How to Treat an Ankle Sprain with Physiotherapy

What do you do if you sprain your ankle playing sport? 

Most people who are active and have played sport through their life have at some point sprained their ankle and gone through the painful process of watching it swell, using tonnes of ice and strapping for a long period of time. Research shows, however, that despite this injury being so common (up to 14% of all sports injuries), that at a 1-4 year follow up close to 55% of patients still report instability. As a physiotherapist, I can certainly say that this figures are consistent with what I see in the clinic as most patients do not consider this a “serious” injury and follow the full rigorous rehabilitation to return to sport without ongoing issues.  

What is an ankle sprain?

An ankle sprain occurs when the ligaments around the ankle are stretched and sometimes torn due to the ankle joint being rolled. This most commonly occurs to the lateral or outside ligaments (ATFL/CFL) as these are much weaker than the medial or inside ligament (deltoid ligament). 

Ankle sprains can also occur to the mid foot (e.g. bifurcate and spring ligament), the high ankle (e.g. syndesmosis) and result in fractures or bony bruising (e.g. 5th metatarsal and talar dome). All of these injuries are managed very differently, and it takes an expert assessment and diagnosis to ensure that nothing is missed or mismanaged. 

When to get an X-ray?

Given the high amount of pain and potential for a fracture, it is important to rule out any broken or avulsed bones early. The Ottawa Ankle Rules developed by Dr Ian Stiell are a set of clinical tests which are up to 100% sensitive for picking up a fracture in the mid foot and ankle and can reduce unnecessary ankle xrays by up to 30-40% when performed accurately by a qualified Physiotherapist or Doctor. Another important thing to remember is to get them done in weight bearing to check for any separation of the distal tibio-fibular joint as this could indicate a syndesmosis injury which is very important to differentiate early. 

How do I manage an acute ankle injury?

The RICER (Rest, Ice, Compression, Elevation and Referral) principles are the best steps to follow. With an accurate diagnosis of lateral ankle sprain, regaining ankle dorsiflexion range of motion, restoring normalised walking pattern and working on strength and balance are the key things to work on in the early phase as guided by a qualified physiotherapist. 

If the ankle sprain has affected the syndesmosis, generally a period of time is spent early in a boot to allow the AITFL ligament to knit back together unless surgery is indicated (this depends on how severe the injury is). Usually a full assessment of the ankle post syndesmosis injury will wait for around 10 days to avoid further injury to the structure and allow proper healing. 

Physiotherapists can help manage swelling/oedema, manual therapy to the muscles and mobilisations of the joints, taping/bracing for stability and most importantly a structured exercise program geared towards a specific and personalised return to sport plan. 

When can I return to sport? 

There are a few tests that we will check as a physiotherapist to determine an athlete’s readiness to return to sport, including:

  • Knee to wall ankle dorsiflexion 
  • Peroneal reaction time 
  • Single leg calf strength
  • Hop tests (e.g. triple hop, z hop, hop and stick landing)
  • Running (straight line, change of direction, full intensity stop/start/change direction

The extensive research that has been done on ankle sprains and chronicity shows that failing to achieve cut offs on the above tests indicates a much higher risk of re-sprain or chronic instability of the ankle. The timelines for each person will be different, depending on a number of factors and for this reason return to sport largely depends on achieving these milestones rather than an arbitrary time frame of 8 or so weeks that most ligaments take to structurally heal. 

As such, at Total Physiotherapy we employ this rigorous testing, treatment and exercise programming to ensure the best outcomes for our patients/athletes to allow a safe, successful and sprain free return to sport following rehabilitation. 

Written by Physiotherapist, Justine Walker.

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