Ankle Sprains - Top Exercises Recommendations From a Physical Therapist

Aside from acute low back pain, rotator cuff injuries, and the occasional knee ache, the ankle and foot complex is a sneaky culprit of pain in many patients I see. It's why I devoted my blog to center around this information, not only because I suffered from my own Achilles issues, but also because I realized that this susceptible body part might actually be glossed over. In fact, ankle sprains are one of the most frequent musculoskeletal injuries, impacting individuals of all ages, with an occurrence rate of almost 2 million annually in the United States.

The following information will help you heal your ankle, improve your confidence to return to the activities you love doing, and, most importantly, reduce the odds of this type of injury occurring again.

First, a quick anatomy lesson, let's take a few steps back and dive into the ankle.

Anatomy

An ankle sprain occurs when the ligaments (the fibrous connective tissue that attaches bones to bones) are overstretched. This typically occurs when the foot rolls inwards, causing increased stress and microtearing of the ankle ligaments, also known as an inversion sprain.

Ankle sprains are categorized on their severity, as illustrated below.

Grade	Damage to Ligaments	Symptoms	Recovery Time
I- Mild	Mild stretching	Minimal swelling, pain, and decreased ROM.	1- 3 weeks
II- Moderate	Partial tear	Moderate swelling, pain, and tenderness. Decreased mobility, strength, or ability to bear weight.	4-10 weeks
III- Severe	Complete tear	Significant bruising, discoloration, and swelling. Unable to bear weight without considerable pain.	> 3-6 months

Do We Still RICE?

We've all heard the adage: RICE. However, as science and research developed considerably, our knowledge of managing and rehabbing injuries have improved.

So what are peace and love, and how does it relate to your painful ankle, and specifically a ligamentous injury?

Now before everyone gets all up in arms, let me clarify. I'm not saying to neglect resting altogether. Research supports that, in some cases, a short period of immobilization and protection initially is necessary. Then, we can slowly reintroduce movement and activity. The balance lies in how much rest and protection we allow, and this largely depends on the severity of the sprain.

For most ankle sprains, early mobilization with functional support (bracing, taping) and exercise is favored over immobilization. Early mobilization results in faster return to work/sport, less persistent swelling, better range of motion, and higher patient satisfaction.

On the flip side, short-term immobilization (a few days up to 10 days) can be beneficial for severe ankle sprains, leading to better functional outcomes compared to immediate functional treatment alone.

So, don't be afraid to get your ankle moving, even it if goes contrary to what you've been led to believe. Graded exercise and an appropriate amount of movement stimulates the healing process within our bodies which is exactly what you need. Not sitting on a couch with rest, ice and slices of pizza.

.....Okay, so instead of RICE, what should you be doing then?

PEACE & LOVE[1]

Protect- avoid exercises that cause significant pain. Mild discomfort while performing activities is safe!

Elevate

Avoid anti-inflammatories and icing

Compression

Education

Load

Optimism - remain optimistic! Your body is resilient and has a natural ability to l

Vascularization- movement, and mobility increase blood flow to the area

Exercise

What Exercises Should I Do For My Ankle?

1. RESTORE MOBILITY

The first step is to improve the ankle's flexibility and range of motion. Perform these exercises daily and up to 3-5 times a day. Remember, motion is lotion.

1. Ankle ABCs

   1. While seated in a chair with your lower leg relaxed, visualize yourself sketching the alphabet using your foot. Create the letters in a large and controlled movement.

      
      

2. Ankle pumps

   1. Place your heel on the floor and flex your foot in the direction of your nose. Hold this position for a second or two, then gradually lower your foot as far as possible. Try to complete 2-3 sets of 15-20 repetitions.

      
      

3. Seated heel slides

   1. This exercise enhances calf flexibility. Plant your foot, keep your heel down, and slide your foot under the chair to stretch the Achilles. Hold for 3-5 seconds and repeat.

   
   

4. Seated Isometric Heel Raises

   1. Sit with your feet hip-width apart. Ensure your weight is evenly distributed on both feet. Slowly raise your heels off the ground, shifting your weight onto the balls of your feet. Maintain the raised position for 15-30 seconds. Focus on keeping the weight even through both feet.

Understanding the Pain Response

As mentioned previously, a gradual return to exercise and activity is emphazised to get better results. Incorporate the following exercises once your mobility is restored with minimal discomfort.

Remember, a mild increase in discomfort/pain is a normal response when first diving back into activity. The key is that your pain levels should return to your baseline soon after completing the activity. This means if you spike up to a 4/10 pain while doing calf raises, don't be too alarmed, try to push through and monitor your symptoms. If they return back to a 2/10 within 2 hours, then the intensity and effort of the exercise is fine.

To summarize: the exercises are meant to be challenging, but they should be tolerable.

A final caveat is that D=delayed and prolonged muscle soreness for up to 48 hours is also entirely safe and regular. Not all pain is equal though. What I do recommend is to Avoid sharp, stabbing, burning pain, especially if it lingers into the day.

2. Strengthen and Load

Generally, after the first 7-10 days of low grade isometrics and mobility exercises it's time to transition to strengthening of and ankle and foot muscles that have naturally weakened over time.

Ankle band 4-way

Loop and elastic band around the bottom of your foot. Hold on to the other end, pull on the band to create tension, and make it taut. Perform 20 reps for two sets.

Inversion: Sit on the floor or a chair and slowly turn the injured foot inward, creating a pull in the opposite direction.

Eversion: Slowly turn the injured foot outward this time, going against the band's resistance.

Dorsiflexion: Loop the band on the top of your foot and the other end around your uninjured foot. Slowly pull the foot toward you. Hold for a few seconds.

Plantar flexion: Loop the band around the bottom of your injured foot and move the foot down as you pull the band towards you.

Heel Raises

Progress from isometric heel raises to using dumbbells for external load. Start light, maybe consider 7-10 kg and then increase appropriately.

Complete three sets of 15-20 reps and hold each rep for 2-3 seconds.

From here, there are many variations you can do. But a standard progression is to transition from seated to standing, to eccentrics, and then single leg activities. See the examples below.

1. Double leg on a flat surface

2. Double leg on 4-6" step

3. Double leg to single leg (eccentric)

4. Single leg on an even surface

5. Single leg on 4-6" step

Sit to Stands

Sit in a chair with a staggered stance, placing your injured foot a few inches ahead of your uninjured foot. Ensure your feet are shoulder-width apart. A wider base of support will make standing easier.

Use your upper body for support if needed, but aim to distribute your weight evenly between your feet. As you progress, adjust your injured foot to be parallel with your uninjured side.

Complete 2-3 sets of 10-15 repetitions.

Side Steps

Loop a band around your knees. Slightly bend your knees and maintain a slight mini squat position.

Take a step with your lead foot and keep the tension on the band by taking a small step with the trail leg.

Set a timer for 30-45 seconds and repeat for 3 rounds.

3. BALANCE/PROPRIOCEPTION

If not managed properly, your risk of re-spraining your ankle is high for the following 12 months. Research shows that up to 40% of ankle sprains develop chronic or persistent weakness, pain, or instability.

Challenge and improve your ankle stability by focusing on exercises that target balance feedback and perception of your joints.

• Tandem Balance - Stand with your feet directly in front of each other. Heel touching your opposite toe. Stand and hold for 30 seconds. Repeat 5 times.

• SLS (single leg stance) - balance on one leg and hold. Use upper body support as needed. Standing close to a counter for support.

• Balance on a foam surface - Using a pillow or foam pad. Try to stand on an unstable surface. Transition from two feet to tandem stance to one leg at a time.

4. Plyometrics

Saved for the later stages of your rehab. Perform these exercises once you experience no pain with SL calf raises and can perform at least 12-15 repetitions continuously.

Double leg hopping

Bend both your legs and push off. Try to elevate a few inches off the ground and land softly on your knees and ball of your feet. Set a timer for 30 seconds. Perform slow and controlled jumps. Repeat 3-5 times.

Lateral to Lateral shuffle

Maintain a mini squat and focus on quickly picking up your feet and shifting side to side. Repeat the recommended time and reps as above.

References:

1. Duboius, B. Sports tissue injuries simply need peace and love. British journal of sports medicine. 2019 Apr, 26.

2. Gaddi, D., Mosca, A., Piatti, M., Munegato, D., Catalano, M., Di Lorenzo, G., Turati, M., Zanchi, N., Piscitelli, D., Chui, K., Zatti, G., & Bigoni, M. (2022). Acute Ankle Sprain Management: An Umbrella Review of Systematic Reviews. Frontiers in Medicine, 9. https://doi.org/10.3389/fmed.2022.868474.

3. MacKenzie M, Herzog, et all. Epidemiology of ankle sprains and chronic ankle Instability. J Athl Train. 2019 Jun; 54(6): 603–610.

4. Mugno A and Constant D. Recurrent ankle sprain. National library of medicine. 2022 Aug.

5. Bohm, S., Mersmann, F., & Arampatzis, A. (2015). Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults. Sports medicine - open, 1(1), 7. https://doi.org/10.1186/s40798-015-0009-9

Disclaimer:

No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or another qualified clinician.