An ankle sprain is a well-known injury that involves the strain of the ligaments that support the ankle joint. Most commonly, it is the ligaments on the outside of the ankle that are injured (a lateral ankle sprain), as the ligaments on the inside of the ankle are much broader and stronger. On the outside of your ankle joint, three ligaments attach to the bony knob called your lateral malleolus. The ATFL (anterior talofibular ligament) spans forwards in the direction of your toes. The CFL (calcaneofibular ligament) joins to your heel bone directly under the bony knob. Finally, your PTFL (posterior talofibular ligament) spans towards the back of your heel. On the inside (medial) of your ankle, a larger ligament called the deltoid ligament fans out from the knob on the inside of your ankle to provide strong support.
What causes ankle sprain?
Lateral ankle sprains happen when the foot rolls inwards under the leg (called inversion), straining the ligaments on the outside of the ankle that prevent this movement. This can sometimes happen when walking or running over uneven ground, or when changing direction suddenly. Most people have rolled their ankle throughout their lifetime, though perhaps not seriously. It’s common to think that these injuries do not require rehabilitation; however, rehabilitation should occur after all ankle sprains, in order to reduce the likelihood of them happening again.
Medial ankle sprains are much less common due to the greater reinforcement on this side of the ankle, and occur when the ligament is stretched or strained by the foot rolling out under the leg (called eversion). They sometimes also occur after heavy, flat-footed landings.
How do I know if I have ankle sprain?
Ankle sprains always occur after a specific incident, such as your foot rolling inwards, or stepping on a pothole. They lead to pain and swelling over the affected ligaments, and often some difficulty walking. Ligaments provide information to the brain about how the ankle is positioned in space (called proprioception), so that movement can be coordinated. In an injury, this is disrupted and pain inhibits the function of your muscles. A physiotherapist can diagnose and help rehabilitate a sprained ankle. It is vital, particularly for those playing sport, to work to regain the strength, proprioception and function around your ankle, as these injuries often become recurrent. Your physiotherapist will need to assess the severity of the injury, and will perform tests to assess the stability of the joint. If there is significant tenderness over the bones around the ankle, or you are unable to walk on the leg, an X-ray should be ordered to rule out fracture.
How can physiotherapy help with ankle sprain?
In the initial phase after your injury, following the POLICE protocol (protect, off-load, ice, compression and elevate) can help settle down early symptoms. Complete non-weight bearing is likely not needed, unless the injury is very severe, in which case your physiotherapist will likely refer you for an X-ray to rule out a fracture. You will be able to begin moving your ankle and walking around on your ankle from day one, and this will help you return to activity quicker.
Strengthening and balance exercises
As soon as you are able, your physiotherapist will create a program of exercises to regain movement at the ankle, strengthen the muscles around the ankle (such as the calf), and also work on your joint position sense and confidence with challenging single leg tasks. These balance type exercises are sometimes called neuromuscular exercises, and should be similar to the activity you are returning to (eg, a basketball player should work on jumping, landing and cutting exercises).
Mobilisation and manual therapy
It is important to regain full range of motion after an ankle sprain and also to reduce pain quickly to get back to your desired activity. Your physiotherapist may mobilise around your ankle joint, and use soft tissue work to help with any swelling or muscle tightness.
Taping and bracing
It may be beneficial to have your ankle taped or braced when you return to activity, to help supplement the support of your ligaments and muscles, and to provide confidence using your ankle for full function. Your physiotherapist can show you how to tape your ankle or advise you on what brace to purchase.
How effective is physiotherapy for ankle sprain?
Only around seven per cent of lateral ankle sprains receive active treatment and it is estimated that up to 30–40 per cent of ankle sprains go on to have recurrent instability. Therefore, it is vital that you seek adequate rehabilitation and treatment for this injury.
Strengthening and proprioceptive exercises are strongly supported by research for reducing pain, returning to sport quickly and preventing further re-injury. Most studies, however, look only at short-term outcomes. A high-quality randomised controlled trial showed that accelerated rehabilitation (beginning exercises early in the first week) had superior short-term outcomes compared to resting and offloading in the first week.
Mobilisation and manual therapy is also supported by research as helping to improve range of motion and reduce pain in the short term, and is a good addition to rehabilitation (alongside exercises).
Taping and bracing is also shown to be effective in reducing future injuries and was recommended to be worn for six months or more following an injury.
Ice appears to be helpful in reducing pain in the short term and is best applied 10 minutes on and off.
Anti-inflammatory medication is also strongly supported as helping reduce pain in the short term.
The following treatments are not supported by published research:
What can I do at home?
As your pain allows, movement of the ankle will help to regain function quickly. An easy exercise to start movement with is to draw the alphabet with your foot every few hours throughout the day. You can also start some muscle activation and strengthening exercises by doing 5 x 10-second holds, pushing your foot down, up, in and out against a resistance such as your own foot or a wall.
Once you are over the early phase of the injury, your physiotherapist will prescribe an exercise plan involving exercises such as calf raises, single-leg balance and gentle bounding or hopping exercises. You can do balance exercises anywhere in your spare time, such as when waiting for a coffee or standing in a queue.
How long until I feel better?
Usually swelling and pain should begin to settle within the first week. Minor ankle injuries may not require much time away from sport or activity; however, they will still require 3–6 weeks of strengthening and exercise. It is important to get back your full ankle function that you had previously to reduce the risk of the injury recurring. More major ankle sprains may result in some time off from your desired activity, and your physiotherapist will be able to give you a guide to when you can return.