How to treat your ankle sprain

THE ANKLE SPRAIN SELF-TREATMENT SERIES:

• How to diagnose your ankle sprain

• How to know whether you've broken your ankle

• How to treat your ankle sprain (this article)

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How long it will take you to recover from a sprained ankle heavily depends on how badly you've sprained it and what structures you've injured - something that our team of sports physios can easily help you diagnose via an online physio consultation. In this article, I'll walk you through the different treatments that you should apply if you want your ankle to make a quick and strong recovery.

You can sustain any combination of the following injuries when you twist your ankle:

• Ligament damage

• Muscle strain or tears

• Cartilage damage

• Bone bruising

• Fractures or broken bones

You can find out how to determine the extent of your injury in this article about how to diagnose ankle sprains. I've also written a piece on how to know if you've broken your foot or ankle that you may find useful.

I've also discussed this topic in detail in this video:

As a rule of thumb, I usually find that ankles that swell up a lot within a short period of time (30 minutes) takes longer to recover (8 to 12 weeks). Mild swelling or swelling that appears over the course of a day, usually indicates a quicker recovery time (4 to 6 weeks).

It's very important to regain full flexibility and strength before you try and play your sport. My patients are always keen to strengthen up other injured body parts, e.g. knees, but they often neglect ankle injuries. They seem to think that they will just get stronger by themselves.

You can end up with a chronically unstable ankle if you don’t rehabilitate it properly. You may have an unstable ankle if you find that you twist it often and without much effort. I have had patients who continuously sprain their ankles by just walking in the street.

The good news is that this instability is often what we call a ‘functional’ instability (poor muscle control) rather than a ‘structural’ instability (ligaments have fully ruptured) and it can usually be rectified by following a specific exercise programme.

The treatment of ankle sprains can be roughly divided into 2 stages:

1. Acute management

2. Rehabilitation / exercise therapy

Your treatment plan should also take the stages of healing into account. If you do too much too quickly, you may reinjure yourself. Do too little and you'll see no improvement.

Sprained Ankle Treatment: Acute Management

Research update: The information in this article is still valid, but Steph has recently done an updated version of this article where she incorporated the latest research findings and recommendations for treating sprains which you may find useful.

The acute phase for an ankle sprain can last anything between 4 to 6 days depending on the severity of your injury.

Manage acute sprains as follows:

• Stop what you're doing.  Continuing to run etc. when you've injured your ankle causes further injury and internal bleeding and will make your recovery take much longer.

• Apply ice and gentle compression for 10 minutes immediately after twisting your ankle. It may also help to elevate your foot above the level of your heart, if possible. This helps to limit the internal bleeding and swelling. Excessive internal bleeding and swelling can cause increased pressure on the surrounding, healthy tissue. This pressure can cut off the blood circulation and oxygen supply to adjacent cells and you can end up with more damage than what the original injury actually caused. WORD OF CAUTION: applying the ice for longer than 10 minutes or applying very strong compression, may have the opposite effect.

• Do not use nonsteroidal anti-inflammatory drugs (NSAIDS) or corticosteroids during the first 3 days post injury. Inflammation is an important part of the initial phase of wound healing and you can delay your recovery by limiting this process. It is safer to use ice to decrease swelling and pain since it does not cause a decrease in the inflammatory response to the same extent that NSAIDS does. You can apply ice every 2 hours over the first 3 days.

• You may find that using a crutch for a day or two after injury can help speed up your recovery in severe cases. Crutches should never be used for more than 2 days without consulting a physiotherapist or medical professional, since prolonged use can also hinder your recovery. WORD OF CAUTION: Being over-protective of an injury can lead to poor recovery outcomes.

• You may have to wear a rigid ankle brace, boot or cast for up to 10 days if you have severe pain and swelling. Do not keep the ankle immobilised for too long – research has shown that doing early functional exercises leads to a quicker recovery than prolonged immobilisation.

• Moving your ankle within its pain free range can help to decrease your pain and help speed up recovery. I usually tell people to start doing this on the second day after injury depending on how bad it is. So, if you injure it today, start moving it from tomorrow. The type of ankle sprain you sustained will determine what movements you start with. I usually get people to do very gentle dorsiflexion/plantar flexion movements (pull toes up and point toes down) for the typical inversion ankle sprain (where you pull the ligaments on the outside of your ankle). The movement should be done pain free and repeated 10 times in one go. You can do it often during the day.

Ankle dorsiflexion

Ankle plantar flexion

Sprained Ankle Exercises

A recent review of the literature has found that rehabilitation exercises are effective in preventing recurring ankle sprains. You can usually start doing some rehabilitation exercises on the 4th day post injury, but this time will vary depending on the extent of your injury.

Remember to think about the stages of healing and not be too quick to progress your exercises. None of the exercises should cause you more than just a mild discomfort. It may be worth consulting a physiotherapist for guidance.

Exercises should always be progressed from doing them on a stable base (two legs) to an unstable base (one leg), from stationary (standing still) to dynamic (stepping, jumping, running), from slow to fast and from simple (one movement) to complex (combined activities).

A successful rehabilitation programme should include the following components:

1. Flexibility

2. Proprioception and coordination training

3. Foot/ankle control and strength training

4. Hip control and strength training

5. Sport specific drills

1. Ankle Flexibility

You should aim to regain full range of motion in the ankle within 4 to 6 weeks for a mild ankle sprain. More severe sprains can take 12 weeks or longer to regain full range. What does full range of motion mean? It just means that your injured ankle and foot should be able to bend up and down and turn in and out as far as your good ankle and foot can.

Do not be aggressive with any stretches during the first 2 weeks after spraining your ankle. I usually get people to avoid the injuring movement for at least 1 week. For instance, if you went over on your ankle and pulled the ligaments on the outside of your ankle, you should avoid turning your foot in for a week.

Start with free active dorsiflexion and plantar flexion (picture 2) as well as inversion and eversion (picture 3). This can be progressed to weight bearing dorsiflexion stretches and manually assisted inversion or eversion stretches.

Ankle inversion (turning your ankle in)

Ankle eversion (turning your ankle out)

2. Ankle proprioception and coordination

Simply put, proprioception is the ability to know where your foot, ankle, finger, bottom etc. is without having to look at it.  Without proprioception we would have to continuously look at our feet while walking since we would have no idea where we are placing them (it’s actually pretty cool).

This ability to know where your body part is without looking at it, is accomplished mainly through mechanoreceptors in joints, ligaments and muscles that continuously send messages to your brain while you move.

When you injure any of these structures in the ankle, these messages aren't as clear and the brain’s ability to detect where you put your foot is reduced. This is one of the reasons why it is so easy to go over on your ankle, even while just walking in the street, once you've sprained it a first time.

Decreased proprioception leads to what we call a functionally unstable ankle. This just means that the ligaments are strong and the joints stable, but you keep spraining it because your control over the ankle is poor.

The good news is that proprioception is extremely easy to retrain! Here are some of the basic exercises that you should master before you can do more complex things.

First aim to balance on one leg for 30 seconds without moving around. Once you can manage that, try to maintain your balance while moving your head from side to side.

Proprioception exercises should be progressed to be sport specific and test you in the body positions and activities that you use during your sport. While standing on one leg is a good starting point for a footballer, it will in no way prepare him for what he has to deal with during a match.

3. Foot and ankle control and strengthening exercises

Many of the exercises used to retrain proprioception will also double as strengthening exercises for the muscles of the foot and ankle as long as you make sure that you control your foot’s arch properly while doing them.

The video below shows you how to correct your foot's position. You should maintain good ankle and foot posture during all your exercises.

You should also target specific muscle groups that may have sustained injuries when you sprained your ankle. A common group of muscles involved in lateral ankle sprains are the peroneal muscles.

You can strengthen them in the early days post injury using an elastic band or wobble board. I usually start these exercises about 2 or 3 weeks post injury depending on the severity of the ankle sprain.

Peroneal exercise: Start with the foot turned in.

Peroneal exercise: Turn your foot out against the band

You should retrain these muscles in isolation first and then integrate it into more functional movements.

4. Hip control and strength training

I always look at my athlete’s hip control when treating them for ankle sprains.

If the muscles that control the hip (glute med and glute max) are weak, your hip will turn in when you walk and run. This in turn makes your knee turn in and can cause your foot to roll in or pronate excessively. The net effect is that you have extra strain through the ankle joint.

You can find a quick test for hip control as well as examples of some strengthening exercises here. It will help you decide if your hip muscles are weak or not.

5. Sport specific drills

You must include sport specific drills towards the end of your rehabilitation. Examples of this are for instance sprinting and cutting moves or sprinting and turning for football. In netball it will include jumping, catching a ball and landing. Steph demonstrates this well towards the end of this video

You should do them at a slow pace at first. Once you feel confident you should start increasing the speed and difficulty.

Need more help?

Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate.

References:

1. Kerkhoffs, G. M., van den Bekerom, M., Elders, L. A. M., van Beek, P. A., Hullegie, W. A. M., Bloemers, G. M. F. M., et al. (2012). Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), 854-860.

2. Lephart, S. M., Pincivero, D. M., & Rozzi, S. L. (1998). Proprioception of the ankle and knee. Sports Medicine, 25(3), 149-155.