How to Treat an Ankle Sprain

So you rolled your ankle – what do you do next? This guide will provide you with some simple steps to take towards a speedy recovery. We will also discuss when you need to get x-rays to rule out a broken bone.

Is my ankle broken?

This is obviously the most important question to answer after you’ve injured your ankle. There are times where a bony fracture is quite obvious – there are no shortage of YouTube fail videos where this is the case. When there is no overt signs of bony fracture, then there are some useful guidelines that ER doctors follow when determining if an x-ray is required. These guidelines are called the Ottawa Ankle and Ottawa Foot Rules. If you you have any of the following findings, you need an x-ray!

Ottawa Foot and Ankle Rules

  1. You can’t take more than 4 unassisted steps both immediately and when you are being assessed (limping is ok)
  2. Boney tenderness  at the posterior (back) edge of the lateral malleolus (see picture 1)
  3. Bony tenderness at the posterior (back edge) of the medial malleolus (see picture 2)
  4. Bony tenderness at the base of the 5th metatarsal (see picture 3)
  5. Bony tenderness at the navicular (see picture 4)

If you don’t have any of the above issues, then you likely do not have a fracture and do not need an x-ray. However, if you have any suspicion, it’s best to err on the side of caution and go to see a doctor.

Once a fracture has been ruled out, you can get on the road to recovery as you work through the various phases below.

Acute Management (3-7 days post-injury)

At this stage, the goal is to control pain and try not to get in the way of the healing process. Simply put, you need to do some activity pacing/modification and start using some gentle movement to help guide the healing process. 

Absolute rest is rarely indicated for most types of injuries. That’s right, lying on the couch watching Netflix for days on end without moving is not a good idea! With that being said, you do want to be smart about how much walking/weight bearing you’re doing. Everyone will be different as to how much they can do. This will also vary from one week to the next as things heal up. The rule of thumb is you want to stand/walk until you have the onset of pain/fatigue and not to the point where it’s getting so sore that it forces you to stop what you’re doing. If you keep pushing to this level, you will likely delay your recovery by interfering with the healing process. 

You only need to focus on one simple exercise in the early days post-injury. The goal of this exercise is to help guide the healing process in you ankle and prevent it from stiffening up. There is no expectation that you will restore full range of motion at this time. As such, it’s crucial that you only work into stiffness or very mild discomfort, not pain! If you push into pain you will disrupt the healing process and it will then take you longer to recover.

Ankle Active Range of motion

  1. Slowly point foot downwards as if pushing the gas pedal of a car
  2. Slowly tilt foot backwards towards your shin
  3. Be sure to work into stiffness or mild discomfort, NOT PAIN!!

 – do 15-20 repetitions in each direction

 – repeat this 3-5 times per day

Subacute Management: (3 days to 3 weeks post-injury)

At this stage we want to work on gradually restoring full range of motion for the ankle. You will now need to use some external forces and start to sustain the stretch positions in order to restore the normal flexibility to the tissues in your ankle. As mentioned before, we are trying to guide the healing process, not get in the way of it. Again, it is very important that you continue to work into stiffness/discomfort, not pain! If it hurts, you are being too forceful and you need to back away from that point in the movement.

There will now be 3 directions we want to work on stretching individually. 

Ankle Dorsiflexion Stretch

  1. Place a rolled towel under your knee
  2. Loop a belt/towel around your foot
  3. Use belt to help tilt your foot backwards until you feel stiffness/mild discomfort and hold
  4. Return to neutral and repeat

Ankle Plantarflexion Stretch

  1. Sit with ankle crossed over your opposite knee
  2. Grab your foot fairly close to your ankle joint (ie not at your toes)
  3. Use your hand to gently point the foot downwards until you feel stiffness/mild discomfort and hold
  4. Return to neutral and repeat

Ankle Inversion Stretch

  1. Sit with ankle crossed over your opposite knee
  2. Grab your foot from underneath (pinky toe side)
  3. Scoop your foot up towards the ceiling as if trying to get the sole of your foot to face the ceiling – work into stiffness/mild discomfort, not pain
  4. Return to neutral and repeat 

Programming for Ankle Range of Motion Exercises

Subacute Strength/Balance Exercises: (start 2-3 weeks post-injury)

You are ready to start doing some strengthening and balance exercises once you can walk with little to no limping. The goal with these exercises is to start to restore strength/function in the muscles that move and stabilize your ankle. These exercises should not be painful (other than muscle burning/fatigue feeling). If they are painful, you likely need to spend more time with the range of motion exercises above and/or allow your ankle more time to heal.

Below are both the basic/starting versions of the exercises and their progressions. You can move to the progressions provided once you are able to do all the reps/sets of the exercises without much strain/effort.

Single leg balance

  1. Set a timer for 1 minute
  2. Stand on one foot
  3. If you lose your balance, let the timer continue to run and try to get back on the one foot as quickly as you can
  4. Once the time is done rest a minute or do the exercise on the other foot

Single leg balance progression 1: unstable surface

  1. Set a timer for 1 minute
  2. Stand on one foot on a cushion/pillow/folded towel
  3. If you lose your balance, let the timer continue to run and try to get back on the one foot as quickly as you can
  4. Once the time is done rest a minute or do the exercise on the other foot

Single leg balance progression 2: unstable surface and dual task

  1. Set a timer for 1 minute
  2. Stand on one foot on a cushion/pillow/folded towel
  3. If you lose your balance, let the timer continue to run and try to get back on the one foot as quickly as you can
  4. While trying to maintain your balance, play catch with a partner, bounce a ball on a tennis racket or throw a ball against a wall
  5. Once the time is done rest a minute or do the exercise on the other foot

Calf strengthening : Double leg calf raises

  1. Place your hands on a wall to help with balance
  2. Lift up onto your toes
  3. Hold 5 seconds
  4. Slowly lower back down and repeat 

Calf strengthening progression 1: Single leg calf raises

  1. Place hands on wall to help with balance
  2. Stand on one foot, then lift up onto your toes
  3. Try to keep the weight towards your big toe/ball of your foot
  4. Hold 5 seconds
  5. Slowly lower back down and repeat

Calf strengthening progression 2: Single leg calf raises on step

  1. stand on a stair or step stool and hold the wall or railing for balance
  2. Allow your foot to drop below the plane of the step
  3. Lift up onto your toes
  4. Try to keep the weight towards your big toe/ball of your foot
  5. Hold 5 seconds
  6. Slowly lower back down and repeat

Resistance band inversion:

 – insert video for resistance band inversion

  1. Tie one end of a resistance band around your foot, just below your toes
  2. Step on one end of the band with your other foot to hold it in place
  3. Cross your ankle over your knee (there should be some tension on the band in this position
  4. Scoop foot up towards the ceiling (so sole of foot is facing upwards)
  5. Hold 5 seconds
  6. Slowly lower to the starting position

Resistance band inversion progression:

– insert video for theraband inversion doubled

  1. Tie a knot in the band so it makes a loop
  2. Step on one end of the loop and place the other end over your foot, just below your toes
  3. Cross your ankle over your knee (there should be some tension on the band in this position
  4. Scoop foot up towards the ceiling (so sole of foot is facing upwards)
  5. Hold 5 seconds
  6. Slowly lower to the starting position

Resistance band eversion:

  1. Tie one end of a band on a table leg
  2. Tie other end of band around your foot, just below your toes
  3. Start with some tension in the band with your foot tilted towards the origin of the band
  4. Tilt foot outwards away from the origin on the band and hold
  5. Be careful to move only your foot and not your entire leg (you can hold your knee/leg with your hands to help with this)
  6. Slowly return to the starting position and repeat

Resistance band eversion progression:

  1. Tie a knot in the band so it makes a loop around a table leg
  2. Place your foot inside the loop, with band just below your toes
  3. Start with some tension in the band with your foot tilted towards the origin of the band
  4. Tilt foot outwards away from the origin on the band and hold
  5. Be careful to move only your foot and not your entire leg (you can hold your knee/leg with your hands to help with this)
  6. Slowly return to the starting position and repeat

Programming for Balance Exercises

Frequency: once per day or minimum 3 times per week

Repetitions: 3

Timer: 60 seconds (let this run, if you lose your balance, just get centred again as quickly as you can)

Rest: 60 seconds between sets or just do the exercise on the other foot.

Programming for Strength Exercises

Frequency: once per day or minimum 3 times per week

Sets: 3

Repetitions: 10-15

Hold per repetition: 5 seconds

Rest: 30-90 seconds between sets

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