The ankle plays a very important role in absorbing force, producing force, adapting to uneven surfaces, and adjusting to the body’s centre of mass shifting outside its base of support. All these factors highlight the importance of rehabilitating an ankle sprain properly to ensure optimal performance and prevention of future injury.
Here are 5 key components of ankle sprain rehabilitation to ensure your athlete is ready
to return to the training field!
1. Range of Motion (ROM) / Ankle Mobility
The first checkpoint which we must tick off is regaining the range of motion (ROM) that was lost during the acute stage of injury. Depending on whether the ankle sprain required a cast or boot to prevent movement, will determine the length it takes to regain full ROM however for the most part, ankle sprains will not require immobilisation and have better outcomes if avoided.
Some limiting factors in the protection phase of our rehab plan include inflammation, pain and swelling due to damaged tissue and these are best to be addressed first using off feet active recovery, manual therapy, and exercise. Once addressed, this phase will mostly consist of low load and isolated sub-maximal isometrics and simple active assisted ROM exercises using a towel or band, that help reduce pain levels while allowing the ankle to move normally again.
Beginning with some basic exercises to move your foot through all the ankle motions and activate the muscles around the ankle. Some examples of exercises in this phase are:
Tracing the alphabet (start with print then try cursive)
Active Assisted ROM exercises (using towel or bands to assist with range)
Knee to wall exercise
Low load eversion and inversion isometrics through range (using bands or fixed object to push against)
Low Dragon pulses/holds
2. Sensorimotor Control – Dynamic Postural Control/Balance and Proprioception
Once we have addressed ankle ROM, we can begin to work on sensorimotor control or balance exercises as most would know them. This includes:
Dynamic Postural Control/Balance: which is our ability to maintain our centre of mass within our base of support while being exposed to both internal and external perturbations (both controlled and reactive).
Proprioception: which is our body’s ability to perceive or be aware of where it is positioned in space (its location) and its movements and actions. Eg. Being able to walk without looking down at your feet or consciously thinking about our environment.
Some examples of exercises in this phase include:
Single Leg Balance +/- balance board, foam or bosu ball
Single Leg Rotational Exercises (Pallof Press, Med ball throw etc.)
Y balance
Lunge Matrix in sagittal, frontal, and transverse plane
Balance exercises can be useful for improving not only dynamic postural control and proprioception yet starting to challenge the muscles responsible for inversion and eversion of the ankle helping to begin to strengthen the muscles as well.
3. Muscle Strength, Endurance and Power
Generally, this phase of rehab will begin at a similar time to sensorimotor control, yet it is important to understand that it needs to be tailored to the individual/athlete. Timelines will be dependent on the athlete’s symptoms, current functional level, goals and demands of the sport they play.
As mentioned earlier, isolated sub maximal isometrics are a great exercise for the reduction of pain in the early stage and can also be used at the beginning of our strength program to create a solid foundation which we can build on throughout the rehab program.
From here we can add in some resisted banded work for the ankle dorsiflexors, and plantar flexors followed by banded eversion and inversion of the ankle. Keeping the reps high (20 reps+) in this stage to allow repetitive use of each muscle to regain strength though range.
Once competent with home exercises program exercises above we can shift our focus to regaining capacity in the gym focusing on 4 key strength areas across all 3 planes of motion:
Double leg Strength (Squat variations, leg press, hamstring curls, knee extensions)
Single Leg Strength (Knee Dominant) (Step downs, Bulgarians, Front foot elevated lunges)
Single Leg Strength (Hip Dominant) (Glute bridges, Hip thrusts, RDL’s)
Heel Raises (Standing, Seated, Split Stance)
4. Plyometric Ability/Stiffness
In this phase on rehab, we are working towards Sport Functional Performance. Taking the demands/requirements of the athlete’s chosen sport and exposing them to these demands in a controlled and predictable environment to begin with before increasing chaos and unpredictability as confidence and ability is regained. Generally, the focus of this phase includes hopping and jumping, change of direction and agility, sport specific activities and regaining the ability to complete full training session.
Reactive plyometrics should play a crucial role in the end stage/return to play of all sporting injuries, especially ankle sprains. Beginning this phase in controlled predictable setting working on breaking down the three major components of a jump/hop. These being force absorption, force production and stability. A variety of stimulus is required to expose the athlete to the greater demands of their chosen sport. These initially include:
Double Leg/Single Leg Force Absorption (Altitude Drops, Drop Jumps, Depth Jumps)
Double Leg/ Single Leg Force Production (Pogo’s, Broad Jumps, Box Jumps)
Combination Force Absorption and Force Production (Line hopping, Hurdles, Drop Jump to Box Jump)
It is important to focus on each of these components in each of the 3 planes, beginning with the sagittal plane then progressing to the frontal plane and lastly the transverse plane.
Once the athletes have developed adequate performance in each plane in isolation, it is important to replicate the demands of the athlete’s sport through multi-vector plyometrics where the athlete is required to transfer force between planes in a controlled manner before adding a reactive component to further challenge the athlete. Eg. Drop Jump forward then lateral over hurdles.
5. Change of Direction & Agility
The same principles can be applied to the change of direction and agility component focusing on ensuring a controlled and predictable environment to begin with before progressing to a more chaotic and unpredictable environment. Some examples of exercises in this phase include:
Y Cone Drill
H Cone Drill
Z Cone Drill (Forward and Lateral)
These exercises can begin in the gym in a controlled and predictable way by walking through 5 reps stepping off the left foot followed by 5 reps stepping off the right foot at 50% of max effort before progressing to the field where we will gradually be progressing difficulty as confidence and strategy improves. To increase chaos a reactive or cognitive component can be added where a verbal or visual cue will decide the next direction once the cone is reached. This will begin to prepare the athlete for sport specific activities replicating on field
scenarios where the athlete must perceive and process relevant information before selecting and carrying out an appropriate movement response within a reasonable timeframe (OODA Loop).
Once again, it is important to understand that it needs to be tailored to the individual/athlete and the demands/requirements of training and playing their chosen sport. It is important to tick off the components listed above however is just as important to assess the athlete’s perception and psychological readiness to determine how confident/ready they are in their ankle’s ability to perform the tasks at hand.