Ankle Sprain Physiotherapy

Ankle sprains are some of the most common but often underrated injuries with regard to their severity. Often you hear of people who just say to “rest it up”, “strap it up”, or “just stay off it and you’ll get better”. This couldn’t be further from the truth in my opinion. Ankle sprains should be treated with the same approach as we do any other ligament injury or muscle injury. We should approach treatment with the intent to maximise your rehabilitation and reduce your risk of re-injury rather than the lackadaisical approach some clients take.

The recurrence rate for ankle injuries has been speculated to be as high as 73%, and a prevalence of 25% for the presence of chronic ankle instability with a range between 7% and 53%. I don’t hear many people who have chronically rolling ankles telling me how much they love it, so surely doing a good job of rehabilitation the first time around and minimising your risk. Getting an early assessment and diagnosis by a physiotherapist is the first key, our hands-on diagnostic skills are integral and we are also able to recommend whether we believe further imaging may be needed.

What we will discuss:

As with any other acute injury I want to know as much as you can remember about how it happened. The more detail you can give me the better. Truly understanding the mechanism of injury and whether it was a contact, indirect contact, or a non-contact injury is a key factor in developing an injury prevention plan. It’s also the first step in helping me determine what structures may be involved in your injury. Some clients may feel as though the injury happened “too quickly” to recall what happened with their ankle. in these instances I often like to run through what you were doing at the time, for example changing direction, or jumping for a contested ball, this can often give us a good idea of how the injury occurred.

Your symptoms and what you felt at the time of the injury and following is often the next discussion point. Whether you had swelling and bruising start along with how quickly it occurred is a crucial piece of information. Then understanding the pain and how it develops and behaves throughout the day. For example, some clients may wake up and their ankle feels stiff and then loosens up with activity but will feel a dull, diffuse, achy sensation by the end of the day, whereas others may just feel sharp pains only during activity. Every ankle sprain is different and we should be treating and assessing them as such.

One of the questions I always ask about is sensations of looseness, giving way, instability, or a feeling of the ankle being about to roll during day-to-day life. These symptoms during normal day-to-day activities matched with a history of ankle sprains could potentially indicate more of a chronic ankle instability presentation rather than just a “normal ankle sprain”. These should be managed differently and it is not a symptom to take lightly.

Lastly, your sporting history and your goals for rehabilitation is often our last discussion point. Understanding you as an athlete, and the role you play within your team is key for me as a physiotherapist to understand the demands you will place on your ankle and what we need to optimise for a successful return to sport.

What we will assess:

For an acute ankle sprain, the first and most routinely applied assessment for ankle sprains is applying to Ottawa Ankle Rules. These are a set of rules and tests used to determine whether the presence of a fracture around the ankle is likely. This testing battery is highly sensitive but not very specific. What that means is that they will pick up a lot of fractures, but may also pick up a lot of things that aren’t. If you are returning positive tests on this testing battery your best course of action is to get an x-ray which I am able to refer for. It’s easier to manage a fracture earlier on and reduce weight bearing as needed than getting 4 weeks in and we both are sitting there wondering why.

Next, we will often move onto more of a specific clinical assessment of the ankle where first I will look at how much active range of motion you have in comparison to how much passive range of motion you have. Determining the difference between the two and what is restricting one of them can help us determine a potential causative factor to your symptoms. The next step will be to perform specific ligament stress tests. For a lateral ligament sprain, we will perform a test for the ATFL (anterior drawer test) and for the CFL (talar tilt test). These tests are designed to assess the integrity of the ligaments and assess for laxity and pain reproduction.

Isometric assessment of muscles is often my next step in the assessment. Often I will perform an isometric assessment for ankle inversion, eversion and dorsiflexion on the treatment table, and I will assess calf function and plantarflexion in standing. These tests are adequate at picking up potential muscle strains or if there may be potential tendon involvement in the injury. Often I will combine this with a manual muscle test and I will compare the two sides to assess for potential hesitancy to contract the muscles as well as any strength deficits.

The functional aspect of the assessment I commonly perform last. Whilst some may argue it’s the most important, in the initial assessment I don’t want any irritation of symptoms from functional testing making the diagnostic process more difficult. The functional portion of the assessment will consist of a few different functions including:

Walking
Calf raises – double or single leg
Single leg balance – eyes open or eyes closed
Knee-to-wall measurement
Squat
Tip toe walking
Jumping
Hopping
Multi-directional hopping
Running

The level of assessment that we work up to is highly individual and dependent upon symptoms and irritability. In most cases we won’t be assessing higher load activities such as hopping on the first assessment, I have simply included it in the list to give you a guide of what may be included at later dates.

How we treat them

There are a few key puzzle pieces to optimising the rehabilitation of an ankle sprain. Number one on just about every physiotherapist’s list should be improving and normalising ankle dorsiflexion range of motion. Ankle dorsiflexion is the capacity for your knee to go over your toes and flex through the front of the ankle joint. Without this movement capacity running becomes a lot more difficult as does the certain change of direction manoeuvres. Improving this mobility can be done in a lot of different ways, the key to determining which way will be best is through the knee-to-wall assessment, where you feel the restriction or stiffness will tell us where we need to work. Often I find clients have restrictions through the calf muscle and the ankle joint itself, but some may have anterolateral restriction caused by the lateral malleolus so some specific work there may be needed in some clients. For a lot of people, a range of joint mobilisations and soft tissue release coupled with a targeted flexibility and mobility program will get the results you need.

The next key is to get rid of any swelling around the ankle joint ASAP. Hands-on techniques work really well when coupled with strategies like compression and elevation. Compression should be utilised as a way of reducing any swelling building up at the ankle, and elevation and self-massage should be seen as a way to get rid of whatever swelling is already there. The massage to reduce swelling doesn’t need to be hard, all we are trying to do here is simply mobilise the swelling up and out and away from the ankle.

Taping can be utilised in a variety of ways in various different stages of management. Some physios may utilise a taping technique to assist in getting rid of the swelling, others may utilise taping as a way of stabilising the ankle joint in the early stages and allowing the healing of the ligament to improve, others may utilise strapping as a way to allow the foot to take more load and thereby reduce forces at the ankle joint. Whichever way you choose to go is completely up to the physio and the client as none of these management strategies are wrong, it just comes down to which strategy will work best for that client and their presentation. In the later stages approaching returning to training and returning to sport utilising either taping techniques or an ankle brace is routinely recommended to reduce your risk of re-injury.

Last but not least is the age-old exercise program. I know every client loves it, they always tell me how much fun it is. Optimising your movement strategies, muscle strength and endurance, and joint range of motion and muscle flexibility are key to returning to sport successfully. If you cannot return these factors to baseline or above, you will simply increase your risk profile. The other strategy that we need to optimise is balance. Often I hear of everyone balancing with their eyes open and eyes closed, but nobody ever really does that in the real world, do they? We need to ankle to be able to operate autonomously and recorrect while performing a movement task and simultaneously having mental stimulation. The later stages of where I progress my balance rehabilitation to is balancing on one leg and throwing or kicking a ball whilst counting down from 100 by a certain number. This provides both a sport-specific physical task along with mental stimulation to remove any conscious thought to the ankle joint and encourage it to operate autonomously.

Do I need a scan?

Probably not in most cases. The most common reason to need a scan is to determine whether there is a fracture present which is often easily identifiable in the early stages, I think there has only been one ankle fracture in my career so far that hasn’t been picked up on an x-ray. So the chances of missing it are pretty slim. The Ottawa Ankle rules as we’ve mentioned are really quite good at picking up potential fractures and referring them on.

The next reason that some clients may go for a scan is to confirm their diagnosis. Often they will go for an ultrasound to assess ligament integrity as well as assess tendon structures. Personally, not a huge reason for me to go spend the money on something that is incredibly unlikely to change our clinical pathway.

The cases where I think it may be useful to go for either an MRI or ultrasound is if something just isn’t responding the way we expect it to. More often than not things make sense in physio, it’s when something doesn’t that we as clinicians have to sit down and think whether there is a piece of the puzzle we are missing.

Returning to Training and Sport

Every athlete’s goal is always to get back to training and back to playing competitive games as quickly as possible. I get it, athletes are naturally competitive people who want to be out there being a part of the team and helping them put wins on the board. But sometimes, it may be smarter to hold back a touch than it is to go racing off as quickly as possible. Most ankle sprains I find take at least 2 weeks or longer depending upon the type of injury we are dealing with.

For a return to training the benchmarks I like people to be hitting include:

Hopping on spot
Hopping forwards
Lateral hopping
Knee to wall 10cm

Returning to training should then be a graded process. Of course, when I’m talking about returning to training I’m talking about working back into gameplay scenarios. Prior to this you can and should be doing some sport-specific work on your own. Often on initial return to gameplay training, I would be looking to have either ankle strapping or a brace in place.

Returning to sport is the bigger decision. Some people view this as a very black-and-white decision but unfortunately, I think there is a lot more to it than just “can you return to sport?” I often think of it as a risk:reward scenario, how risky is the decision vs what is the potential reward? If it’s early in the season I may often tend towards giving someone an extra week off if I think they will be better off for it. Whereas if it’s the semi-final it’s a do-or-die, the risk is higher, but so is the reward for the athlete. Ultimately the choice isn’t solely mine. The athlete and the coach must also be consulted to ensure they are on board with the decision and happy to play with whatever risk may be there.

Ankle strapping vs ankle brace

Probably the most common question I tend to get asked by clients who’ve suffered an ankle sprain is “should I tape it or buy a brace?”. Personally, I don’t find there’s a huge difference in the overall result, with the result being preventing future injuries. Personally, I find it is much more of a comfort decision, I find taping much more comfortable than a brace due to the somewhat bulky nature of braces. I also find that taping can be personalised a lot easier with varying amounts of tension and angles that the tape can be applied to ensure the athlete feels secure.

Often I find the reason athletes or parents opt for a brace is purely and simply the ease of them. It is much easier to slip on a brace, tighten two velcro straps and do up some laces. Totally much easier I completely agree, but I feel there should be more to the decision than just “how can I make my life easier?” when we are talking about the prevention of injuries.

At the end of the day, it is a personal decision and neither is wrong, both have shown positive effects with regard to reducing future injury risk. As long as you are choosing one that you are comfortable with and you will use, I’m happy.

Treatment Packages

3 Week Program

Our 3-week program was designed for clients who have suffered an acute injury and want to get out of pain ASAP. This package could be suitable for clients who have sustained a low-grade ATFL or CFL sprain or potentially a combination of the two.

Our 3-week program is inclusive of the following:

3xweekly 45min physiotherapy consults
$40 equipment allowance for bands, trigger point balls, foam rollers etc.

Total cost: $940

Package price: $770

6 Week Program

Our 6-week program is designed for clients who have sustained a higher-grade injury and want to not only rehabilitate their injury but also address causative factors and ensure a safe return to sport. Injuries such as an ATFL or CFL sprain, a medial ankle sprain, or a low to mid-grade high ankle sprain would respond well to this treatment package.

Our 6-week program is inclusive of the following:

2xweekly 45min physiotherapy consults
$80 equipment allowance for bands, trigger point balls, foam rollers etc.

Total cost: $1280

Package price: $1050

12 Week Program

Our 12-week program is designed for clients who have sustained higher-grade injuries and want to address causative factors but also want to return to sport as a more complete athlete than what they were when they got injured. Injuries such as a fracture or high-grade multi-ligament injuries such as a combined CFL and ATFL sprain, or higher-grade high ankle sprains would respond well to this treatment block.

Our 12-week program is inclusive of the following:

2xweekly 45min physiotherapy consults
$150 equipment allowance for bands, trigger point balls, foam rollers etc.

Total cost: $2550
Package price: $2050