Introduction

Lateral ankle sprains (LAS) commonly occur in sports, with highest incidence in field or court sports such as basketball, netball, and handball. A common maxim is ‘ankle sprains are self-limiting’ – a bit of ice, some rest, and everything will be fine? But this is not supported by existing data, whereby 20-50% suffer long-term symptoms after LAS, such as pain, feeling of instability, or recurrent injury. So, what are we doing wrong? As always, the answer is complex, but an important predictor of outcome post LAS is the quality of rehabilitation.

Following on from my recent 3hr Masterclass on Ankle Sprains, here are 5 ways to maximise rehab after LAS (1).

1. Master the Sagittal Plane (but don’t stop at dorsiflexion)

Mastering the sagittal plane is an early rehab goal after many lower limb injuries; and is a key milestone for LAS. As the talocrural joint has a sagittal plane dominance, it is logical to restore this, before addressing the more challenging subtalar joint (STJ) underneath. Even moderate restrictions in talocrural joint range reduces force attenuation and creates loading spikes; it also has a ripple effect on proximal movements, driving aberrant compensation at the knee, hip and pelvis (2). Most clinicians focus on regaining dorsiflexion (which is great), but don’t forget about plantar flexion! A recent study in elite soccer found that on returning to sport post ankle sprain, a large proportion of players had residual plantar flexion range of motion deficits (3).

2. Ligaments are Alive, so Recruit Them Fully

You can try to stimulate ligaments using light, heat, vibration, or electric current, but most of the time they won’t respond that well. As ligaments are mechano-responsive, they thrive when stimulated through tensile loading. Therefore, rehabilitation (e.g. movement and exercise) is the ideal medium to stimulate tissue healing. This ultimately restores its morphology and key biomechanical properties (such as tensile strength and stiffness) after injury. However, the clinical literature (along with many therapists) suggests that the majority of ankle rehabilitation is limited to plantigrade foot positions (4).

This is, of course, safe and comfortable in the early stages post injury, but it only partially recruits the lateral ligaments. Optimal ligament recruitment (which then drives maximal adaptation) occurs when we challenge the ankle beyond plantigrade. Foot position should be progressed away from plantigrade, by incorporating wedges, slopes and cambers (eg. can they balance in plantar flexion?). Vary other loading parameters through changes in underfoot running conditions (e.g. progressing from predictable surfaces such as flat concrete) to more liable foot ground interactions (e.g. foam pads and sand pits).

3. Think – What Are You Trying to Prevent?

Less is more when it comes to exercise prescription. Patients can become overwhelmed with complex interventions, but how do we decide which ones are best? As our rehab goal should ultimately be to prevent re-injury, exercise selection must be informed by LAS mechanics and the common inciting events.

Thanks to case reports on the ‘serendipitous’ capture of an ankle sprain event in a laboratory, we know that many LAS are characterised by a greater than normal supination angle at initial foot contact. As this represents an impairment in the open chain (and our ability to feedforward), our rehab must involve both implicit motor retraining (e.g. single leg balancing) and more explicit repositioning tasks in the open chain. This approach has already been used to good effect for sensorimotor training at the shoulder joint and in the cervical spine (eg. using laser pointers and wall targets). We also know that motor impairments due to ankle sprain affect both the knee and hip regions. Therefore, your exercise content should incorporate more global, whole system rehabilitation exercises.

4. Don’t Hesitate – Supinate

Strength training strategies in the clinical literature focus largely on concentric loading of plantar flexors and evertors post LAS, whereas inversion/supination training is often overlooked (4). But, inversion weakness is a perennial problem in chronic ankle instability; this may be underpinned by physiological inhibition in the acute stages, or that patients are reluctant to recreate the movement pattern that injured them.

Restoring supination range and strength is essential for the athlete, as it allows optimal close packing of the STJ, and propulsion during gait and running. To rectify a SubSuD (Subtalar Supination Deficit), forget stretchy bands, and get back to good old proprioceptive neuromuscular facilitation (PNF). The tactile nature of PNF not only provides reassurance to the patient, but it gives the practitioner control of the degrees of freedom at the ankle complex. This helps to isolate strengthening to the requisite muscle groups and movement patterns.

5. Fighting Against Evolution

Chimps don’t sprain their ankles thanks to their wide base of support, grasping feet, and abducting toes. By walking exclusively on two legs, humans have created a perfect (biomechanical) storm when it comes to LAS. Our foot and ankle complex must function paradoxically to attenuate external forces, or function as a rigid lever (or a mixture of both).

Good rehab should include exercises that challenge the patient to fine tune the ‘stiffness’ of the joint. Again, this can include running on surfaces with different material properties and cambers, and/or varying stride length, jump height and running speeds. Note that many ankle sprain mechanisms are underpinned by large adduction moments acting on the STJ; this challenges our anatomy, as the long tendons crossing the ankle complex (eg. peroneal longus and brevis) have frontal, rather than transverse plane dominance. Despite this evolutionary disadvantage, it is still important to optimise the available strength and stability of our foot and ankle complex in the transverse plane.

Conclusion

To conclude, this blog briefly outlines 5 methods to improve your ankle rehabilitation. We explored the importance of not restricting our ankle rehab to just plantigrade movements, optimising ligament recruitment, how to select our exercises based on LAS mechanics, exposing the ankle to supination and how to create ‘’stiffness’’ in the ankle.

Of course, this is just a whistle stop tour. If you want to learn more about ankle sprain rehab, be sure to check out my 3hr Masterclass HERE.

5 Ways to Improve your Ankle Sprain Rehabilitation