Ankle sprains are a very common injury. Whether you work with elite or recreational athletes, people who train in the gym or the general population, you have more than likely dealt with a client struggling with or returning from an ankle sprain.
As with any injury, inefficient or incomplete rehabilitation after an ankle sprain results in an increased chance of injury recurrence.
Most rehab protocols fall short of restoring the ankle’s most important function: responding and adapting to perturbation.
just because you stood on a BOSU for 3 sets of 30 seconds, does not mean you have restored this very important function
That is, as a matter of fact, exactly my point.
While many of the more common, classic ankle sprain rehab exercises serve a purpose in the acute stage, the bigger picture lies in what we do beyond those stages and how we do it.
If you have not explored ankle sprain rehab beyond exercises with tubing and unstable surfaces like the BOSU, here are 3 key exercises, or rather, 3 key elements you need to include in your ankle sprain rehab programs.
ACUTE STAGE REHAB
As I mentioned previously, many of the more common, classic ankle sprain rehab exercises like ankle range of motion and strengthening exercises using tubing have a purpose in the acute stage.
With the exception of Grade 3 sprains, isometrics in plantar flexion, dorsiflexion, inversion and eversion can be incorporated very early, and active range of motion in plantar flexion and dorsiflexion within pain-free ranges are allowed.
When a joint is injured, the muscles that cross that joint become inhibited – this is called arthrogenic inhibition. Open kinetic chain isometrics or tubing exercises allow for reactivation of these muscles while still protecting the injury in the early stages (ie. non-weight bearing).
By the way, light resistance with higher repetitions is less detrimental for the healing ligaments, which is why it’s actually ok to use the classic 3 sets of 10 reps here.
These classic approaches are not all wrong. Alone, however, they are insufficient at best because they will not help recover the entirely of ankle function.
There is an aspect I see neglected in early rehab when it comes to ankle sprains, and that is the foot.
Your feet are very important and provide a stable foundation for all of your movements. Even just a few days, let alone a few weeks, of limping and/or limited weight-bearing from an ankle sprain will wreak havoc on your intrinsic foot function.
This is why upregulating the foot needs to be an inherent part of acute stage rehab.
For more on this, head to my article Ankle Sprain Rehab: Tips for a Faster Recovery.
« Functional » …
That word that gets thrown around so much.
What I mean by functional stability is the ability to dynamically stabilize the joint for proper movement and control.
Functional stability is actually something we always need, ankle sprain or not. The elements of acute stage rehab discussed in the previous section as well as in my previous article on ankle sprains are certainly important in restoring functional stability.
Injury to joint structures results in damage to peripheral joint mechanoreceptors responsible for conveying afferent information on joint motion and position. These perturbations in proprioception result in decreased neuromuscular control and in turn, this leads to functional instability.
So, restoring joint range of motion and strength of the joint is for sure important.
However, in a dynamic environment like changing direction on the field or even just walking on uneven terrain, the brain does not rely only on proprioception provided by the joint mechanoreceptors.
If you want to be more effective in restoring the ankle’s ability to function in this dynamic environment, you need to include 3 key strategies in your rehab:
1 – Load the visual and vestibular systems
2 – Work on closed chain dynamic control
3 – Include unanticipated perturbations for reactive control
KEY #1 – VISUAL AND VESTIBULAR INTEGRATION
The proprioceptive, visual and vestibular systems work together to tell the brain (or Central Nervous System) where the body is in space. In fact, the vestibular system is the fastest system in the body and can make very quick adaptations to perturbations.
In a dynamic environment, like the real world or the field of play, there is not an equal distribution between the proprioceptive, visual and vestibular systems.
Vestibular and visual loading exercises are key exercises that can be integrated into ankle sprain rehab to ensure that these systems can tolerate load well and contribute to overall adjustments to perturbation, that is, functional stability.
I like to use drills from my friends over at Integrated Kinetic Neurology. For ankle sprains, exercises that integrate the vestibulo ocular reflex to the lower limb work well. To put it simply, these exercises load the lower limb while incorporating gaze fixation with head movements.
What is great about these is that the client will actually really feel the stability requirement that this imposes on their ankle:
You can also perform tracking or pursuits to shift to the visual system.
WATCH THE MAIN VIDEO OF THE ARTICLE TO SEE HOW THESE ARE PERFORMED
KEY #2 – CLOSED-CHAIN DYNAMIC CONTROL
Dynamic balance and range of motion control are important elements of ankle sprain rehab. Many of the classic lower limb strengthening exercises we utilize in the gym, like split squats, lunges, step-ups, etc., don’t take clients into the same ranges of motion involved in a more dynamic environment.
The Star Excursion Balance Test (or SEBT) is a dynamic test typically used to either screen for deficits in dynamic control or to compare the injured to non-injured side. Like many tests, it can also become a very useful tool to work on range of motion, balance and control.
The star set-up forces the client to reach in the anterior, anteromedial, medial, posteromedial, posterior, posterolateral, lateral and anterolateral directions. This ensures they keep working in that functional range of motion for the ankle and not compensating on the way they are distributing load through the foot.
WATCH THE MAIN VIDEO OF THE ARTICLE TO SEE HOW THE SEBT IS PERFORMED
KEY #3 – UNANTICIPATED PERTURBATION FOR REACTIVE CONTROL
Plyometrics are the end game, especially if you are working with someone playing a sport. The added advantage of working on plyometric progressions is that you can use them to promote reactive neuromuscular control.
With an injury to the lower extremity, I am always most concerned with the ability for the extremity to initially tolerate and then distribute load. This is why my plyometric progressions typically begin with landings.
Can they absorb force through the ankle efficiently?
This can start very simply with single-leg landings in the sagittal plane. Because when an athlete has rolled over on their ankle, the thing they will probably be least eager to do is load their ankle in the frontal plane.
You can then progress these to lateral absorptions. Stepping to the outside will be more apprehensive after a lateral ankle sprain, and towards the inside for a medial ankle sprain. As an FYI, lateral ankle sprains are much more common.
Jumping and landing is the obvious next area of progression. Again, knowing that we are preparing the client for a dynamic environment, reactive capacity is key. We need the joint, muscles and nervous system to react in a precise and timely fashion to adapt to perturbation.
While classic balance training like standing on a BOSU ball is what people tend to consider “reactive”, it will actually only train the ankle (and foot) to sense slow inversion moments.
Don’t get me wrong, this does help work on dynamic stabilization, which is essentially the muscles anticipating and reacting to joint loads. Balance exercises are great for this purpose.
reactive neuromuscular control requires unanticipated joint perturbations
When you have a client stand on a BOSU, they know what’s about to happen. This is not unanticipated and is not comparable to unexpectedly stepping onto the edge of a hole in the field or being pushed while catching a ball in mid-air forcing you to land in a less than optimal position.
What can you do to create unanticipated perturbations?
Re-create these real-life situations as closely and as safely as possible. For example, you could have the client doing consecutive jumping squats and gently push them in a different direction while they are mid-air.
DISCLAIMER: Please do not get carried away. The key word is gently push them. Don’t tackle your clients, and if you do, I am not responsible.
THE KEY IS THE STRATEGY
While I lured you in by taunting you with 3 key exercises, these are actually 3 key elements that need to go into your ankle sprain rehab. People are always looking for the exercises, but it is not the exercises that are key, it is what you are trying to achieve with them.
Yes, range of motion and tubing exercises, and all of the other classic rehab exercises have their purpose. But proprioception is not the only system that provides information to the central nervous system, especially in a dynamic environment.
And sure, you can use the BOSU, but it’s for balance training. It’s not going to solve the issue of restoring reactive neuromuscular control. There are other strategies to do that and many other exercises that you can utilize.
Remember that restoring functional stability following ankle sprain rehab involves restoring proprioceptive and kinesthetic sensation, dynamic joint stabilization, reactive neuromuscular control and functional motor patterns. No single set of exercises is going to do all of that.
Choose the goal and then the exercise, not the other way around.
HÜBSCHER, M., ZECH, A., PFEIFER, K., HÄNSEL, F., VOGT, L., & BANZER, W. (2010). Neuromuscular Training for Sports Injury Prevention. Medicine & Science In Sports & Exercise, 42(3), 413-421. doi: 10.1249/mss.0b013e3181b88d37
Huang, P., Jankaew, A., & Lin, C. (2021). Effects of Plyometric and Balance Training on Neuromuscular Control of Recreational Athletes with Functional Ankle Instability: A Randomized Controlled Laboratory Study. International Journal of Environmental Research and Public Health, 18.