ANKLE SPRAIN REHABILITATION

PHASE 1: EARLY REHABILITATION (ACUTE PHASE)

5-10 DAYS
GOALS TREATMENT PROGRESSION CRITERIA
 Manage swelling and pain  RICE protocol  Decreased pain and swelling
 Regain full ankle dorsiflexion (DF) o Ice compress x 20 mins x twice daily  Full (near full) ankle DF
 Regain balance and proprioception  Antero-posterior mobilization of talus, gentle  Normal gait pattern without
 Normal gait pattern oscillations crutches
 Muscle re-education and activation  Achilles tendon stretching  Single leg balance
 Maintain athletic fitness  Daily ankle taping
 Crutches
 Manual therapy
 Pain-free active range of motion (AROM), all
planes x 10-15 reps x 3 sets
 Activation and strengthening of pain-inhibited
muscles
 gait retraining with heel-to-toe walking
 balance exercises
 Fitness maintenance: weights training for upper
body, ergometer bike
PHASE 2: STRENGTHENING (SUB-ACUTE PHASE), FUNCTIONAL REHABILITATION
2-3WEEKS
GOALS TREATMENT PROGRESSION CRITERIA
 Full ankle active range of motion  Continue modalities for pain and inflammation  Decreased pain and swelling
(AROM) as needed  Pain free ankle AROM
 Normal gait at increased speeds  Continue talocrural joint mobilization, midfoot  Higher-levelgait
 Regain balance and proprioception mobilization  Star Excursion Balance Test
 Calf raises (single and double leg) (SEBT) equal on both ankles
 Proprioception/balance exercises orwithin 95% of
 Strengthening program for hip/knee/core The unaffected side
 Aerobic/endurance activity with weight bearing
 as tolerated

Ankle sprains are often treated conservatively. The acute phase is the most critical since the goal is to reduce swelling, normalize gait
patterns, and maintain optimal joint alignment to prevent chronic concerns like ankle instability and sprain recurrence. The acute
phase consists of symptom treatment followed by rehabilitation. The RICE (rest, ice, compression, elevation) is implemented as an
initial management for pain and swelling (Starkey, 1976), with talocrural joint mobilization to improve ankle range of motion. These
interventions are applied in accordance to the protocol described by Green et al. (2001). Rest is defined as the avoidance of pain-
inducing activities, thus the subject is advised to stop from team training and is only permitted to exercise after the prescribed
interventions. It is recommended that the subject applies ice for at least two 20-minute sessions daily. To impart compression to the
ankle and calf, an elastic bandage is applied also on a daily basis. For added support and protection, daily ankle taping using a rigid
sports tape is recommended. Furthermore, the subject is told to raise one foot above the heart for at least 25% of the day. Every
therapy session, a passive joint mobilization is to be conducted before the application of the RICE, specifically talocrural joint
mobilization at the limit of its pain-free range of motion in dorsiflexion with a moderate oscillatory technique described by Maitland
(Hengeveld & Banks, 2013). Following these procedures has been shown positive effects, including fewer treatment sessions, early
restoration of ankle dorsiflexion with improvement of gait parameters (Green et al., 2001), while functional support through the use of
elastic bandage, tape, and braces have been proven to be beneficial in reducing pain and swelling, preventing recurrent sprains, and
supporting ankle instability, with patients receiving improved range of motion (ROM), less persistent swelling, and reporting a higher
percentage of return to sports or work-related activities (Kerhoffs et al., 2002).
The use of nonsteroidal anti-inflammatory medications (NSAIDs) is supported by current data, with participants who used NSAIDs
during the first two weeks after a sprain reported a substantial improvement in function in the long run when compared to a placebo
(XXXXX).

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 Antero-posterior mobilization of talus

Range of motion must be regained before proceeding to the next stage when functional rehabilitation is
initiated. Achilles tendon stretching should be instituted within 48 to 72 hours of injury, regardless of
weight-bearing capacity, in light of the tissue's tendency to contract after trauma. Once ROM is achieved and
swelling and pain are controlled, the patient is ready to progress to the strengthening phase of
rehabilitation. Strengthening of weakened muscles is essential to rapid recovery and is a preventive
measure against reinjury (Thacker et al., 1999). Exercises should focus on the conditioning of the peroneal
muscles because insufficient strength in this group has been associated with CAI and recurrent injury
(Hartsell & Spaulding, 1999). However, all muscles of the ankle should be targeted and all exercises
performed bilaterally. Strengthening begins with isometric exercises performed against an immovable
object in 4 directions of ankle movement and progresses to dynamic resistive exercises using ankle weights,
surgical tubing, or resistance bands.

Hartsell, H. D., & Spaulding, S. J. (1999). Eccentric/concentric ratios at selected velocities for the invertor and evertor muscles of
the chronically unstable ankle. British journal of sports medicine, 33(4), 255–258. https://doi.org/10.1136/bjsm.33.4.255

Thacker, S. B., Stroup, D. F., Branche, C. M., Gilchrist, J., Goodman, R. A., & Weitman, E. A. (1999). The prevention of ankle sprains
in sports. A systematic review of the literature. The American journal of sports medicine, 27(6), 753–760.
https://doi.org/10.1177/03635465990270061201

 Green, T., Refshauge, K., Crosbie, J., & Adams, R. (2001). A randomized controlled trial of a passive accessory joint
mobilization on acute ankle inversion sprains. Physical therapy, 81(4), 984–994.
 Hengeveld, E., & Banks, K. (2013). Maitland’s Peripheral Manipulation E-Book : Management of Neuromusculoskeletal
Disorders - Volume 2. Butterworth-Heinemann.
 Kerkhoffs, G. M., Rowe, B. H., Assendelft, W. J., Kelly, K., Struijs, P. A., & van Dijk, C. N. (2002). Immobilisation and
functional treatment for acute lateral ankle ligament injuries in adults. The Cochrane database of systematic reviews, (3),
CD003762. https://doi.org/10.1002/14651858.CD003762
 Starkey J. A. (1976). Treatment of ankle sprains by simultaneous use of intermittent compression and ice packs. The American
journal of sports medicine, 4(4), 142–144. https://doi.org/10.1177/036354657600400403
PHASE 2
Additionally, performing balance and ankle strengthening exercises during and after the subacute phase is beneficial for those with
chronic ankle instability and those predisposed to recurrent ankle sprains.

PHASE 1 TO PHASE 2
Manual therapy has shown to increase ankle function up to one month following the treatment. In addition, current evidence proves
that Mulligan’s mobilization with movement technique (anterior to posterior glide of the talus) during the subacute phase, is effective
in increasing dorsiflexion range for participants with Grade 2 ankle sprains.

Evidence-based treatment of acute ankle sprain

Functional support is preferable to immobilization for most ankle sprains. Functional support involves the use of a removable and
variable immobility device and therefore often includes an exercise component in the treatment. A meta-analysis found significant
differences in favor of functional support, which included brace, elastic bandage, tape, softcast, or wrap over immobilization.12
Differences in favor of functional support included a higher percentage of people returning to sports, shorter time to return to work,
less persistent swelling, and greater range of motion. However, neither Kerkhoffs et al.12 nor a subsequent review13 found a
difference in rate of instability, either objective or subjective, or recurrent sprain between immobilization and functional support.
In contrast to these results, a recent large pragmatic randomized controlled trial comparing immobilization for 10 days in a below-knee
cast with tubular bandage, a Bledsoe boot or an AircastTM brace, found that people with the cast had better clinical benefits at three
months post-injury;14 however, all differences had disappeared by 9 months. While this study appears to contradict the previous
reviews and current practice, it needs to be noted that this study exclusively recruited patients with severe ankle sprain (unable to
weight-bear for at least 3 days). In addition, there are a number of limitations that should mitigate decision making during practice.
Outcomes were by self-reports so there was no assessor blinding. The drop-out rate was 17% before the first follow-up, and the
compliance rate with the functional supports was unknown. Therefore, current practice of using functional support rather than
immobilization for most ankle sprains should remain in place until follow-up of the latest trial confirms the result.

The type of functional support that is preferable to use may depend on the main outcome desired. A systematic review comparing the
use of one type of functional support with another (included elastic bandage, tape, semi-rigid support, and lace-up ankle support)
found them equally effective in reducing pain, swelling, ankle instability, and preventing recurrent sprain.15 A semi-rigid support
appeared more effective for earlier return to sport, and tape resulted in more skin complications. A more recent comparison of an
Aircast ankle brace with elastic support bandage group demonstrated a significant improvement in ankle joint function at 10 and 30
days when using the ankle brace.16
There is fairly consistent evidence that the use of non-steroidal anti-inflammatory drugs during the first 2 weeks following ankle
sprain, administered orally or topically, is more effective than a placebo.17,18 Only one study followed patients for a longer period;19
it reported that Piroxicam taken for 1 week significantly improved function at all time points up to 6 months compared with a placebo.
However, the study also reported greater range of motion restriction and mechanical instability in the intervention group in the short
term.

The extent and quality of the available evidence for the effects of electro-physical agents for treatment of acute ankle sprains are
limited. Ultrasound does not appear to be effective although as the tested dosage range and treatment times are limited, there may be
an effect using untested variables.17,20 The use of laser has conflicting evidence of effectiveness. In one study, low-level laser with
rest, ice, compression, and elevation (RICE) was shown to reduce swelling up to 3 days after the treatment when commenced within 8
h of injury and given twice a day, compared with RICE alone, or RICE and placebo laser.21 Another study showed that neither high
nor low-level laser was more effective than placebo in reducing pain.22 Furthermore, those in the placebo group had significant
improvements in some outcomes compared to those who received laser, most markedly on the re-uptake of work and sports.
Manual therapy in a number of forms has been shown to have positive effects after acute23,24 and subacute ankle sprain.25,26
However, this evidence is weak (generated from small randomized controlled trials or cross-over studies) and the effects may be short-
lasting (Table 1). Following acute ankle sprain, a passive anteroposterior glide of the talus was better at increasing dorsiflexion range
of motion than rest, ice, compression, and elevation at the end of the treatment period.24 The addition of osteopathic ankle
manipulation to standard care reduced swelling and pain at the end of the treatment session.23 These effects appeared clinically
worthwhile but disappeared at the short-term (5–7 days) follow-up.
PHASE 2
During the subacute phase, both Mulligan’s mobilization with movement25 and a chiropractic mortise adjustment technique26
increased dorsiflexion range immediately following treatment in participants with Grade ii and Grades i and ii sprains, respectively.
Manual therapy also increased ankle function up to 1 month following the treatment.26

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3103112/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164373/
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0262023
https://www.amhealthperformance.com/single-post/2017/11/18/the-rolled-ankle
https://www.amhealthperformance.com/single-post/2017/11/18/the-rolled-ankle
https://academic.oup.com/ptj/article/81/4/984/2829522
https://pubmed.ncbi.nlm.nih.gov/12137710/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164373/
https://www.researchgate.net/publication/51203481_Evidence-based_treatment_for_ankle_injuries_A_clinical_perspective
https://www.europeanreview.org/wp/wp-content/uploads/1876-1884.pdf