We’ve all been there – you’re in the middle of an activity, a sporting event, or simply going about your day when suddenly, you misstep or land on something unexpected. Your foot twists awkwardly, and you end up with a sprained ankle. Now, your foot starts to swell to the size of a baseball and turns various shades of purple, leaving you wondering what to do next. In this post, we’ll cover the initial steps to take following an ankle sprain, the various types of sprains you may encounter, and specific exercises for medial ankle sprains.

Ruling Out A More Serious Injury

Immediately following an ankle sprain, the most important next step is to determine whether or not an x-ray needs to be taken if there is an increased risk of a fracture. If a medical provider is present at the time of the sprain, they will walk you through a series of tests known as the Ottawa Ankle Rules

This set of rules includes five components/questions to examine, which are broken down into two parts:

Part 1:

  • Is there tenderness along the outside portion of your ankle?
  • Is there tenderness along the inside portion of your ankle?

The provider will recommend an x-ray of the ankle if there is pain around the ankle from part 1 and ANY one of the following from part 2 is present:

Part 2:

  • Is there tenderness just above the base of your pinky toe on the outside of your foot?
  • Is there tenderness along the navicular, the big bump on the inside of your foot?
  • Can you put weight through your foot immediately after injury and in the emergency room?

Once the ankle is cleared of any type of fracture, it’s time to focus on addressing the next steps to calm down the initial inflammation, which will vary depending on the severity, grade, and type of the sprain (5).

You can read more about those grades here:

READ: EARLY ANKLE SPRAIN REHAB & TREATMENT 

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Types of Sprains

There are three main types of ankle sprains that you may have experienced:

  1. Lateral ankle sprain: This type of sprain is the most common and occurs when you “roll your ankle” inward, causing the ligaments on the outside of your ankle to stretch or tear. The lateral ankle ligament complex (LLC) consists of three ligaments: the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL).
  2. Medial Ankle Sprain: Making up about 15% of sprains, this type occurs when your foot bends too far upwards towards your shin or collapses inward towards the ground, stretching or tearing the ligaments on the inside of the ankle. The ligaments involved in a medial ankle sprain are commonly referred to as the “deltoid ligament” (1).
  3. High Ankle Sprain: This sprain is caused by a forceful outward rotation of the foot, leading to the separation of the ankle bones and the tearing of the tissue between the ankle and lower leg bones. The primary tissue affected in a high ankle sprain is the syndesmosis, a fibrous structure that connects the tibia and fibula.

LEARN MORE ABOUT OUR ANKLE SPRAIN REHAB PROGRAM

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Looking to tackle that ankle sprain once and for all? Check out our Ankle Sprain Rehab and Ankle Sprain Prehab programs to get started! Designed to target all the necessary areas to get back from an ankle sprain the right way! 

This blog will primarily focus on how to address medial ankle sprains.

When looking at medial ankle sprains, the ligaments on the inside of the ankle, known as the “deltoid ligament,” are stretched, or torn.  This ligament is responsible for stabilizing the inside of your ankle, and along with other muscles and tendons, provides support for the arch of your foot.

 

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There are several similarities in rehab for both medial and lateral ankle sprains. Although many of the general principles are the same, there are some key differences between the two. With medial ankle sprains, there is typically a slightly slower transition to weight bearing, as well as a greater focus on strengthening posterior tibialis and other medial stabilizers.

If you are interested in learning more about high ankle sprains and lateral ankle sprains, check out our podcast here:

 

LISTEN: TREATING HIGH ANKLE SPRAINS VS LOW ANKLE SPRAINS

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Is Performing R.I.C.E Enough?

It can be a good start in some cases, but there’s more to the story.

R.I.C.E (rest, ice, compression, elevation) was once a popular protocol following any short-term injury. It can still be useful in the very early stages (first 24-48 hours); however, other recovery approaches now have much stronger evidence.

Before we move on, let’s take a moment to discuss the role of ice, as it is a widespread recommendation for ankle sprains. If you experience significant pain, ice can be used initially for the first day or so to help manage pain, especially if it limits ankle movement. However, inflammation is an essential part of the healing process. Continuous icing can potentially impact and delay healing time.

READ: WHAT TO KNOW ABOUT TISSUE HEALING TIMELINES

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Another quick consideration for immediate treatment is the use of a brace. If the injury is severe, it may be appropriate to wear a brace initially, but not for more than 10 days. For less severe injuries, a brace is not required. After you finish using intermittent ice for a short period, it becomes important to begin placing weight on the foot early and often. If needed, use a crutch or two, depending on how much weight you can tolerate. Use whatever support you need to comfortably put some weight through the injured ankle, and gradually reduce the amount of support you are using as your tolerance to standing and walking improves.

Following the initial period of gradual weight bearing, you should start a rehab program focusing on active range of motion, stretching, neuromuscular control training, and balance training. Don’t worry, we will cover each of these components and how to address them during the remainder of this blog

 

Active Range of Motion

Now that the initial inflammation and swelling have decreased, it’s incredibly important to begin to move the joint and do so frequently. Doing so can increase blood flow around the area, reduce swelling, and rebuild proprioception, all while beginning to restore motion. Following a medial ankle sprain, one of the most common deficits is decreased dorsiflexion range of motion, or your ability to pull the foot upward. It’s important to begin to address this deficit early on, as if left untreated, may lead to an increased risk of future ankle sprains (2).

To initiate an active range of motion, try the exercises below:

 

 

Gradual Loading

As mentioned previously, one of the number one indicators of a successful rehab is how quickly you can build up tolerance to weight bearing. In most cases, the sooner you can gradually expose the ankle joint to weight, the better off you will be.

To initiate increased loading, outside of increasing your time in standing or walking with crutches, consider performing the following exercise over the day.

 

 

When performing exercises that place an increased load on the ankle, it is important to gradually progress. Specifically when strengthening the calf, start in the seated position as shown above and gradually progress towards standing. It’s also appropriate to increase the number of repetitions of the exercise when it starts to get easier, rather than progressing to standing calf raises right away, especially if prolonged standing provokes symptoms. (4)

 

Strengthening Medial Stabilizers

Following a medial ankle sprain, the muscles and ligaments on the inside of the ankle that support the arch of the foot will often become weaker. The most prominent muscle responsible for supporting the arch is the posterior tibialis. Other muscles to consider in the area include the flexor digitorum longus and flexor hallucis longus, both of which help control movement at the toes.

 

 

A study by Kulig et. al found that the exercise providing the greatest muscle activation to the posterior tibialis was performing band-resisted foot inversion, shown below. This is a great way to gradually improve support and control of the muscles on the inside of the foot that are responsible for maintaining your arch (3).

 

 

Neuromuscular Control and Balance Training

These two categories often work closely together when it comes to returning to the previous function. However, there are a few main differences.

Neuromuscular control: focuses on the coordination and timing of muscle activity to stabilize joints and enhance movement efficiency, incorporating proprioception and functional movements. 

Balance training: specifically targets the ability to maintain your equilibrium, including both static and dynamic stability exercises to improve overall steadiness.

 

 

Depending on the focus of the exercise, the two can work hand in hand. The following examples include a more obvious demonstration of a balance exercise, as well as a split stance functional movement that will help not only retrain balance but also restore proprioception through improving spatial awareness at the ankle.

 

 

Main Takeaways

  • After an ankle sprain, it is essential to first rule out fractures using the Ottawa Ankle Rules, which guide whether an x-ray is necessary based on tenderness and weight-bearing ability.
  • Understanding the type of sprain you have (whether it’s lateral, medial, or high ankle) is crucial for effective treatment. Starting with the R.I.C.E. method can be useful in the early stages, but it’s important to transition to weight-bearing activities as soon as possible to promote faster healing.
  • Once you get into more active methods of rehab, the focus should be on restoring the active range of motion, gradually increasing load on the ankle, and strengthening key medial stabilizers, particularly the posterior tibialis muscle Incorporating both neuromuscular control and balance training exercises for the medial structures involved in a medial ankle sprain is also vital to enhance coordination, stability, and overall movement efficiency.
  • By following these steps, you can address the immediate concerns of a medial ankle sprain and work towards a full recovery. Following this approach will help ensure you are giving yourself the best chance to get back on your feet and prevent future injury!

LEARN MORE ABOUT OUR ANKLE SPRAIN REHAB PROGRAM

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Resources:

  1. Doherty, C., Delahunt, E., Caulfield, B., Hertel, J., Ryan, J. and Bleakley, C., 2014. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports medicine, 44(1), pp.123-140.
  2. Hoch MC, McKeon PO. The effectiveness of mobilization with movement at improving dorsiflexion after ankle sprain. J Sport Rehabil. 2010 May;19(2):226-32. doi: 10.1123/jsr.19.2.226. PMID: 20543222.
  3. Kulig K, Burnfield JM, Requejo SM, Sperry M, Terk M. Selective activation of tibialis posterior: evaluation by magnetic resonance imaging. Med Sci Sports Exerc. 2004 May;36(5):862-7. doi: 10.1249/01.mss.0000126385.12402.2e. PMID: 15126722.
  4. Plotkin D, Coleman M, Van Every D, Maldonado J, Oberlin D, Israetel M, Feather J, Alto A, Vigotsky AD, Schoenfeld BJ. Progressive overload without progressing load? The effects of load or repetition progression on muscular adaptations. PeerJ. 2022 Sep 30;10:e14142. doi: 10.7717/peerj.14142. PMID: 36199287; PMCID: PMC9528903.
  5. Schiper SP, Rodrigues HM, Reis JELE, Silva MBE, Dinato M, Pagnano RG. IMPLEMENTATION OF OTTAWA ANKLE RULES IN UNIVERSITY HOSPITAL EMERGENCY ROOM: PILOT STUDY. Acta Ortop Bras. 2023 Oct 23;31(5):e266034. doi: 10.1590/1413-785220233105e266034. PMID: 37876862; PMCID: PMC10592341.

 

About the Author

John Schaefer

PT, DPT, CSCS

[P]rehab Writer & Content Creator

John is a native of Rochester, MN and a double graduate of Saint Louis University, where he studied marketing and exercise science before earning his DPT.

Always up for an adventure, John traveled to Boston following graduation to intern at Champion PT and Performance. There he was able to work with high-level high school, college, and professional athletes. Following this experience, he headed south to pursue orthopedic residency training in Houston, TX at Harris Health System, working with a largely underserved and non-English speaking population.

John’s treatment philosophy hinges on empowering movement through extensive education and easy-to-replicate exercises, as well as meeting patients where they are. This perspective is shaped by his personal experiences, including five broken bones and two surgeries, during a multi-sport childhood filled with lots of activity and adventure.

Outside of work, you can find John cycling, attending concerts/festivals, hiking, and traveling!

Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.

 

About the author : John Schaefer PT, DPT, OCS, CSCS

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