Ankle Sprains, Part II

Phase 2 – Rehabilitation phase
The rehabilitation phase begins when swelling stops increasing and pain lessens. This means the ligaments have reached the point in the healing process where they are not in danger of being re-injured from mild stress.

Improve mobility and flexibility
Seated foot tapping may be beneficial for an ankle that has reduced mobility. Initially plantar flexion (down) / dorsi flexion (up) and then progress to inversion (in) / eversion (out) as pain allows.
For the first 2 to 7 days after injury you can start to move the ankle straight up and down but do not turn it in or out. This will help increase mobility and start to strengthen it up. Do as much as pain will allow. Try 2 sets of 40 reps while the ankle is iced and elevated and increase as you can.
As swelling and pain lessen, you can start to invert and evert the ankle (move the soles of you feet inwards and upwards and outwards and upwards). This will start to put more stress on the damaged structures, so be careful not to do too much.
Stretching the Achilles tendon regularly is important. Have available a specific Achilles stretching board throughout the day (or lean into a desk or counter, keeping heels on the floor) to ensure a few minutes of stretching daily.

Strengthening the ankle joint
Again as the ankle improves you can start to do strengthening exercises where you pull the foot and toes up and hold for 10 sec’s and then push down and hold for 10 sec’s This can also be done for inversion and eversion as pain allows. Try 3 sets of 10 reps twice a day and build on that. Begin using your hand to resist these ankle movements.
Continue to apply cold therapy to the joint regularly – at least 3 times a day for 20 minutes.
If you see no further improvement with ice then start to apply heat in the form of a hot bath / bucket or via a specialist with ultrasound.
Strapping and taping may still be beneficial here.
You should be able to maintain fitness by swimming or cycling if pain allows.

Re-establish co-ordination and proprioception
Proprioception exercises are thought to be important in avoiding recurrent ankle sprains. Early weight bearing is thought to help reduce proprioception loss. Try balancing on one leg with your eyes closed. This will improve proprioception (the neuromuscular control you have over your muscles). This will have been damaged when you injured the ankle. Aim to be able to balance for 1 minute without wobbling.
Return to full fitness / functional training
In order to start the functional rehabilitation phase (activity and sports specific training), it is important the athlete has full range of motion and 80 to 90% of pre-injury strength. When you can comfortably do all of the above then you are ready to start phase 3 and begin your return to activity.
Cardiovascular exercises is important and should begin the first day after injury depending on what pain will allow. It is important that the athlete maintain some kind of CV exercise not just for the physical benefits but for psychological well being as well. Stationary cycling, running in water and swimming are all possibilities depending on severity of injury and what pain will allow.
Running may begin as soon as walking is pain free. It is a good idea to tape the ankle before starting running training particularly during early sessions until confidence, proprioception and strength has returned. A laced ankle brace can also provide support and is less expensive in the long run, particularly if laxity in the ligaments means a support needs to be worn permanently.
Running should begin on a clear flat surface such as a running track. Grass or bumpy surfaces will increase the risk of re-injury. Jog the straights and walk the curves.
Speed should be gradually increased over time to a sprint.
Sports specific drills using cones can be introduced. Changing direction, running in a figure of 8 pattern and zig zagging between cones.

In the final article, Ankle Sprains Part III, we will discuss ways to reduce the liklihood of ankle sprains.

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