Injuries
      Back to home
      1. Help Center
      2. Understanding Results
      3. Injuries

      Not Just A Simple Ankle Sprain

       

       

      Ankle sprains are the most common injury in those who play sports, affecting athletes across all levels of competition. Research indicates that approximately 70% of the general population will sustain an ankle sprain at some stage in their life, highlighting the prevalence of this injury. 

      However, the implications of an ankle sprain extend beyond the initial injury. This type of injury has the highest re-injury rate in the lower limb, meaning that once an individual has sprained their ankle, they are at an increased risk of experiencing another sprain in the future. Alarmingly, studies show that around 40% of those who suffer an ankle sprain may develop chronic ankle issues, such as ongoing pain, instability, or a reduced range of motion. These complications can significantly impact an individual's ability to participate in sports and daily activities.

      Given these statistics, it begs the question: are these injuries "just a simple ankle sprain"? The answer may surprise you. 

      You'll need to tune in to find out.

      A Criteria Based Approach

      1. Preoperative Phase (If Applicable)

      For most ankle sprains, “preoperative” may not apply unless surgery is indicated for severe ligament damage or associated fractures. If no surgery is required, consider this the acute management phase in the first few days post-injury.

      Goals

      1. Minimize swelling and inflammation in the acute stage.
      2. Protect the ankle from further damage.
      3. Maintain any available, pain-free range-of-motion (ROM) and gently encourage neuromuscular activation.
      4. Educate the athlete on realistic timelines and the importance of gradual loading.

      Key Actions

      • RICE principles (Rest/Protection, Ice, Compression, Elevation) to reduce swelling and pain 1,2
      • If tolerable, begin gentle, non-painful ankle ROM exercises (e.g., ankle pumps, circles) to prevent stiffness 3
      • Protected weight-bearing (e.g., with crutches or ankle brace) if needed, especially for Grade 2–3 sprains 2,4
      • Basic isometric activations (e.g., submaximal isometrics for dorsiflexors, plantarflexors, invertors, evertors) to maintain muscle engagement.
      • Patient Education: Discuss timeframes (e.g., 2–3 weeks for Grade 1, ~4–6 weeks for Grade 2, 10–12+ weeks for Grade 3) and a criteria-based approach (rather than strictly time-based).

      2. Early Phase

      Goals

      1. Protect healing tissues and avoid stressing the injured ligaments excessively.
      2. Begin restoring pain-free ROM and reduce swelling.
      3. Achieve a “quiet ankle”: minimal swelling, improved dorsiflexion/plantarflexion ROM, and early neuromuscular control 5
      4. For more severe sprains (Grade 2–3), ensure safe transition from partial to full weight-bearing when cleared.

      Key Actions

      • Manage Swelling & Pain: Continue ice, compression, elevation, and possibly an ankle brace or taping to control instability 1
      • Restore ROM:
        • Grade 1: Typically recover near-full ROM within 1–2 weeks.
        • Grade 2: Emphasize gentle mobilizations; aim for significant ROM gains by ~2–3 weeks.
        • Grade 3: More gradual approach; carefully monitor pain and effusion.
      • Neuromuscular Drills:
        • Gentle isometric exercises and foot intrinsic work (towel curls, marble pickups) to stimulate stabilizers 6
        • Begin proprioceptive training with simple static balance (e.g., single-leg stance on a firm surface, eyes open, force plate biofeedback) 7
      • Criteria to Progress:
        • Minimal to no effusion; swelling should be reducing steadily.
        • Pain-free active ROM approaching ~75–80% of the uninjured side (especially dorsiflexion).
        • Ability to weight-bear without significant pain or limping (Grade 1 might achieve this in days, Grade 2 in 2–3 weeks, Grade 3 in 4+ weeks).
        • Safe, stable single-leg stance for ~15 seconds without compensatory strategies, <10% asymmetry in COP metrics using force plate.

      3. Intermediate Phase (Weeks 1–2 for Grade 1; Weeks 2–4 for Grade 2; Weeks 4–6 for Grade 3)

      Once pain and swelling have decreased and weight-bearing tolerance has improved, more challenging strength and proprioceptive exercises begin.

      Goals

      1. Continue to normalize ROM (target near-full ankle dorsiflexion and plantarflexion).
      2. Improve muscular strength (particularly peroneals, tibialis posterior, and calf muscles) and neuromuscular control 8
      3. Gradually normalize gait and progress functional activities without protective devices, if safe.

      Key Actions

      • Progressive Strength Work:
        • Strength exercises (inversion, eversion, dorsiflexion, plantarflexion) 6,9
        • Start calf raises (double-leg to single-leg) as tolerated.
        • Balance/Proprioception: Single-leg stance on foam pads or wobble boards; light perturbation training.
      • Functional Movements:
        • Grade 1: May start light hopping, step-ups, and mini-squats within ~1–2 weeks.
        • Grade 2: Introduce these slightly later (2–3+ weeks).
        • Grade 3: Focus on restoring stability and strength before impact drills; this might take around 4–6 weeks.
      • Criteria to Progress:
        • Near-full functional ROM (dorsiflexion within ~90% of the uninjured side).
        • Strength ~60–70% of the uninjured side for key motions (e.g., eversion strength measured via isometric handheld dynamometry).
        • Stable single-leg balance for ~30 seconds with minimal sway and <10% asymmetry. Reductions in key balance metrics7
        • Pain-free walking with normal gait pattern (no limp, normal stride).

      4. Strength & Neuromuscular Advancement (Weeks 2–3 for Grade 1; Weeks 3–6 for Grade 2; Weeks 6–8 for Grade 3)

      In this phase, the athlete builds more robust strength and dynamic balance needed for sport-specific drills.

      Goals

      1. Regain foundational lower-limb strength nearing pre-injury levels.
      2. Incorporate more advanced neuromuscular and balance exercises (unstable surfaces, directional changes).
      3. Lay groundwork for safe reintroduction of running, jumping, or cutting.

      Key Actions

      • Strength Testing & Training:
        • Track improvements in ankle evertors/invertors isometric strength (using a dynamometer).
        • Increase load on calf raises (weighted single-leg, standing or seated) 10
        • Add squats, lunges, step-downs, focusing on proper alignment and stable foot/ankle mechanics.
      • Neuromuscular Training:
        • Expand balance challenges (e.g., single-leg stance on wobble boards while catching a ball).
        • Begin low-level plyometrics if Grade 1 or mild Grade 2 (2-footed hops, mini hops in place) 7
      • Criteria to Progress:
        • Ankle strength ~80% of the uninjured side.
        • Pain-free capacity for moderate single-leg hops or bounding in place. Set baseline. Track asymmetries using force plate assessment.
        • No significant dynamic valgus or “rolling in” of the ankle during exercises.
        • Sufficient control shown during basic agility drills (e.g., side shuffles, figure-8 walks).

      5. Intro to Impact & Jump Training (Weeks 2–3 for Grade 1; Weeks 4–6 for Grade 2; Weeks 8–10 for Grade 3)

      Timing will differ greatly: a mild Grade 1 sprain may introduce hop/jump progressions within a couple of weeks, while Grade 3 may only be ready around 8+ weeks.

      Goals

      1. Safely reintroduce impact to prepare for dynamic sport demands (landing mechanics, basic plyometrics).
      2. Improve single-leg braking and propulsion.
      3. Continue closing any remaining strength or power deficits.

      Key Actions

      • Landing Mechanics & Plyometric Progressions:
        • Bilateral to single-leg jump and land drills.
        • Small drop jumps or step-off landings (progressive height). Test on force plates for force output and assymetries.
        • Emphasize proper foot strike and minimal ankle “wobble” 7,8
      • Force-Plate Monitoring (if available):
        • Assess landing asymmetries, peak force, and shock absorption between limbs.
        • Identify any “offloading” of the injured ankle.
      • Progressive Plyometrics:
        • Hopping in multiple directions, bounding, low-level side-to-side hops.
        • Grade 1: Could be introduced around week 2–3.
        • Grade 2: Typically weeks 4–6.
        • Grade 3: Possibly 8–10 weeks, once stability is established.
      • Criteria to Progress:
        • Limb symmetry index (LSI) for strength ~85–90%.
        • Pain-free single-leg landing from low heights.
        • No increase in swelling after introducing impact drills.

      6. Reintroduce Running & Change of Direction (Weeks 3–4 for Grade 1; Weeks 6–8 for Grade 2; Weeks 10–12+ for Grade 3)

      As the athlete tolerates moderate plyometrics, it’s time to rebuild tolerance for running and sport-like directional changes.

      Goals

      1. Progress linear running volume and speed.
      2. Integrate planned change-of-direction (COD) drills safely.
      3. Improve confidence and dynamic stability at higher speeds.

      Key Actions

      • Running Readiness:
        • Confirm no effusion, near-normal ROM, and adequate ankle strength (≥80% LSI) 9
        • Gradual run/walk intervals → continuous jogging → sprint progressions.
      • COD Drills:
        • Begin planned low-velocity cuts (e.g., 45°), gradually increasing angle and speed 5
        • Include ladder drills, cone drills, and eventually reactive elements.
      • Assess COD Performance:
        • If available, use force plates or inertial sensors to measure ground reaction forces.
        • Look for symmetrical deceleration forces, stable foot contact, and no “rolling” episodes.
      • Criteria to Progress:
        • Near-symmetry in strength/power measures (≥90% LSI).
        • Pain-free jogging/running at moderate to high intensity.
        • Competent, stable performance on low- to mid-speed COD drills with no excessive ankle strain.

      7. Late Stage / Return-to-Sport Preparation (Weeks 3–4+ for Grade 1; Weeks 6–10+ for Grade 2; Weeks 10–12+ for Grade 3)

      The final push back to full competition. Grade 1 sprains might reach this phase as early as 3–4 weeks, while Grade 3 injuries may require 3+ months.

      Goals

      1. Achieve sport-specific power, agility, and neuromuscular demands at pre-injury or near pre-injury levels.
      2. Demonstrate performance benchmarks consistent with safe sport return.
      3. Validate psychological readiness and confidence in the ankle.

      Key Actions

      • Sports-Specific Conditioning:
        • Practice sport drills at near-full intensity: sprints, cutting, jumps, reactive agility.
        • Integrate into progressively higher intensity practices or scrimmages.
      • Advanced Plyometrics & Power Tests:
        • Depth jumps, bounding sequences, single-leg drop jump progressions.
        • Assess reactivity (e.g., RSI - reactive strength index) for minimum benchmarks.
      • Return-to-Play (RTP) Criteria:
        • Strength near 90–100% LSI for key muscle groups (evertors, plantarflexors).
        • Satisfactory performance on jump/hop tests (≥90% LSI).
        • Confident execution of sport-specific tasks with no pain or laxity.
      • Decision-Making:
        • Use data-informed metrics (strength, hop tests, agility runs) + movement quality + psychological readiness 11.
        • Typically, Grade 1: 2–3 weeks total. Grade 2: 4–6+ weeks. Grade 3: 10–12+ weeks.

      8. Ongoing Maintenance & Long-Term Monitoring

      Goals

      1. Prevent re-injury and manage any chronic ankle instability.
      2. Maintain or improve performance capacity in the long term.

      Key Actions

      • Performance Testing at Regular Intervals:
        • Hop tests, balance tests (e.g., Y-Balance) to detect deficits early 7
        • Periodic reevaluation of ankle ROM, strength, and neuromuscular control.
      • Continued Neuromuscular Training:
        • Balance circuits, sport-specific agility drills, targeted stabilization exercises 12
        • Consider prophylactic measures (bracing or taping) if re-sprain risk is high 2
      • Movement Strategy Refinement:
        • Regularly review foot/ankle mechanics in sport (e.g., cutting, landing technique).
        • Address any ongoing asymmetries or compensations.
      • Psychological & Technical Support:
        • Maintain communication with coaches and possibly a sports psychologist to address any lingering fear of re-injury.

      Key Takeaways

      1. Objective Measurement Guides the Process:

        • ROM, balance tests, dynamometry (strength), and hop tests help track progress.
        • Clear numeric milestones (e.g., ≥90% LSI) ensure consistency in decision-making.

      2. Phase Progression Depends on Meeting Criteria:

        • Each phase has distinct ROM, strength, neuromuscular control, and functional benchmarks.

      3. Individualized & Athlete-Centered:

        • Adjust for the athlete’s sport demands (cutting, pivoting, jumping) and personal recovery rate.

      4. Don’t Rush:

        • Even a Grade 1 sprain needs adequate rehab to avoid re-injury; a Grade 3 can take up to 3+ months.

      By aligning healing timelines (2–3 weeks for Grade 1, 4–6 weeks for Grade 2, and 10–12 weeks for Grade 3) with criteria-based milestones, practitioners can guide athletes from acute ankle sprain management through to safe return-to-sport. Utilizing objective tests and progression criteria at each stage ensures a structured yet flexible approach that reduces reinjury risk and fosters confidence in the athlete’s recovered ankle.

      References (Sample/Key)

      1. Fong DT, et al. A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007.
      2. Doherty C, et al. Effectiveness of rehabilitation strategies for acute lateral ankle ligament sprain. Br J Sports Med. 2017.
      3. Bleakley CM, et al. Conservative management of acute ankle sprains. Lancet. 2008.
      4. van Rijn RM, et al. What is the clinical course of acute ankle sprains? Am J Sports Med. 2008.
      5. Hupperets MD, et al. Effect of unsupervised home exercise program vs. supervised on acute ankle sprains. BMJ. 2009.
      6. Munn J, et al. Eccentric vs. concentric exercises for ankle evertor strength. Phys Ther Sport. 2008.
      7. McKeon PO, et al. Balance training improves function and prevents recurrent sprains. J Athl Train. 2008.
      8. Kaminski TW, et al. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains. J Athl Train. 2013.
      9. Wikstrom EA, et al. Dynamic postural stability after ankle sprains. Med Sci Sports Exerc. 2004.
      10. Brumann M, et al. Calf-raise endurance and single-leg hop for distance in ankle function. Clin J Sport Med. 2013.
      11. Ardern CL, et al. Psychological readiness to return to sport. Br J Sports Med. 2016.
      12. Verhagen E, Bay K. Optimizing ankle sprain prevention. Br J Sports Med. 2010.