Rehabbing an Ankle Sprain Part II – Building a Program

Now that we understand what benefits rehabbing the ankle sprain can provide, we can build a program targeted at gaining those benefits.

The program has three phases corresponding to the [three phases of healing] I discuss in another article. The phases are delineated by your ankle’s function rather than weeks because timelines will vary for everyone based on a multitude of factors.

Phase I – Inflammatory and Early Proliferative

In the time immediately following an ankle sprain the goal is to protect the ankle and set a foundation for the further stages of healing.

Initially, the ankle may be so painful it hurts to bear weight through it. If it is, I suggest going to urgent care or the emergency department to 1) ensure that you did not fracture the ankle as well and 2) to get the right equipment to offload and stabilize the ankle—whether that is a tape wrapping, a boot, or an assistive device.

There are two goals in this phase.

First, build up to normal weight bearing gradually. Walking is the most basic and, in daily life, most useful form of gait. Subsequent stages of rehab will require more advanced forms of gait, so a foundation of walking is a priority.

Second, normalize and regularly move through a full range of motion. After a ligament is damaged it becomes more lax. Therefore, stretching it will only contribute to increasing this laxity, which we don’t want. However, with prolonged immobilization the new tissue laid down will be short. A short and weak tissue can get injured from seemingly normal movements. Actively moving the ankle through its full pain-free range of motion regularly, without resistance, will ensure the fibers do not heal too short.

Moving the ankle actively through its range of motion means moving the ankle under your own muscle power up-and-down and side-to-side without resistance or assistance. If you get to a point that you can’t go any further under your own power and then use some form of assistance—your hand, a strap, pressure into the ground, etc.—to move the ankle even further, you are now stretching it. It is best to avoid this type of motion at this stage.

Once your ankle can bear your whole body weight with minimal pain, you are able to actively move it through its normal range of motion with minimal pain, and the swelling is mostly gone you are ready to move onto the next phase.

Phase II – Proliferative to Early Maturation

By this point your body should be rapidly laying down new tissue. Our job here it to make sure that it is good quality tissue.

As we discussed in the previous article, ligaments have a structural function--they passively resist forces on a joint—and a perceptual function—stretch on them give information to our body about the orientation of our joint in space.

Balance training will address both of these functions early on. Balance is all about your body rapidly identifying the difference between where your body is and where it needs to be so that you don’t fall over. How this improves our proprioception should be clear. Balance training also improves the strength of the ankle. All of those small adjustments require muscular activation.

Balance is a combination of three systems: visual, vestibular (inner ear), and proprioceptive. All of these systems should be challenged in your training.

• The visual system is challenged by rapidly moving your point of focus or closing your eyes.

• The vestibular system is challenged by turning your head side-to-side or up-and-down.

• The proprioceptive system is challenged by standing on an uneven surface such as foam or a rocker board.

Start by standing on one leg on even ground for 15-60 seconds at a time. When a minute is easy, add in one of the challenges. Don’t worry about doing too much here, balance is almost impossible to overtrain.

If you are advanced enough, you can combine the challenges. Stand on a pillow with your eyes closed and turn your head side-to-side. Not easy!

Beyond balance, we also want to begin gradually strengthening the ankle through its full range of motion. This can be done cheaply with resistance bands as is explained in this video.

Once the balance, strength, and endurance of the injured ankle is similar to that of the uninjured side, you are ready to progress to the next phase. If your other side is also injured, try to guestimate to how you would have been pre-injury.

Phase III – Maturation and Return to Activity

Once you’ve made it this far, the boring painful part is out of the way. Now we focus on getting the ankle back to doing what it does in real life: force absorption, dynamic stabilization, and power production.

Our ankles do more than just stabilize us we stand in place. They enable us to absorb and develop force with grace in movements such as a rapid cut in soccer, a grand jeté in ballet, or a hard flip in skateboarding. These are also the movements our ankles are most likely to get hurt doing.

Start with the easiest dynamic movements. Light skipping and double leg hopping will be the best tolerated in the beginning because the ankle never fully absorbs the full impact on its own. The important point is to keep amplitude low and progress in volume initially. Perform 5-15 seconds of work followed by 30-60 seconds of rest.

Once you can tolerate a 30 minute session of this with minimal pain, progress to exercises involving absorbing and producing forces on one foot. These include hop scotch, single leg hops forwards and backwards, and light jogging.

The next step is increasing the amplitude of these motions while introducing light side-to-side dynamic movement such as skips and skater jumps. The latter will be the most stressful form of movement because they directly stress the damaged tissue, so really keep them light at first.

The final step is gradually building towards 100% effort explosive movement incorporating change of direction as well as the skills directly related to your chosen activity.

To supplement these dynamic movements, I suggest heavily loading the ankles as well with movements such as weighted calf raises and weighted toe walks. You can also start gradually practicing walking on the outside of the ankles, and then start adding weight. This final movement, if loaded appropriately, can build a lot of resilience in the usual ankle sprain position which can prevent injuries down the road.

Conclusion

When you make it all the way through to the end you should be good to get back to living life as you were before.

It should be noted that the boundaries between phases are not really as black and white as I’ve described: you can probably start light balance training before you’re walking perfectly and light dynamic movement before you have equal strength. The milestones I chose are conservative and fool-proof to enable someone who may have never rehabbed an injury on their own have the highest likelihood of success.

Working proficiently in that gray area can speed up the process, but requires a breadth of experience and specialized knowledge to minimize the risks of overshooting. This is where working with a highly skilled physical therapist or coach comes into play.

If you are following this progression and have any questions about the particulars or would like coaching through these stages, reach out to me at elias@eliassaric.com

Best of luck in your healing journey.