In Part I of the ankle sprain blog, we went over some basic anatomy, types of ankle sprains, causes, and acute treatment. Now in Part II we will focus on the post acute phase. Research has shown that exercise therapy is an essential element to treatment ankle sprains. Therefore, my goal is to illustrate to you some components to focus after you have surpassed the acute phase of your injury. The focal point will be centered on working towards getting you back to running!
Keep in mind that everyones rehabilitation will vary, what I present here is more of a very basic outline, as I have said before for grade III sprains go get checked by a medical professional just to rule out any other possible structural involvements.
Now lets get started.
1. How long does the healing process take?
In regards to ligament tissue healing times, the length will depend once again on the grade of the sprains. ( see part I for explanation of each grade)
Grade 1 ligament sprains take about 0-3 days to heal
Grade 2: 3 weeks – 6 months
Grade 3: 5 week – 12 months.
Remember that in Grade II and III sprains you are also experiencing some discomfort and soreness from the surrounding ankle muscles. Therefore, when it comes to rehabilitating from a sprain, yes, the focus is on allowing the ligament to heal, but you are normalizing the injured surrounding muscles.
We really can’t physiologically speed things up, but we sure can protect and promote healing by doing the right things.
2. You have been working on the swelling and range of motion. What should you focus on next?
Progression timelines will vary depending on the grade of sprain and of course the individual. Meaning someone who experienced a grade I sprain may be able to progress to exercises after day 3, where is grades II and III, that day may be moved back to day 7 or 8. For Grade II-III ankle sprains expect the acute inflammatory phase to last up to 7 days post injury. Ligaments will be at their weakest during healing process anywhere from day 5 to day 21 post injury. I know that this is a very wide timeframe, but once again all this means if you have to be careful to no progress any exercises too quickly.
Some factors that should be taken into consideration before progressing to strengthening and balance exercises are:
1. Has the pain has significantly decreased?
2. Have you been able to manage the swelling and stiffness?
3. Have you been working on range of motion with noted improvements?
4. Can you weight bear on the inured lower extremity with minor to no pain?
If you answered YES to all of these questions, then some of the focus can begin to shift over into foot/ankle strengthening and proprioceptive training. Otherwise, continue with pain control, range of motion normalization, and weight bearing capacity.
There havebeen an number of studies that demonstrate positive outcomes and return to sport when there is an implementation of strengthening and proprioceptive training (2,3,6).
You- jou et al., found in his study that implementing balancing exercises helped strengthen the ankle muscles and therefore create more stability, which is exactly what you want to develop post ankle sprains, especially for those athletes who have suffered reoccurring ankle sprains.
3. What are some balance and strengthening exercises?
In the first part of this blog I introduced some basic single leg balance exercises, as those balance exercises get easier the progressions for balance will become more dynamic. They will challenge the ankle via unstable surfaces and added directional forces.
Dynamic balance exercises require the ability to first be able to carry out static (still) balance, and my requirement is 60 second holds.
Once you have accomplished that and have been able to carry out the forward step and hop to single leg balance, we transition to lateral movements. With running, our cadence, step rate, and direction is very linear, but for trail and cross country runners you will need lateral ankle stability.
Figure 1: Double leg heel raise 3x25
Before you progress your dynamic balances however, I would work on general strengthening of the ankle. Here are some exercises that you can implement:
1. Double leg Heel raises: I would recommend reading back into the posterior tib post where we went over the short foot position, which is what I implement with heel raises. Attempt to create an arch in the foot, and as you lift your heels you should feel most of the weight roll over your big toe, not the outside toes hold for 3 seconds and slowly return to the starting position. Repeat.
Figure 2: Ankle Inversion with Band 3x25 , 10 sec holds.
When this gets easy then you would then progress to a single leg heel raise.
Figure 3: Ankle Eversion with Band
2. Ankle Inversion with Band. Place the band around foot, below the toes, and create tension using the opposite leg as shown . Then point the foot down and inwards and hold for 10 seconds and slowly return to the starting position. Repeat 25 x.
3. Ankle Eversion with Band: This is similar to the prior exercise except the direction changes to pointing the toes down and out. Hold for 10 seconds and repeat 25x
I really like the balance exercises because I think that they are more functional driven towards running. Strengthening is great, and needed however balance is where you get you judge where you are in terms of tolerating impact and evaluate how well and how fast your ankle reacts to the stresses and external instabilities.
The Balance Exercise Rules:
1. With dynamic movements start with:
-multidirectional reaching
-small lateral steps
-large lateral steps
-small lateral hops
Figure 4: Star Excursion on stable surface: Single leg balance with contralateral leg reaching forward, sideways, back, and back to opposite hip
Reaching in all directions = 1 rep , Goal 3x5 Reps
-big lateral hops.
2. always start on a stable surface (even stable ground)
3. Progress to an unstable surface ( foam pad/pillow)
The start excursion reach is a great exercise to challenge balance and general lower extremity proprioception. Today is used to help assess for asymmetries between legs in order to help identify for possible risks of knee or ankle injury (7).
With the star excursion reach, you will be balancing on the affected foot/ankle and then reaching as far as you can forward, out to the side, back, and back cross body towards the opposite hip.
As you are reaching you do want to maintain proper knee alignment and keep core engaged.
Once again when you master the reaching on the ground you will then progress to a foam pad.
Figure 5: Star Excursion on Unstable Surface 3x5 reps
Figure 6: Lateral hop on stable surface. Goal is to stick the landing for 5 seconds. x20 each side . The Knee should maintain alignment with hip and foot.
Now lets jump into the lateral dynamic balance exercises.
As seen below the lateral hop on a stable surface promotes ankle stability and improvement in ankle reaction to instability.
With the lateral hop:
- You will start in 1/4 squat, make sure your knee is line with ankles and tracking over your foot, not facing inward
-You are going to hop side to side starting on the right foot and jumping to the left foot
-Land softly on the balls of your feet, mindful that your knee isn't coming past your toes or falling inward, then your heel softly rolls down, then you repeat to the opposite side.
Figure 7: Lateral hop to unstable surface, goal is stick landing for 5 seconds x 20
Knee should be aligned with foot and hip.
The PROGRESSION would be to do the same but now on an unstable surface like a foam pad.
Once you have handles doing these exercises the progression from here on out would be to slowly start going back to prior exercise routine.
For example:
1. squatting
2. Single leg squatting
3. Box Step ups
4. Lateral Box Step ups.
Around this time (4-6 weeks for grade II and III sprains) that you are progressing back to usual work out routine. You can start assessing how you feel with jogging on level surfaces. If it feels good, start by jogging for 20 minutes. If you can do that without pain or excessive soreness that next day then increase by 5 minutes each run.
If it takes a tad bit longer to progress your running tolerance ... guess what IT'S OKAY.
Remember that it takes 6-8 weeks to develop strength gains, and studies have demonstrated that after 6 week of strengthening and balance programs there is a positive improvement in ankle stability (1,2,3,4,5,6)
Like many other injuries healing takes time, but so does rehabilitation. Do not get anxious, the goal is to train and strengthen enough do that you are less likely to experience another sprain in the future.
TRAIN SMART,
JESSICA MENA DPT, CSCS, RUNNER
Feel free to email me for further questions/concerns: drjmenadpt@gmail.com
1. Cleland JA., Mintken P, McDevitt A., Bieneik M, Carpenter K, Kulp K., Whitman J.M. Manual Physical Therapy and Exercise in the Management of Patient With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial. Journal of Orthopaedic and Sports Physical Therapy. (2013) 43(7)p443
2. Hanci E., Seir, U., Gur H., Akiva B. Eccentric Training Improved Ankle Evertor and Dorsiflexor Strength and Proprioception in Functionally Unstable Ankles. American Journal of Physical Medicine Rehabilitation. 2016 95(6)p448
3. Ismail MM, Ibrahim MM, Youssef EF, El Shorbagy KM. Plyometric training versus resistive exercises after acute lateral ankle sprain. Foot Ankle Int. 2010;31(6):523–530.
4. Han K, Ricard M, Fellinghma G. Effects of a 4-Week Exercise Program in Balance Using Elastic Tubing as Pertubation Force for Inidividuals with a History of Ankle Sprains. Journal of Orthopaedic and Sports Physical Therapy. 2009 39(4)p246
5. Mattacola C.G., Dwyer M.K. (2002) Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. Journal of Athletic Training. 37(4)
6. Sefton M.J., Yarar, C., Hicks-Little, C.A., Berrytm J.W., Cordova, M.L. (2011) Six Weeks of Balance Training Improved Sensorimotor Function in Individuals with Chronic Ankle Instability. Journal of Orthopaedic and Sports Physical Therapy. 41(2)’
7. Stiffler MR, Bell DR, Sanfilipo JL, Hetzel SJ, Pickett KA, Heiderscheit BC. 2017. Star Excursion Balance Test Anterior Assymetry is Associated with Injury Status in Division I Collegiate Athlete. Journal of Orthopaedic and Sports Physical Therapy. 47(5)p339.
8.You-jou H (2015) Neuromuscular Control and Rehabilitation of the Unstable Ankle. World Journal of Orthopedics 6(5)p434-438