Chronic ankle sprains and instability rehab

Ankle sprains are one of the most common injuries to become a recurring condition. A study in The Journal of Athletic Training reports that as many as 70% of ankle sprains result in some form of residual physical disability. Surprisingly, 50% of ankle sprains treated in the ER are not from sports. These stats are likely because many treat an ankle sprain like a bruise: get back to full work as quickly as possible without doing anything special to heal it. Without some degree of training and activity modification, the ankle is likely to sprain again and again which lengthens the ligaments of the ankle resulting in more sprains and eventually ankle instability.

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The old recommendation was hard rest. Let the body heal, your body knows what it’s doing but if you keep reinjuring your ankle it can’t so stay off of it. What healthcare has discovered over the last two decades is that controlled exercise as soon as you can leads to stronger ligaments. The exercise we want trains the body to move safely and efficiently, and puts a load on the ligament that at most causes a mild dull pain while avoiding sharp pain. This kind of exercise results in the ligament growing back strong instead of weak. In mild and most moderate sprains you can draw the ABCs with your ankle almost immediately, gradually progressing to more strenuous activity. Lastly, ligaments take 3-12 months of training to return to full capacity.

Here we describe the general principles of healing, but you should see a chiropractor, physical therapist, or another medical professional focussed on rehab and training to make a plan for long term ankle stability. Healing occurs in 3 stages that last varying amounts of time. Healing is faster if you are eating healthy, manage stress well, sleep well, and if you exercise often. Phase 1 is the acute/inflammation phase, right after the injury. It is a short phase characterized by bruising, swelling, and pain from a fresh injury. The second phase is subacute/proliferative, which is where most people go wrong that take care of their own injuries. This is usually a days after the initial injury while most people are still resting, and lasts 1-2 months. The last phase is either chronic or healed/remodeling. This phase starts around a month after the injury.

Acute phase-fresh injury: Depending on the severity of the injury you should rest the ankle for 1-3 days. Usually a brace will be sufficient to remind you to be cautious, using your ankle for everyday activities only. Do any activities you can do without sharp pain
Subacute phase-1-3 days after the injury. As soon as the swelling has gone down start trying some of the moderate exercises listed below and twice a day at low intensity do whichever you can without sharp pain.
Chronic/Remodeling phase- 1-12 months after injury you need to consistently train the ligament up to the kind of activity you need it to do.

Ankle Specific Training

Easy (do as soon as you can)

ABCs - trace each letter of the alphabet in the air with your ankle
Single Leg Balance - Balance on your injured foot

Moderate (wait 1-3 days and do as soon as you can without sharp pain)

Hop to Stabilization
Star Excursion - This is a test that trains the balancing foot when performed as an exercise.
Calf raises
Peroneal Exercise - the peroneal muscles dissipate the force that would cause a sprain when they’re working properly

Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of Ankle Sprains and Chronic Ankle Instability. Journal of athletic training, 54(6), 603–610. https://doi.org/10.4085/1062-6050-447-17

Photo by Nina Uhlikova
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