Ankle Sprains: How to Progress Rehabilitation to Cutting & Change of Direction

Ankle sprains are one of the most common sports-related injuries and are most prominent among 15- to 35-year-olds. It has been estimated that ankle sprains constitute between 15-56% of injuries in sports involving running and jumping activities, e.g., soccer, basketball, and volleyball (1).  

The ankle is heavily involved in absorbing ground reaction forces, adapting to uneven surfaces, or responding to the body’s center of mass moving outside of the base of support.  Rehabilitation progressions must center around this and must also expose the ankle to the many stresses it encounters in the sports environment.

In order to avoid the risk of re-injury, the introduction of multidirectional exercises and Change of Direction (COD) is very important once all the previous phases and criteria have been accomplished. 

This article will take you through a thorough rehab progression for ankle sprains so you can make sure that you are not skipping any key steps in the process.

PHASE 1 & 2: FROM ACUTE INJURY TO RESTORING FUNCTION

First and foremost, let’s begin by establishing what type of ankle sprains we may need to deal with.

Ankle sprains can be divided into acute and chronic. Almost all lateral ankle sprains occur in inversion trauma. When the ankle moves into increased inversion, the medial malleolus acts as a fulcrum, losing its stabilising function and increasing the strain on the lateral side. Over 90% of all ankle sprains involve injuries to the ligaments of the lateral aspect of the ankle (1) and many of them lead to residual anterolateral instability.

Isolated ligament injuries on the medial side are less frequent. The injury mechanism is an eversion ankle sprain that can result in rupture of the deltoid ligament. This injury usually often gives rise to chronic medial pain rather than chronic instability on the medial side (1).

Contact injuries can lead to syndesmotic ankle sprains due to forced ankle dorsiflexion and external rotation of the foot. Miss-diagnosis may result in long term pain and dysfunction for your athlete, so is very important to conduct a precise diagnosis with imaging to establish the severity of the injury before planning the ankle rehabilitation.

Common findings following acute and chronic ankle sprains are:

– Reduced Range of Motion (ROM) (2) 

– Reduced Rate of Force Development (RFD) in landing (2,3)

– Reduced proprioception (2,4) 

– Increased Joint Landing forces (2,5)

– Loss of rear foot and tibia coupling in swing phase of gate (2,6) 

In Phase 1 and 2 of the rehab, it is vital that factors such as range of motion, strength, proprioception, motor control and eccentric loading are restored and tested periodically. 

Normally, the target for function would be a limb symmetry index of > 90% as a reliable indicator of symmetrical performance of both limbs. 

Phase 1: Acute Injury Management & Movement Restoration   

During the acute phase, interventions are centred around preserving the integrity of the damaged tissues by managing inflammation and pain and decreasing oedema and swelling through the use of different modalities, manual therapy and exercise.

Isolated submaximal isometric contractions have been demonstrated to reduce pain. Isometric contractions can be performed during the acute phase, initially avoided the affected planes.  For example, avoid inversion initially in the case of a lateral ankle sprain.

Taping or the use of a brace can be used to protect the ankle.  Depending on the severity of the injury, the use of crutches may also be warranted, particularly if the athlete is unable to walk without pronounced limp (2).  

Progression to touch down, partial, then full weight-bearing should be encouraged early, with the exception of syndesmotic ankle sprains, which may require a longer period of non-weight bearing.

Balance exercises can be helpful to maintain proprioception and stimulus of the Central Nervous System.  Once weight-bearing is tolerated, sensory reweighting exercises can be helpful:

Also remember: Strength is everything.

It is crucial to consider the overall strength and conditioning of the athlete.  You can train the athlete avoiding load on the ankle promoting different fitness, strength, and core stability exercises because it is beneficial for physiological healing and will prepare the athlete for the next phases.

The following criteria should be achieved before progressing to Phase 2:

– Resolution of inflammation and swelling

– Full pain free ROM 

– Normal Gait 

– Single leg weight bearing

Phase 2:  Low-level load functional exercises 

During this phase, there are four aspects to focus on, which I will discuss in detail.

First, we want to re-stablish functional kinematics with attention to the rocker system of gait.  A common clinical finding following ankle sprain is a persistent loss of dorsiflexion which has been linked to injury risk both to the lateral ankle ligament complex and more recently, at the patellar tendon in jumping athletes (2, 7). 

Therefore, is very important to assess the heel, ankle and forefoot movement to work on mobility and re-training movement patterns.

Second, we need to train balance and proprioception.  The nervous system allows reflex correction to joint position and muscle force in addition to interpretation by higher centres.  This allows the potential for conscious learning/skill acquisition and enhancement (2). 

Some studies have shown that even 5 minutes per day of balance training using unstable surfaces can reduce the risk of re-injuries after ankle sprains (2,8).  Again, these can also be coupled with vestibular loading exercises such as the one provided in the previous section of this article.

Third, we need to progress our localised strength exercises.  In earlier stages, such as in Phase 1, the use of isometrics is considered for its analgesic effects. Subsequently, exercise progressions from isometric to eccentric is recommended in all planes.

Particular attention should be paid to eversion and inversion, as these affected planes were avoided in Phase 1. Intrinsic foot strengthening should be performed for 6 weeks or more as it results in improved strength/gait motion and/or increased performance in jump height (9).  Make sure you read this article on the blog, as it discussed the foot and how it acts to absorb force and develop power.

Strengthening the glutes is also very important to improve proximal stability reducing weakness caused by gait adaptation, use of crutches and/or proper training sessions. 

Furthermore, there are studies that confirm a myofascial correlation between the glutes and the lateral compartment of the ankle, so a holistic approach is recommended (10).

Rotational control exercises, airplanes, single leg Romanian deadlifts, and step ups are all great variations to work on lower limb stability:

Fourth, we need to develop strength and fitness without landing/impact tasks. This is a fundamental aspect where athletic function must be developed starting with correcting neuromuscular movement strategies, strengthening and improving the function of a specific area of deficiency, maintaining fitness with unloaded exercises, and finally progressing with functional movement aiming to increase loads and introduce low level of plyometrics. 

The following criteria are recommended before progressing to the next phase:

– Pain Free in >90% of ROM

– Symmetry with single leg balance exercise

– No adverse reaction to low load functional training

PHASE 3 & 4: FROM FUNCTIONAL TRAINING TO SPORT-SPECIFIC SKILLS

In end-stage rehab, a multi-disciplinary approach is recommended which requires teamwork between specialists in the medical and performance departments. It is essential that each step is undertaken in succession per criterion-based progression and that each step be fully completed (11).

Figure 1 represents the functional recovery model (return to sport and performance). The transition from the rehabilitation phases of functional recovery (rehabilitation) to the actual performance is highlighted. Four stages are indicated, starting from on-field rehabilitation (OFR), to return to training (RTT), then return to competition (RTC) and finally return to performance (RTP). The model is applicable to any type of sport and the transition from one item to the next is based on criteria rather than on time. Above the figures indicate the person/team who are essentially in charge of the case at that period of functional recovery, involving a close working relationship between medical and performance teams during the OFR to RTC stages (11).

Furthermore, testing and re-testing is crucial to ensure exit criteria for a robust and valid athlete before allowing maximal intensity training and a return to unplanned situations and/or contact training.

Phase 3: Increase functional training with impact/landing and progressive multidirectional re-training

The aims of this phase are to expose the foot/ankle to a progressive program of impact and multi-plane stresses and to ensure that the athlete is fully ready to return to maximal intensity, multidirectional training (2).

During this phase, it is necessary to progress gradually with dynamic exercises and plyometrics developing reactive stabilizing and reactive energy distribution mechanisms. 

Here is what a general progression would look like: 

1. Starting with In-line drills.  It is very important to progress with in-line exercise like straight-line running making sure the athlete has a correct stride without limping. Other exercises can be fast walking, backward walking on treadmill, or skipping/landing on bouncer.

2. Managing the training surface.  Based on the facilities available, it may be indicated to start running/skipping on a trampoline, sand or other soft surface such as a mat, to retrain foot proprioception, landing mechanics or plyometrics while limiting ground reaction forces.

3. Coaching correct landing mechanics prior to higher level plyometrics. Landing exercises performed barefoot are a good stimulus for the neuromuscular system and ankle/foot proprioceptors. 

4. Progress plyometric exercises bilateral to single leg.  Managing load is fundamental at this stage.  Furthermore, it is crucial to progress with single leg jump and hold, single leg drop jump and stick or hops to increase load tolerance of the ankle and introduce in-line force absorption before change of direction. 

5. Acceleration and deceleration drills: Initially, straight line acceleration/ deceleration with speed and distance progressions allows the introduction of low-speed deceleration in the sagittal plane.  We would then progress to deceleration/acceleration in different movement planes, such as running in curved lines. 

6. Lateral Drills and change of direction: The exercise can be manipulated according to the type of injury to put less/more stress on the determined anatomical structure. For example, for lateral ankle sprains, sidestep and holds, skaters, lateral shuttles are good progressions that increase load on the lateral compartment of the ankle joint. If the ankle has no adverse reaction and the athlete shows good stability, progressions with wider angle COD at lower intensities can be used. Progressions should be initially performed at low speed and intensity, then progress to higher speeds and/or with perturbation to prepare the athlete for on-field rehabilitation:

Progression through to the next phase requires completion of several validated functional performance tests to gauge limb symmetry dynamically.  The choice of these tests will be based on the facility’s instrumentation (e.g., force plates, etc.).  Previous research has highlighted the use of the three-hop distance test, adapted crossover tests (2) and/or broad jump related to the player’s height as a means of determining functional performance with minimal equipment.

Phase 4: Maintaing Strength and movement patterns adding on field training sessions

While this phase will not be discussed in detail, it is appropriate to understanding the importance of this stage.  Many re-injuries are due the lack of return to practice and rushing athletes straight to competition or play after gym-based rehab sessions. 

On-field rehabilitation is a complex process based on restoring movement quality, physical conditioning, restoring sport-specific skills, and progressively developing chronic training load. These constitute the 4 pillars of high-quality on-field rehabilitation, allowing the clinician to effectively bridge the gap between gym-based rehabilitation and the competitive team environment. Understanding the demands of the sport and the risk of reinjury will help the rehabilitation clinician devise a program to effectively prepare the athlete to safely return to the team and be prepared for competition and performance (12).

Figure 2: On field rehabilitation is a key step for a safe Return to Play. At this stage you move from a gym, where you can perform any exercises in a more controlled environment, to the field where you start to practice sport-specific skills and modified training with the team. This figure represents the six main aspects that must be re-trained before a return to play.

In this phase, it is important to gradually introduce sport-specific skills during acceleration or COD e.g., passing a ball, kicking a ball, tracking a ball, or collision with opponents. These aspects may have been included in the previous phase in the gym environment and are now introduced on-field.  

Assessing an athlete’s readiness to return to competition requires data on strength, power and endurance capacities. Dependent on the sport, such performance indices may include: 

• Running speed over 10, 20, 40 meters for explosive running sports (2)
• Agility Tests (e.g. T-test)
• Vertical Jump Test (with or without force plate
• Validated endurance tests (e.g. Maximal Aerobic Speed (2))
• Single-leg strength and rate-of-force development testing (to maximize validity in weight-bearing sports this should be done in closed chain) (2)

IN SUMMARY

As a general rule, diagnosis and assessments are essential in establishing the right plan in rehabilitation. Knowledge of the injury mechanism, anatomical structure involved, affected planes, biomechanics and training principles all serve to guide you through the rehabilitation process and determine appropriate progressions.

Breaking down the movement and gradually progressing with load and intensity to achieve multidirectional acceleration and changing of direction both reduces injury risk and improves performance.

Taking an athlete from rehabilitation to performance is a continuum.  Building progressions with functional criterion-based rehab helps to reduce risk of re-injuries. 

REFERENCES

1. J. Karlsson, K. Samulesson Ligament injuries of the ankle joint. J. Karlsson, K. Samulesson. Sports Surgery
2. D. Joyce, D. Lewindon Sports Injury Prevention and Rehabilitation. 2016
3. Docherty, C. L., & Arnold, B. L. (2008). Force sense deficits in functionally unstable ankles. Journal of Orthopaedic Research , 26 (11), 1489–1493.
4. Hertel, J. (2008). Sensorimotor deficits with ankle sprains and chronic ankle instability. Clinics in sportsMmedicine , 27 (3), 353–370.
5. Dayakidis, M. K., & Boudolos, K. (2006). Ground reaction force data in functional ankle instability during two cutting movements. Clinical Biomechanics , 21 (4), 405–411.
6. Drewes, L. K., McKeon, P. O., Casey Kerrigan, D., & Hertel, J. (2009). Dorsiflexion deficit during jogging with chronic ankle instability. Journal of Science and Medicine in Sport , 12 (6), 685–687.
7. Malliaras, P., Cook, J. L., & Kent, P. (2006). Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players. Journal of Science and Medicine in Sport , 9 (4), 304–309.
8. McHugh, M. P., Tyler, T. F., Mirabella, M. R., Mullaney, M. J., & Nicholas, S. J. (2007). The effectiveness of a balance training intervention in reducing the incidence of noncontact ankle sprains in high school football players. The American Journal of Sports Medicine , 35 (8), 1289–1294.
9. Unger, C. L., & Wooden, M. J. (2000). Effect of foot intrinsic muscle strength training on jump performance.The Journal of Strength & Conditioning Research , 14 (4), 373–378.
10. J. Bullock-Saxton. Local sensation changes and altered hip muscle function following severe ankle (1994). Physical Therapy
11. M. Buckthorpe, A. Frizziero, G.S. Roi. Update on functional recovery process for the injured athlete: return to sport continuum redefined (2018). Sports Med
12. M. Buckthorpe, F. Della Villa, S. Della Villa, G.S. Roi. On-field Rehabilitation Part 1: 4 Pillars of High-Quality On-field Rehabilitation Are Restoring Movement Quality, Physical Conditioning, Restoring Sport-Specific Skills, and Progressively Developing Chronic Training Load.

Federico Picchetti, Sports Physiotherapist, CSCS

Federico is a Sports Physiotherapist specialized in sports rehabilitation and injury prevention in Italy. For the past 8 years, he has worked in different clinics in Pisa, London and Bologna learning different manual therapy skills, technical skills and rehabilitation methodologies. Since 2020, he has set up his own clinic in Pisa where he treats clients and athletes.