In today’s blog I’d like to discuss one of the most prevalent injuries in sports, especially those activities that are performed on your feet and in multi planar directions, the Ankle Sprain. I will get into possible causes, the nature of the injury, the rehab process and how to best prevent this injury or it’s recurrence.

Ankle sprains occur when the ankle is forced out of its regular position causing the ligaments on the inside, outside or above the ankle (high ankle sprain) that support the joint structure to overstretch, or partially- or fully tear. Often other supporting structures such as tendons and cartilage are also injured in the process. This occurs most commonly when the athlete takes a fall and twists the ankle in the process, or an athlete jumps or pivots and rolls the foot awkwardly over the outside or inside edge of the foot, or during play on an uneven surface.

The most common symptom of any ankle sprain is pain, especially when loading the joint. There can be swelling and bruising as well, depending on the severity of the injury. Due to the occurrence of swelling the ankle mobility is typically limited.

First Aid
The approach to first aid of a sprain injury depends on the severity of the injury, the amount of pain and swelling you experience. The old school approach would lead you to initially follow the PRICE (Protection, Rest, Ice, Compression, Elevation) protocol for 24 to 72 hours and then move on to the MICE (Motion, Ice, Compression, Elevation) protocol. There are however some studies that indicate that early mobilization of the injured ankle might result in a more rapid recovery and return to work or play. In any case whether, you follow the old school approach and start mobilization 24 hours or more post injury, or the new school approach and start mobilizing immediately, your attempts to mobilize the ankle should stay below the sharp pain threshold. Uncomfortable is ok, but sharp pain likely leads to further injury.

To begin remove all ankle bracelets and toe rings from the injured foot.

Ice is being applied for its vaso-constricting and analgesic qualities, helping prevent intensive bruising, swelling, and reduce pain. It can be applied in form of ice cubes in Ziploc bags, frozen peas from your freezer or the commercially sold blue cold packs. I recommend to place a moist thin towel between ice pack and skin for better conduction. Ice for 20 minutes and reapply throughout the next 24 to 72 hours. Make sure to take at least 90 minute breaks between applications to prevent frost-bite.

Compression and Elevation (preferably above heart level) are reducing blood flow into the injured area and reduce the risk of tissue swelling, which prolongs the healing process. You can use an ACE bandage or similar product to wrap the injured ankle.

There are light, moderate and severe ankle sprains (Level 1-3). An ankle sprain increases your risk of re-injury by about 40-70%, proper management of the injury and the rehabilitation are crucial to reduce that risk.

Utilizing the PRICE protocol the rehab for all three levels is similar in treatment, but the rehab process increases in length of time with the severity of the injury.

Level 1 – Phase 1: 0-72 hours after injury
Level 2 – Phase 1: 0-7 days after injury
• Continued ice and rest. Apply ankle brace or tape for stability. Full weight bearing as early as pain-free possible. Avoid lateral ankle movement or any high risk activities

Level 1 – Phase 2: Days 3-7
Level 2 – Phase 2: Days 8-21
• Start ankle mobility and strengthening exercises as pain permits. Active dorsi- and plantar flexion (pulling foot up – pointing foot) for mobility. Resisted dorsi- and plantar flexion as well as isometric ankle eversion and inversion (pushing ankle outward/inward against resistance without actually moving the ankle) to start strengthen the joint structure. Possibly introduce alternate hot/cold therapy to increase circulation and speed up healing.

Level 1 – Phase 3: Day 8 plus
Level 2 – Phase 3: Day 22 plus
• Progressively increasing stress on ligaments to promote healing. Careful at this time to avoid re-injury. Move to active eversion and inversion exercises, start single leg stance and unstable surface balance exercises to increase proprioceptive stimulation, move from walking to jogging to sprinting in straight lines and finally start hopping, jumping and cutting and other sports specific training drills.

Level 3 injuries should not be self-treated due to possible other injuries to the joint structure and complications. Crutches might initially be advised when moving. Please seek professional help with your rehabilitation. Prolong initial rehab (Phase 1: mobility exercises only) for first two weeks. The full rehab process for Level 3 injuries is typically 8-12 weeks.

Prevention and Secondary Prevention
To prevent ankle sprains it is important that your training routine includes ankle stability training, and balance exercises to stimulate the different players of your proprioceptive system. Such exercises include single leg stance, exercises performed on unstable surfaces such as “Airex” pads, wobble boards etc. There is a bit of controversy in the literature about how much peroneal latency affects ankle stability and especially the risk of recurring sprains. I think it can’t hurt though to integrate some exercises into your routine that improve peroneal latency. Peroneal latency refers to the electromechanical delay and reaction speed of motor response of the peroneus longus (evertor muscle), which according to some helps prevent ankle rolling. Multi directional lunges into single leg stance performed barefoot on a firm surface while activating Janda Short Foot have shown some success in reducing latency. In addition, sports specific drills that offer controlled simulation of the stress placed on the ankle during sports activities should be part of a training program focused to prevent ankle sprains.
Other studies performed with individuals with recurring ankle sprains didn’t show any significant differences in peroneal latency, but showed reduced ankle proprioception and weakness in evertor muscles, which quite possibly are responsible for chronic ankle sprains.
Secondary prevention therefore starts with a refined rehab protocol after the initial sprain. The better and more successful the initial rehab, the smaller the chances of recurring sprains.

We will show some of the exercises mentioned in our next Video Exercise Work-Shop, so please come back and visit us for that!

I hope this short blog helped to better understand ankle sprains and what can be done to prevent those from occurring and recurring.

In good health,