Suzie Says... Let's Talk About Ankle Sprains and Exercises

Disclaimer: This article is intended to be for educational purposes only, and does not constitute medical advice or replace professional assessment. Please seek a professional assessment before undertaking a new exercise program especially if you have any medical conditions, any previous or current injuries or other health / physical concerns. If you undertake any of the exercises within this article you do so at your own risk.

Any website pages/links added are also for education purposes only and are not under my control and may change or be removed at any time.

An ankle sprain, in particular spraining the outside of your ankle (lateral ankle sprain) is the most common ankle injury that people suffer from. You may 'go over' on your ankle stepping off a step, walking on cobblestones, hiking the Inka Trail, putting your foot down in the wrong place, going over on high heels, stumbling home after a few too many drinks with new found friends...the list goes on! In my opinion it's never 'just a sprain' that should be 'pushed through'. If left untreated it can lead to chronic ankle instability causing long-term issues like ankle osteoarthritis.

So, who is most likely to get an ankle sprain?

If you've had a previous ankle injury on the same side, or even on the other ankle you are more predisposed to a future ankle injury. Also, if you have reduced ankle movement or a hypermobile ankle you have an increased risk of injury. Those who are active, especially if you like field or court sports you are more likely to have an ankle injury, but there's a huge number of people that injure their ankles and suffer an ankle sprain in normal daily activity as well. If you like riding off-road, hiking, or other extreme sports where your feet are required to take load on uneven surfaces, and you wear crappy boots with rubbish ankle support, don't be suprised if at some point you also end up with an ankle sprain.

It's a massive finacial burden on health services, especially when not treated correctly the first time around.

Ankle sprains can be graded on a three point grading scale like this:

Grade I Mild - Little swelling and tenderness with little impact on function. Grade II Moderate - Moderate swelling, pain and impact on function. Reduced proprioception, Range of movement (ROM) and instability. Grade III Severe - Complete rupture, large swelling, high tenderness loss of function and marked instability.

I would always recommend seeing a physiotherapist if you have an ankle sprain, especially if you have a severe/grade 3 sprain. About 10% of people who go over on their ankle will have a fracture, so if it's bad, get it checked!

What to do if you've just sprained your ankle

You can use the P.O.L.I.C.E. principles when you sustain an acute injury which stands for Protection, Optimum Loading, Ice, Compression and Elevation.

In order to protect the ankle you may need to use crutches and initially rest the injured ankle, however, as 'optimum loading' suggests, you need to not just completely immobilise the joint but gently mobilise it so that you don't lose movement and too much strength and end up with a stiff ankle. Optimal loading means 'replacing rest with a balanced and incremental rehabilitation programme where early activity encourages early recovery' (Bleakley et al., 2012). Obviously, what you should be doing is best determined by a physio, however some of the gentle movement exercises listed below can be done in the early days if you do not have access to a physio, especially if you're travelling in the back of beyond. I have written a little bit about ice therapy below, and this is based on how I would normally advise people in clinic and also based on the findings of an article published by Bleakley et al. (2006) on the use of ice (see reference below).

Compression can be created by using an elastic bandage or tubi-grip...whatever is easiest to find. Obviously you need to check it's not too tight on a regular basis, and make sure your toes are still the right colour, i.e. not bright white or red. You can squeeze your toe(s), they will go white with the pressure, and then let it go. The blood should flow back into the area almost immediately and your toe should then look a 'normal' pinky colour again. These are often readily available at pharmacies and you can ask them for the best advice for whatever compression garment you buy. If there's a language barrier, Google it and often pages can be translated quite easily these days.

Finally elevation. Basically lift your ankle up on some pillows and have a lay down...and no, I don't mean be a complete lazy arse for several weeks, but getting some good periods of elevation can help a lot.

NSAID's (Non-steroidal anti-inflammatories) have been shown to help, however as a physiotherapist I cannot recommend taking these or dosage, however any pharmacist can advise you, and in general, even in the smallest of towns there's always some kind of pharmacy.

Use of ice

Have a plastic ice bag completely filled with water, place it in a freezer, and remove when frozen. Before application, hold the pack under hot water for 30 seconds and wrap it in a single layer of towelling (moistened until just dripping wet). Apply the ice to the area of injury for 10 minutes. Remove it, and then rest the ankle at room temperature for 10 minutes. Reapply the ice for a further 10 minutes. Repeat this intermittent ice therapy every two hours. This is particularly useful within the first 72 hours of injury.

You can also use ice for 20 minutes (same method as described above) every two hours if this is easier, however intermittent ice therapy (2 x 10 minute applications) has been found to reduce pain with activity better within the first week of injury (Bleakley et al., 2006).

Do you need a brace or support?

'Crutches, braces and supports, traditionally associated with rest, may have a greater role in adjusting and regulating optimal loading in the early stages of rehabilitation' (Bleakley et al, 2012). External bracing or taping has been found to be much more effective than casting or full immobilisation, and these things also allow some movement and/or weight bearing, which has been shown to have a positive effect on ankle sprains.

It has been found that exercise therapy and taping/bracing are effective in the management of acute and recurrent ankle sprain however ultrasound therapy, acupuncture and manual therapy do not seem to be effective in the treatment of recurrent ankle sprain (Doherty et al, 2016). Here are some exercises that may help with ankle strength and stability, and prevent future injury.

Please note, if you have just had an ankle injury please try an get it properly assessed before undertaking new exercises, and do not do any exercises which cause you pain. I would not recommend undertaking a new exercise programme which has not been tailored to your specific injury if it is an acute injury, and definitely not in the case of a grade 3 (severe) injury.

Ankle mobility, calf stretching, and basic proprioceptive exercises can help during the first few days of injury (from day 2-3 onwards) in mild to moderate sprains i.e. grade 1 and grade 2 sprains, along with the use of ice therapy.

Some basic early exercises (from day 2-3) are:

Ankle circles

Sit or lie down with your leg out in front of you. Circle your ankle in one direction about 30 times and then go in the opposite direction. Repeat this 2-3 times. Do not continue if it is painful, just do as much as comfortable.

Non-weight bearing calf stretches

Sit down with your legs out straight in front of you. Use a towel or belt to put around the ball of your foot.

To stretch your large (gastroc) calf muscle, keep your leg straight and gently pull your toes towards you holding each end of the belt/towel in your hands. Only pull until you get a gentle but not painful stretch in your calf. Hold 20-30 seconds then release. Repeat this 4-5 times on both sides - it's important to keep your good ankle mobile as well while you're not doing so much.

To stretch your smaller (soleus) calf muscle, bend your knee a little and gently pull your toes towards you holding each end of the belt/towel in your hands. Only pull until you get a gentle but not painful stretch in your calf. Hold 20-30 seconds then release. Repeat this 4-5 times on both sides - again it's important to keep your good ankle mobile as well while you're not doing so much.

Seated heel raises

Sit on the edge of a chair with your feet flat on the floor. Slowly lift your heels as far as you can off the floor leaving your toes in contact with the floor at all times, then lower again. Repeat this 8-12 times as comfortable. Rest and then repeat 2-3 more times so long as it's not painful.

Move your ankle inwards, outwards and upwards (inversion, eversion and dorsi-flexion) with or without assistance (e.g. using a towel).

Sitting with your legs out straight, sat on a bed or chair, gently move your feet outwards without moving your legs and keeping your knees still and in line. Then relax back to the start position. Repeat this 8-12 times as comfortable. Rest and then repeat 2-3 more times so long as it's not painful.

Next move your feet inwards, again keeping your legs still. Then relax. Repeat this 8-12 times as comfortable. Rest and then repeat 2-3 more times so long as it's not painful.

Finally move your feet up towards you as far as possible then relax them back down. Repeat this 8-12 times as comfortable. Rest and then repeat 2-3 more times so long as it's not painful.

If this is too difficult to start with use a towel or belt to assist the movement. It is important that you do not lose movement in your ankle and then get the muscles working correctly early on.

Heel slides seated or lying down

Sit on a chair with your feet flat on the floor. Initially you can place a plastic bag under your feet to help the movement. Slowly slide your feet backwards under the chair as far as comfortable without causing pain and then slide them forwards again. If this is too easy you can remove the plastic bag. If you do not have access to a chair without anything blocking the movement of your feet then lay on your back and slide your feet up as close to your bottom as possible.

Repeat this 8-12 times as comfortable. Rest and then repeat 2-3 more times so long as it's not painful.

Toe crunches

Sit on a chair with your feet flat on the floor. Place a towel, teatowel or other fabric under your feet and then practice scrunching it up using your toes and then releasing after a couple of seconds. Practice for 30-60 seconds. Relax and then repeat upto 3 times so long as it's not painful.

Toe stretches seated

Place your foot over your knee and use one hand to hold your toes and stretch them back. Hold this stretch for 30 seconds then relax. Repeat the stretch 3-4 times.

Elevate your leg and use ice after you do your exercises, rather than using ice immediately before your exercises. If you get increased swelling after exercise you may be doing to much so ease off a little. If things are not improving at all after a week and you have not yet had a professional assessment of your ankle, get it assessed properly.

Exercises to start when comfortable:

Single leg stand

This is nice and simple and can be done whilst brushing teeth, waiting for the kettle to boil etc. Stand on one leg. Keep your balance. That is it! Make sure you have something sturdy close by to hold if needed.

If you're getting good at this then try closing your eyes when you do it. Practice on each leg individually for as long as able. 1-2 minutes maybe. To start with make sure you are holding onto something sturdy.

Single leg stand passing and object or clock-face

If you need more challenge when doing the single leg stand then try passing an object around your middle while trying to keep your balance on one leg, or use one foot (the one you're not standing on) to touch the floor all around you as if you were stood in the middle of a clock face. You can use a few stones or objects on the floor as markers if you like. Keep your hips level throughout this exercise.

Heel raises (double leg then single leg)

Stand upright. With your feet hip width apart push up onto your toes and lower back down. If this is far too easy, do the same but on one leg at a time. You can use support if needed.

Repeat 12 repetitions on each leg. Rest, then do upto 4 sets. This can be done anywhere, and is good to do when brushing your teeth, waiting for the kettle to boil etc.

Weight bearing calf stretches (Gastroc. & Soleus)

Gastroc stretch - Stand facing a wall, worktop or solid object that you can place your hands on. Place one leg straight back behind you with your heel firmly on the floor and lean on your hands. Now let the front knee bend until you feel a stretch in your calf. Hold this for 20-30 seconds and repeat upto 3-4 times each side.

Soleus stretch - Stand facing a wall, worktop or solid object that you can place your hands on. Place one foot in front of the other. Now let your knees bend and make sure the back foot stays on the floor. You should feel a stretch in the calf of your leg which is at the back. Hold this for 20-30 seconds and repeat upto 3-4 times each side.

Resisted ankle eversion, inversion and dorsiflexion (isometric)

The idea is that your injured ankle does not move during these exercises however your muscles will be working.

Sit down on a chair and have your injured ankle slightly out in front of you. Either use a solid object or your other foot to resist the movement of your injured ankle/foot outwards (eversion). Hold for 3-5 seconds as able and relax. Start with 7-8 repetitions working upto 12 repetitions, so long as it's not painful. Rest and do 2-3 sets of this.

The repeat the same exercise however this time resisting the inward (inversion) movement of your ankle/foot. Hold for 3-5 seconds as able and relax. Start with 7-8 repetitions working upto 12 repetitions, so long as it's not painful. Rest and do 2-3 sets of this.

Finally do the same exercise but resisting the upward (dorsi-flexion) movement of your foot. Hold for 3-5 seconds as able and relax. Start with 7-8 repetitions working upto 12 repetitions, so long as it's not painful. Rest and do 2-3 sets of this.

Resisted ankle eversion, inversion and dorsiflexion with theraband (if available)

This exercise is a progression from the previous exercise in that you will be using your muscles and your ankle will be moving. Do not do this if it's painful. You can buy therabands in many places including sports stores, some pharmacies and shops that sell aids. With the brand 'Theraband' the bands are graded from easy to hard from yellow to red to green to blue to black. Other brands differ however I would always recommend starting with the easiest one and progressing through so long as you do not get any advere effects. Do not progress too quickly. If you are managing 3 sets of 12 repetitions of each exercise without any adverse effects like increased pain or swelling for 3-4 consecutive days then consider getting a slightly harder band to work with. Please note that the green band in the picture is not a 'Theraband' and is quite low resistance.

Sit down on a chair and have your injured ankle slightly out in front of you. Place a looped theraband around your feet (or attach it to an immobile object. Take up the slack and move your chair as needed so that your leg is in line with your hip and not at an angle. Then slowly move your foot outwards against the resistance of the band and slowly return to the start position. Start with 7-8 repetitions working upto 12 repetitions, so long as it's not painful. Rest and do 2-3 sets of this.

Next do the same exercise but with the band the opposite way around - note that it's probably easier to keep the band where it is and move the chair to the other side. Then slowly move your foot inwards against the resistance of the band and then slowly return to the start position. Start with 7-8 repetitions working upto 12 repetitions, so long as it's not painful. Rest and do 2-3 sets of this.

Finally sit with the band in front of you and loop it around your forefoot. Slowly move your toes up towards you and then slowly lower. Start with 7-8 repetitions working upto 12 repetitions, so long as it's not painful. Rest and do 2-3 sets of this.

Toe stretches weightbearing

Stand up facing a wall or solid surface. Place your foot up against a wall with your toes in contact with the wall and then slide them down until you get a stretch in your toes/underside of your foot without moving your heel. Hold this stretch for 30 seconds then relax. Repeat the stretch 3-4 times.

After that:

Lunges

Stand straight. Place one foot forwards at about one large step length away (you can adjust if needed). Then drop your back knee down towards the floor and then lift back up again, making sure that your front knee also stays strong and stable during the exercise and does not drift inwards. You can stay in this position and do 8-12 lunges, or you can return to an upright position between each lunge. Make sure you do one set on the right then one set on the left. Rest and repeat another 8-12 lunges on each side. Depending on fatigue, you can repeat this exercises for about 3 sets on each side.

Walking lunges

The other thing you can do to make the exercise a little more dynamic is a walking lunge. Basically, you go into a lunge position (as above) then straight into a lunge on the opposite side, i.e. when you are coming back up from the lunge you transfer your weight onto your front leg, lift your back foot off the floor and place it in front of you to go into the next lunge. It's key here that you have good control over the exercise and you are not wobbling from side to side or leaning over. If this is too difficult, stick to the lunging in place and then move on to a walking lunge at a later date.

Single leg stand with reaching down or throwing a ball/socks etc. (against wall or to someone)

To make single leg balance a lot harder try reaching down to touch the floor or pick up an object whilst stood on one leg. Again, you can place a few stones or objects about a foot away from you in a semi-circle and you can try to pick one up at a time. Only do this if you feel confident to do so and do not have acute back pain.

If you have someone around you can also practice standing on one leg and throwing a ball or a pair of socks to each other starting facing straight on and then get the other person to change angles/position. If you do have a ball then you can also do this by yourself if you have a flat wall nearby to bounce the ball off. Again, only do this if you feel confident.

Start exercises on different surfaces regardless of the activities or sport you want to go back to.

Ok, so for this I will use the example of the single leg stand, heel raise and the lunge. Instead of having your foot on the floor, place something like a pillow under your feet/foot and then do the exercises. ALWAYS start with the easiest form of the exercise when starting this sort of exercise, and have something to hold onto if needed for support. For example, when doing the single leg stand, start with the simple single leg stand, eyes open next to a support with a pillow under your foot.

For the bridge, start with the double leg version with both your feet on a pillow next to a support like a wall. You can then move on to the single leg version if you are confident.

For the lunge, place the front foot on a pillow and just do the in-place lunge. It won't work with the walking lunge unless you can practice on a beach in the sand, but be careful as you will unlikely have any support.

Jumping/Hopping

Start by holding on to a very strong surface, and bounce up and down on both feet. If this is comfy try to jump just an inch or two off the floor, supporting yourself throughout the movement. Try doing a few jumps in a row and then rest.

If this is all ok, bounce up and down on both feet and then slowly shift your weight more onto your injured leg until all of your weight is on your injured leg. Once this is no problem and pain-free, practice jumping an inch or two off the floor holding onto a firm suport.

Once all this is ok, you can practice jumping in place without a support (both feet) before moving onto hopping. Always have something nearby to hold just incase and you must feel confident and not have pain with these movements, although the ankle may feel a little tight to start with.

Please Note: This is not an exhaustive list of exercises, however these are exercises that you can do without any specialist equipment (unless you want to do the Theraband exercise - available from many sports / health stores all over the world), wherever you are. I would always advise to undertake your rehab with the guidance of a trained and registered physiotherapist, however if this is not possible for whatever reason then the above exercises are a good start including progressions. If you're going back to specific sports then you will need further advanced exercises to make sure you're in tip-top condition and to reduce the risk of re-injury.

Most of the above photos are taken as though the right ankle is the injured ankle.

Other things that can help avoid an ankle injury:

Wear supportive boots, especially if riding off-road or undertaking activities on uneven terrain.

Tape your ankle if you're asking a lot from it and have had a previous ankle injury. You could also use a basic ankle support if you don't have anyone around that is any good at taping, however you can learn to do this yourself if taught correctly. HERE is a link to a good YouTube video which shows you how to tape an ankle for stability. ONLY use taping when required for demanding activity, DO NOT use it all the time as the tape can cause skin irritation. It's a good idea to check your skin regularly when using tape to check you are not getting a reaction like blisters, itching or redness. If this occurs remove it immediately, ideally with warm water if available.

Keep up the exercises. Don't give up after a week because it's feeling a bit better. It can take several months to properly rehab and ankle sprain, and keeping up exercises on a regular basis regardless of injury status will help reduce your risk of injury in the future. Also keeping your body fit and healthy as well as strong knees, hips and core all help towards reducing your risk of lower limb injury. Keep active and don't turn into a couch potato with sporadic bursts of activity once in a blue moon.

References

1. PT Source Podcast Episode 15 - Ankle sprains and lower limb injuries.

2. Physio Matters Podcast Session 40 - Ankle Instability - Is it ever 'only a sprain'?

3. BJSM Podcast 10th Feb 2017 - Ankle Sprain Management and Chronic Instability.

4. Bleakley, C., McDonough, S., & MacAuley, D., (2006). Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports Medicine; 40:700–705.

5. Bleakley, C., Glasgow, P., and MacAuley, D. (2012). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine; Vol 46(4): 220-221.

6. Gribble, P., Bleakley, C., Caulfield, B., Docherty, C., Fourchet, F., Tik-Pui Fong, D., Hertel, J., Hiller, C., Kaminski, T., McKeon, P., Refshauge, K., AVerhagen, E., Vicenzino, B., AWikstrom, E., & Delahunt, E. (2016). Consensus statement of the International Ankle Consortium: prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine; 50:1493–149.

7. Doherty, C., Bleakley, C., Delahunt,E., & Holden, S. (2016). Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. British Journal of Sports Medicine; 0:1–17.

8. Jones, M. & Amendola, A. (2007). Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clinical Orthopaedics and Related Research; 455:169-72.

9. Doherty, C., Bleakley, C., Hertel, J., Caulfield, B., Ryan, J., & Delahunt, E. (2016). Recovery From a First-Time Lateral Ankle Sprain and the Predictors of Chronic Ankle Instability. A Prospective Cohort Analysis. The American Journal of Sports Medicine. Available [Online]: http://ajs.sagepub.com/content/early/2016/02/23/0363546516628870

10. The P.O.L.I.C.E. Principle Emergency Treatment for Acute Injuries. (2018, March 01). Sears, B. Retrieved 16:54, May 17, 2018 from https://www.verywellhealth.com/the-police-principle-for-acute-sprains-and-strains-2696549.

11. Ankle Sprain. (2018, February 23). Physiopedia, . Retrieved 16:23, May 17, 2018 from https://www.physio-pedia.com/index.php?title=Ankle_Sprain&oldid=183066.

For any constructive feedback questions please email Suzie at Cyril@AvVida.co.uk

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