- Elevate: above the level of the heart
- Avoid anti-inflammatories or utilise at the discretion of your health care provider
- Compression: external application of support garments
- Education: active rehabilitation and treatment options
- Load: progressive and optimal loading
- Optimism: positive expectations regarding outcomes
- Vascularisation: mobilisation and aerobic exercise to increase blood flow to healing structures
- Exercise: strong support for early improvements and reduction in recurrence rate
The elimination of icing is one that has been debated and may still be recommended by your treating Therapist. Whilst we don’t want to inhibit the vital inflammatory process that is occurring, excessive swelling and pain is often more detrimental. For this reason, use of ice may still be a part of your management.
In the first week following an ankle sprain your treating therapist will rule out an ankle fracture utilising the Ottawa Ankle Rules. If you present to a GP, they may give you a referral for imaging to be completed prior to commencing Physiotherapy. This is however not necessary as imaging can be ordered during your first consultation if required. This first session is best conducted 4-5 days post injury to allow for greater accuracy with diagnostics: observation, palpation, and an anterior drawer test.
Once the risk of fracture has been ruled out and the grading of the sprain confirmed, your therapist will provide information regarding the healing time frame, rehabilitation protocol and return to activity based on your goals.
Rehabilitation goals during this phase include:
- Restoring movement: range of motion
- Graded return to weight bearing
Range of motion is the available movement at the ankle joint in all planes with particular emphasis on dorsiflexion (toes moving towards the head). It is common following acute injury due to the swelling, pain, and muscle spasm for movement to be restricted. Manual therapy techniques such as joint mobilisations may assist with meaningful clinical improvement but is recommended in conjunction with exercise therapy. Exercises include static stretching of the gastrocnemius and soleus musculature, active assisted range of motion and active range.
Weight bearing capacity is dependent on pain levels and range of motion. Your therapist may provide a support garment or mobility aid dependent on the severity of the strain and pain reports. The amount of loading put through the affected limb will be progressively increased and which will further support improvements in mobility. During this time, introduction to balance exercises should commence to address proprioceptive deficits.
With careful consideration of pain reports, early commencement of a strengthening program aims to reduce the risk of recurrent strains and achieve symmetry. Exercises aim to target the musculature within the foot and the surrounding tissues. This may initially begin with open chain and isometric exercises where the foot is not in contact with the ground or moving through range. The exercise program should be supervised for optimal outcomes.
Beyond week 1
There is limited evidence regarding specific rehabilitation parameters for ankle strains beyond acute management. As swelling reduces and mobility continues to improve, loading is progressively increased. Clinically this may include single leg eccentric and concentric exercises for the calf, functional movements such as squatting and lunging and progressions with balance and proprioception.
Tailored programming will occur relevant to your activity levels and sport involvement. This will thus dictate the degree of ongoing Physiotherapy intervention required.
Prevention of recurrent strains
Insufficient rehabilitation of ankle sprains with particular focus on lateral ankle sprains, increases the risk of recurrent strains. In effort to reduce the risk of a repeat injury the evidence supports the use of ankle brace or taping in the sporting population. Whilst the rationale behind its application is limited, use of a support garment if preferential to the patient has its place. Additionally, inclusion of balance, proprioceptive and strength-based training should be implemented early and included in regular training.
1. Dubois B, Esculier J. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54:72-73.
2. Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British Journal of Sports Medicine 2018;52:956.
3. Masafumi Terada, Brian G. Pietrosimone, Phillip A. Gribble; Therapeutic Interventions for Increasing Ankle Dorsiflexion After Ankle Sprain: A Systematic Review. J Athl Train 1 October 2013; 48 (5): 696–709. doi: https://doi.org/10.4085/1062-6050-48.4.11
4. Brison, R., Day, A., Pelland, L., Pickett, W., Johnson, A., & Aiken, A. et al. (2016). Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. BMJ, i5650. https://doi.org/10.1136/bmj.i5650