Last updated: 31-Oct-18
By Karina Teahan, Chartered Physiotherapist
Most of us have heard of the term ankle sprain and many may have had an ankle sprain in the past. This is why it is often dismissed as a fairly straight forward and short term interruptive nuisance to our running. However, some ankle sprains can end up becoming a bit more complicated.
An ankle sprain is where one or more of the ligaments around the ankle are partially or completely torn as a result of “going over on it”. 85-90% of the time it will be the ligament on the outside of your ankle (Anterior Talofibular Ligament: ATFL) that is injured so this is the one that will be addressed here.
Ankle sprains are quite common and account for 3-5% of all emergency department visits in the UK1. They can easily occur on a trail run, over a tree root, off a footpath kerb, on an uneven cross country course or over the inner border of a track. There will be immediate pain, and swelling may be sudden or build over 24 hours depending on the severity of the injury.
40 % of repeated ankle sprains will develop chronic ankle instability (CAI) which is a recurrent giving way of the ankle. Usually this giving way occurs more easily while walking or doing other minor activities or even when just standing.
Because ankle sprains can also involve minor fractures, doctors have developed a set of tests known as The Ottawa Ankle rules2. They suggest that “a patient with traumatic ankle pain with point tenderness on the medial or lateral malleoli (bony prominence on either side of the ankle), or inability to weight bear for 4 steps at the time of injury or on presentation” should go to the emergency department for an ankle X-ray.
If the above does not apply to you then we can assume it is a mild to severe ankle ligament sprain, but there is no fracture present. Return to running is variable depending on the grade of injury and can take 2 weeks to 6 months.
In the past the acronym PRICE (Protection, Rest, Ice, Compression, Elevation) was central to acute soft tissue injuries such as ankle sprains. More recently we have moved to POLICE and have replaced the “R – rest” with “Optimal Loading”3. This will be music to any runner’s ears.
So here’s the (brief) scientific explanation as to why optimal loading is so important. Ligaments do not like to be unloaded for long periods. Unloaded ligaments (for example when they are in a cast or non-weight bearing on crutches) are 50 % less stiff (negative) after 12 weeks, whereas a loaded ligament will show better architecture of the collagen fibres.
Mechanical loading prompts cellular responses that promote positive tissue structural change which helps to facilitate the demands we place on the ligament. The challenge is finding the balance between too little and too much. Excessive loading early on may cause re-bleeding and further injury.
Remember ligament injuries can take 12 weeks to heal and will be particularly vulnerable for the first 3-4 weeks.
Protection may be used in the form of an Aircast or taping if it allows you to move more easily. You can gradually wean yourself off these. External supports such as these are far superior to cast immobilisation for most types of ankle sprain.
Braces/supporting strategies may reduce the prevalence/recurrence/incidence of lateral ankle sprains but a lot depends on the athlete’s preference and comfort and ability to perform while wearing the brace.
We know that swelling (and inflammation) may be the body’s way of “splinting” and protecting us from further injury, but it also causes pain, limits movement, inhibits muscle activity and reduces proprioception.
Although there is no strong evidence for using ice long term, it is used in practice and appears to alleviate symptoms, so try intermittent use of it in the early phase to prevent excessive swelling but not so much as to interfere with the natural healing process.
Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are no longer recommended for ankle sprains or ligament injuries. Read more here about the use of painkillers from Renee McGregor.
The severity of ankle sprains varies so rather than just time frames, think of achieving milestones/goals before progressing onwards.
Tilt board step over.
Gradually restore range of motion (ROM) by gently moving your ankle up and down, little and often. As the pain starts to settle, you can add in side to side movements, again little and often so as to give a healthy, stimulating mechanical stress to the ligament.
You can begin muscle activation work in the form of isometrics in which you contract the muscles around your ankle without moving the joint. For example, push your foot down against the floor/wall, or up/in/out against the other foot.
When the acute phase has settled you need to think about getting the ankle stronger, restoring full range of movement and working on specific balance rehab. Start slowly and avoid sudden twisting/turning or high impact in the early to mid-phase.
Single leg standing with knee swing.
Progress the isometrics above through full range, to add resistance you can start to use a resistance bandlike a Theraband. Then increase the resistance (in all directions) before going to double leg calf raises, then single leg calf raises.
Your aim is to be able to do as many single leg calf raises as your non-injured leg (over time!). Heel walking is useful to help strengthen the muscles in the front of your shin.
Ankle sprains can often result in a reduction of ability to bend your foot towards your shin (dorsiflexion) which will cause other issues down the line. Address this by regaining the flexibility around your ankle using calf stretches and lunges. Specific manual techniques may be needed and will be done by your Chartered Physiotherapist.
You can cross train and a good place to start is low resistance spinning bike, front crawl swimming or aqua-jogging.
Balance & Proprioception (physical self awareness)
(Proprioception is the sense of the relative position of one’s own parts of the body and strength of effort being employed in movement)
This deserves a section in its own right, as it is often not done well and may contribute to the recurrent nature of this injury. Your ankle injury isn’t just isolated to your ankle but is also connected to your brain and spinal cord.
Messages travelling between these systems also “get injured” in the sprain and so need to be involved in the rehab process. Here are a few strategies below to help work on this.
Pivot / swivel board.
- Place 2-3 tilt boards in a row, walk forwards over them and then change the direction of the board by 90 degrees and walk forwards over them again. Repeat 10 times with a good stepping pattern. This is vital to rehab your ankle at its end of range i.e. dorsiflexion (see above) and when your foot points away from your leg (plantar flexion0 as it gets injured (usually) in plantar flexion (with a bit of inversion – turned in) so there is no point in rehabbing your ankle in just neutral.
- Stand on one leg with your knee slightly soft, swing the opposite leg, then walk through this exercise and swing each leg 5 times before the next step, repeat on alternate legs x 10 reps. Repeat this with your eyes closed.
- Place a set of flat athletic ladders on the floor and step though the ladders with appropriate foot placement. Then add a cognitive challenge such as “count back in 7’s from 100”. It’s harder that you think to do this dual task.
- Remember your ankle is triplanar and so moves in lots of directions and all these need to be considered for proper rehab. Using a pivot/swivel board will help with this.
Properly considered rehabilitation will positively change the physiology of the ligament to make it stronger and drive the healing process. However, there is as yet no consensus as to the exact or optimum dosage.
You must strike a balance between optimal loading and impairments. Impairments can be caused by pain. Pain is important but it doesn’t mean you have to unload fully. You can work though some pain as long as it isn’t causing rehab problems.
Best of luck!
All images Karina Teahan.
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- Delahunt E, Caulfield B, Bleakley C. the incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med. 2013. DOI:10.1007/s40279-013-0102-5
- Stiell. Ottawa Ankle Rules. Cam Fam Physician. 1996 Mar; 42:478-480
- Bleakley C, Glasgow P, MacAuley DC. PRICE needs updating, should we call it POLICE? British Journal of Sports Medicine. 2012 46(4).