How to manage your ankle sprain with these exercises

Ankle sprains are common. People can sprain their ankles coming down the stairs, walking on rugged trails, playing a sport, and many other ways.

The most common way to sprain an ankle is rolling or twisting your ankle inwards.

They can vary in severity. There are three grades when categorizing your ankle sprain – Grade I, II, and III.

Grade I sprains are mild. Your ligaments may have overstretched just a little bit, but there is typically no bruising or major swelling.

Grade II sprains are moderate. The ligaments are still intact but are more overstretched than they are in Grade I sprains. You may also notice swelling and bruising.

Lastly, grade III sprains mean there is a complete tear of a ligament. You may notice instability to the ankle, swelling, and bruising.

Anatomy:

There are several ligaments in the ankle that can be affected in an ankle sprain, but the most commonly sprained one is the anterior talofibular ligament ( ATFL). This ligament is stressed when rolling your ankle inward a.k.a. inverting your ankle.

The ATFL connects the talus to the fibula, and its job is to stop excessive plantarflexion (pointing the toes downward) and inversion (bringing the foot towards middle of the body).

You might also be wondering: can other structures in the foot be injured when you sprain your ankle?

The answer is yes. Other ligaments and muscle tendons (such as those of the fibularis muscles) that attach to the side of the lower leg and ankle/foot bones can be irritated/injured, especially in grade II and III ankle sprains.

There are two fibularis muscles (fibularis longus and fibularis brevis) you can find on the outside of the lower leg.

Fibularis longus starts at the top of the lower leg and travels beneath the foot and attaches to the middle of the foot. Fibularis brevis starts 2/3rds down the lower leg and attaches to one of the outer foot bones.

Their job is to evert your ankle or bring the foot outwards. They may also work to limit the amount of ankle inversion.

When you excessively invert your ankle, the fibularis muscles are stressed, which is why people who sprain their ankles may also feel discomfort or soreness to the outside of their lower leg.

Special Tests

Here are some special tests to rule in/out other ankle ligamentous and muscular injuries.

Squeeze test: this assesses high ankle sprains by stressing the syndesmosis found in the distal portion of space between the tibia and fibula. You start off by having the patient sit on a table or chair with their leg hanging off. The PT then wraps their palms around the lower leg and applies a force, compressing the tibia and fibula together. The compression causes the distal aspect of the tibia and fibula to split, thereby stressing the syndesmosis. A (+) result is reproduction of pain.

Talar tilt test: this can test for medial or lateral ligamentous injuries depending on which direction you tilt the calcaneus. The PT will grasp the calcaneus with one hand and stabilize the lower leg with the other hand. A (+) result is reproduction of pain or increased laxity in the test ankle versus the unaffected side.

Eversion stress test: this tests for deltoid ligament integrity. The PT grasps the calcaneus with one hand and stabilizes the lower leg with the other hand. The hand that is holding the calcaneus will evert and abduct, stressing the deltoid ligament. A (+) result would be reproduction of pain or excessive laxity compared to the uninvolved side.

Thompson’s test: this tests for an Achilles tendon rupture. The patient lies prone (facing down) with their injured foot just off the table. The clinician then squeezes the calf muscle from both sides. In the presence of a healthy Achilles, squeezing the calf muscle will cause the foot to plantarflex. A (+) results for an Achilles tendon rupture is if the foot does not plantarflex when the calf muscle is squeezed.

Anterior drawer test: this assesses for ATFL integrity. The patient will sit on a chair or table with their leg hanging off. The PT grasps the calcaneus with one hand and stabilizes the lower leg with the other. Then, the PT will perform an anterior translation of the calcaneus (pull the calcaneus forward). A (+) result is reproduction of pain to the ATFL or increased anterior translation compared to the uninjured side.

Signs and Symptoms:

Mechanism of injury involving twisting your ankle

Possible swelling and bruising

Tenderness to your ankle, especially to ATFL

Reduced ankle range of motion and strength

Possible antalgic gait

Possible impaired balance

When to seek an x-ray

If the ankle sprain is quite severe, and you are unsure whether or not you have fractured your ankle, seek an x-ray from urgent care or the emergency department.

To determine if you need an x-ray, physical therapists and physicians follow what is called the Ottawa ankle rules.

The rules state that if you have pain at the tips of the malleolus, pain to the mid foot at the navicular, or at the base of the 5^th metatarsal along with the inability to put weight through the foot immediately and at the emergency department, x-rays are required.

Treatment for an acute inversion ankle sprain:

Assuming x-rays come out negative for fractures:

If the ankle sprain happened very recently, say a couple of hours or 1-2 days ago, be sure to prevent further harm to the ankle. This means reducing high intensity plyometric exercises, running, and jumping. Depending on the severity, you may also want to use crutches the first 1-3 days to help offload the ankle/foot, especially when ambulating outside of your home (check out this post here on how to use crutches properly).

However, just because you should limit your exercises/physical activities, it does not mean that completely resting your ankle will be best. You should still bear as much weight as you can tolerate through the foot and start moving it around when you can.

For optimal recovery, you want to implement pain-free range of motion ankle exercises for the first couple of days (~1-3 days) to help maintain your mobility. Further recommendations are to ice your ankle 3-4 times a day for 15 minutes each time to control pain and swelling, and elevate your foot to help reduce swelling.

Once you begin to notice improvement to your symptoms, gradually progress and implement more exercises into your program.

Check out these recommended exercises