Physical Therapy Management  Ice: Apply a cold application (15 to 20 minutes, one to three times per day)

 Compression: Apply compression bandage to control swelling caused by the ankle sprain
Mild ankle sprain
 Elevation: Ideally elevate ankle above the level of the heart, but as a minimum, avoid positions
where the ankle is in a dependent position relative to the body

 Natural full recovery within 14 days
 Taping and follow up to evaluate healing progression(level of evidence: 1a)
First time lateral ligament sprains can be innocuous injuries that resolve quickly with minimal
intervention and some approaches suggest that only minimal intervention is necessary. The
NICE guidelines 2016 recommend advice and analgesia, but not routine physiotherapy
referrals [23]. However, it has has also been highlighted that recurrence rate of first time lateral
ankle sprains is 70% [24](level of evidence: 3b). With the recurrence rate so high and the
guidelines not recommending any rehabilitation, this approach has been questioned [25](level
of evidence: 2b).
Severe Ankle Sprain
Physiotherapy is required with functional therapy of the ankle shown to be more efficient than
immobilisation. Functional therapy treatment can be divided in 4 stages, moving onto to the
next stage as tissue healing allows (level of evidence: 1a)
Despite its widespread clinical use, the precise physiologic responses to ice application have
not been fully elucidated. Moreover, the rationales for its use at different stages of recovery
are quite distinct. There is insufficient evidence available from RCTs to determine the relative
effectiveness of RICE therapy for acute ankle sprains in adults. But no evidence exist to reject
the RICE protocol. [29]
Foot and Ankle ROM:
 Patient performs active movements with the toes and ankle within pain free limits to improve
local circulation. [22][30][31]
 Manual therapy in the acute phase could also effectively increase ankle dorsiflexion. [32]
 Anteroposterior manipulation and RICE results in greater improvemen t in range of movement
than the application of RICE alone.
Proliferative Phase (4-10 days)

1. Inflammatory phase,
Goals:
2. Proliferative phase,
3. Early Remodelling,
4. Late Maturation and Remodelling. (level of evidence: 1a)
Recovery of foot and ankle function and improved load carrying capacity.

Inflammatory Phase (0-3 days)

1. Patient education regarding gradual increase in activity level, guided by symptoms.

Goals:
2. Practise Foot and Ankle Functions

Reduction of pain and swelling and improve circulation and partial foot support
 Range of Motion
The most common approach to manage ankle sprain is the PRICE protocol: Protection, Rest,
 Active Stability
Ice, Compression, and Elevation  Motor Coordination

It is important to begin early with the rehabilitation of the ankle. First week exercises produce
Recommendations for the Patient: significant improvements to short term ankle function. [34]

 Protection: Protect the ankle from further injury by resting and avoiding activities that may 3. Tape/Brace :
cause further injury and/or pain
 Rest: Advise rest for the first 24 hours after injury, possibly with crutches to offload the
injured ankle and altering work and sport and exercise requirements as needed  Apply tape as soon as the swelling has decreased.
 Tape or a brace use depends on patient preference
 Boyce et al found that the use of an Aircast ankle brace for the treatment of lateral ligament
ankle sprains produces a significant improvement in ankle joint function compared with
standard management with an elastic support bandage. [35]
 It remains uncertain, however, which treatment (brace, bandage or tape) is most beneficial. [13]
Two examples of ankle sprain taping techniques, but there are many other different
techniques.
Early Remodelling (11 -21 days)
Goals:
Improve muscle strength, active (functional) stability, foot/ankle motion, mobility (walking,
walking stairs, running).
Education:
 Provide information about possible preventive measures (tape or brace)
 Advice regarding appropriate shoes to wear during sport activities, in relati on to the type of
sport and surface
Practise foot and ankle functions (See Resource Videos below)
 Practice balance, muscle strength, ankle/foot motion and mobility (walking, stairs, running).
 Look for a symmetric walk pattern.
 Work on dynamic stability as soon as loa -bearing capacity allows, focusing on balance and
coordination exercises. Gradually progress the loading, from static to dynamic exercises, from
partially loaded to fully loaded exercises and from simple to functional multi -tasking
exercises. Alternate cycled with non-cycled exercises (abrupt, irregular exercises). Use
different types of surfaces to increase the level of difficulty.
 Encourage the patient to continue practicing the functional activities at home with precise
instructions regarding the expectations for each exercise.
Taping/bracing
 Advise wearing tape or a brace during physical activities until the patient is able to confidently
perform static and dynamic balance and motor coordination exercises.
Late Remodelling and Maturation
Goals:
Improve the regional load-carrying capacity, walking skills and improve the skills needed
during activities of daily living as well as work and sports.
Practise and adjust foot abilities (functions and activities)
 Practise motor coordination skills while performing mobility exercises
 Continue to progress the load-bearing capacity as described above until the pre-injury load-
carrying capacity is reached
 Increase the complexity of motor coordination exercises in varied situations until the pre -
injury level is reached
 Encourage the patient to continue practicing at home
Chronic Ankle Instability
On-going issues following a lateral ligament injury within the ankle are reported in 19 -72% of
patients. An ability to complete certain movement tasks, evidence of deficits during the Star
Excursion Balance Test and self-reported function as quantified using the Foot and Ankle
Ability Measure can be utilised as predictive measures of a Chronic Ankle Instability (CAI)
outcome in the clinical setting for patients with a first time lateral ankle sprain injury [38] .
Around 20% of people develop CAI and this has been attributed to a delayed muscle reflex of
stabilising lower leg muscles, deficits in lower leg muscle strength, deficits in kinaesthesia or
impaired postural control.
Chronic ankle instability has been describes as a combination of me chanical (pathological
laxity, arthrokinematic restrictions, and degenerative and synovial changes) and functional
(Impaired proprioception and neuromuscular control, and strength deficits) insufficiencies [41] .
A sound treatment program must adhere to both mechanical and functional insufficiencies.
It is recommended that all patients undergo conservative treatment to improve stability and
improve the muscle reflex and strength of the lower limb stabilising muscles. Although this
will help some individuals, it cannot compensate for the defecit of the lateral ligament complex
and surgery is occasionally required [39].
Ankle Bracing and Taping
Ankle Bracing and taping is often used as a preventative measure which has gained increasing
research. Ankle taping may be used to help stabilise the joint by limiting motion and
proprioception. Ankle taping is said to have a greater effect in preventing r ecurrent strains
rather than an initial sprain [6]. A study on basketball players detailed the effectiveness of ankle
taping on reducing the risk of re-injury in athletes who have a history of ankle-ligament
sprains. The large sample size of the study (n=10,393) and identification of 40 ankle injuries Decrease pain and swelling, increase pain free range of motion, begin strengthening, begin non-
adds reliability to the results expressed. Tropp et al, 1985, undertook a study in soccer players weight bearing proprioceptive training and provide protective support as needed.
who wore an ankle brace. The subjects in the brace group experienced a significant decrease in
the incidence of ankle sprains when compared to no intervention [42]. Surve et al, 1994,
described similar effects in their prospective study with bracing but noted there was no 1) Modalities to decrease pain and swelling
difference in the ankle sprain severity in the braced and unbraced groups [43].

 -Ice and contrast baths

Reports are inconclusive on the effective of ankle taping. Several reports have suggested the  -Electrical stimulation (high-voltage galvanic or interferential)
ineffectiveness of taping [6] [44]. It’s effectiveness is also affected by the experience of the taper.  -Ultrasound
Some of the advantages of bracing over taping are; cost [45], reusability, no expertise is required
 -Cross-friction massage(gently)
for application and minimal effect of an allergic reaction [46] .
 -Soft orthotics with 1/8-3/16 inch lateral wedge, if needed in Ankle Sprain Treatment.

Ankle Sprain Treatment (2) 2) Weight bearing

Acute Stage- Ankle Sprain Treatment

Progress weight bearing as symptoms permit. Partial weight bearing to full weight bearing if no signs
of antalgic gait is present.
 -Grade 1 sprain: 1-3 days
 -Grade 2 sprain: 2-4 days
3) Physiotherapy exercises for ankle sprain
 -Grade 3 sprain: 3-7 days

Goals-Acute Stage-Ankle Sprain Treatment  -Active range of motion exercises- Dorsiflexion, inversion, foot circle, plantarflexion,
eversion, alphabet.
 -Strength exercises- Isometrics in pain free range, toe curls with towel (place weight on
Decrease pain and swelling, protect from re injury and maintain appropriate weight bearing status. towel to increase resistance). Pick up objects with toes (tissue, marble).
 -Proprioceptive training- Seated Biomechanical Ankle Platform System (BAPS). Wobble
PRICE board. Ankle disc.
 -Stretching- Passive ROM- only dorsi flexion and plantar flexion in pain free range. No
eversion or inversion yet. Achilles stretch. Joint mobilization (grade 1-2 for dorsiflexion
 1) Protection Options Taping, functional bracing, removable cast boot (grade2 and 3 and plantarflexion).
sprains)

 2) Rest (crutch to promote ambulation).

 3) Ice Cryocuff ice machine, ice bags, ice with other modalities (interferential , ultrasound, Rehabilitative Stage- Ankle Sprain Treatment
high-voltage galvanic stimulation).
 4) Compression Elastic wrap, TED hose, Vaso-pneumatic pump.  -Grade 1 sprain:1 week
 5)Elevation Above heart level with ankle pump.  -Grade 2 sprain:2 week
 -Grade 3 sprain:3 week
Sub-Acute Stage- Ankle Sprain Treatment
Goals- Rehabilitative Stage- Ankle Sprain Treatment
 -Grade 1 sprain: 2-4 days
 -Grade 2 sprain: 3-5 days
Increase pain-free ROM. Progress strengthening. Progress proprioceptive training. Increase pain-free
 -Grade 3 sprain: 4-8 days activities of daily living. Pain-free full weight bearing and uncompensated gait.

Goals-Sub-Acute Stage-Ankle Sprain Treatment

1) Therapeutic exercises for ankle sprain
  -Stretching- of gastrocnemius and soleus with increased intensity. Joint mobilization
(grades 1,2 and 3 for dorsiflexion, plantarflexion, and eversion, hold inversion).
 -Strengthening- Weight bearing exercises. Heel raises. Toe raises. Stair steps. Quarter
squats.
 Concentric/Eccentric and isotonics (theraband and weight cuff exercises) for inversion,
eversion, plantar flexion, dorsi flexion, peroneal strengthening.
 -Proprioceptive training ( Progress from non-weight bearing to controlled weight
bearing to full weight bearing). Standing BAPS board. Standing wobble board. Single leg
balance activities (Stable to unstable surfaces, without to with distractions). Proprioceptive
training has a major role in Ankle Sprain Treatment.

2) Continue modalities as needed, specifically after exercise to prevent re occurrence of pain and
swelling.

3) Taping, Bracing and orthotics used as needed. To avoid re injury.

Return to Activity stage- Ankle Sprain Treatment

 -Grade 1 sprain: 1-2 week

 -Grade 2 sprain: 2-3 week
 -Grade 3 sprain: 3-6 week

Goals- Return to Activity stage- Ankle Sprain Treatment

Regain full strength. Normal biomechanics. Return to participation. Protection and strengthening of
any mild residual joint instability.

1) Therapeutic exercises

Continue progression of ROM and strengthening exercises. Sports specific strengthening and
training.

2) Running progression

 Unloaded jogging. Unloaded running. Alternate jog-walk-jog on smooth straight surfaces.

Alternate sprint-jog-sprint on smooth straight surfaces. Figure of eight drills. Zig-zag
cutting.
 Agility drills like back pedaling, side stepping, Carioca.
 Plyometrics specific to each sport.
 Progress weight bearing multi directional balance exercises and movement activities.