Physical Therapist's Guide to Ankle Sprain

Ankle sprains are common injuries that occur when the foot twists or turns beyond its normal range of movement, causing the ligaments of the ankle to overstretch or tear. It is estimated that 23,000 Americans experience ankle sprains daily. Of all sports injuries in the United States, 45% are ankle sprains; basketball players are the athletes most often affected.

People who have an increased risk of spraining an ankle include younger athletes, members of the military, and anyone who frequently runs, jumps, and changes direction quickly, while performing an athletic activity (“cutting motion”). Physical therapists help people who have experienced ankle sprains reduce their pain; regain their strength, motion, and balance; return to normal activity levels; and avoid reinjury.

What Is Ankle Sprain?

Sprains are injuries to ligaments (the bands of tissue that hold joints together). Ankle sprains occur when the foot twists or turns beyond its normal range of movement, causing the ligaments connecting the bones of the leg, ankle, and foot to overstretch or tear.

The ligaments on the outer (lateral) side of the ankle are the ones most commonly injured. Ligaments on the inner (medial) side of the ankle, or above the ankle bone, can also be sprained, but are injured less frequently.

 

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An ankle sprain usually takes between 2 weeks to 2 months to heal. The ankle will feel better after a few weeks, and be fully strengthened in a few months. A severely sprained ligament, however, can take 9 months to 1 year to heal.

Recurrent ankle sprains are common; once an ankle ligament is sprained, it is often reinjured. In fact, 73% of people who have sprained an ankle once are likely to do so again. Reinjury is especially likely if muscle strength and balance are not fully restored to, or improved beyond, preinjury levels.
 

How Does it Feel?

Right after an ankle sprain, you may experience:

• Pain
• Swelling
• Inability to stand or walk on the affected foot
• Throbbing
• Stiffness
• Weakness
• A feeling of instability in the ankle joint

After most sprains, you feel pain right away at the site of the ligament stretch or tear. Often, the ankle starts to swell immediately and may bruise. The ankle area usually is tender to the touch, and when you move the ankle, it hurts. In more severe sprains, you may hear or feel something tear, along with a "pop" or "snap."
 

How Is It Diagnosed?

If you see your physical therapist first, the physical therapist will examine your ankle, take your health history, and ask questions such as:

• How did you get injured?
• Did you feel a pop, snap, or tear?
• What activities are you having trouble doing?
• What activities do you want to get back to doing?

Your physical therapist will gently press around your ankle to see if it is painful to the touch, and may use additional tests to determine if other parts of your foot are injured. Your physical therapist will test your strength and flexibility, observe how you can move your foot and leg, and watch how you walk.

Depending on how badly a ligament is damaged, or how many ligaments are injured, your ankle sprain may be classified as:

• Grade 1 (mild). The ligament is overstretched.
• Grade 2 (moderate). The ligament is overstretched or partially torn.
• Grade 3 (severe). The ligament is completely torn.

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Your physical therapist also will test and screen for other, more serious conditions that could be causing the pain and swelling. To provide a definitive diagnosis, your physical therapist may collaborate with an orthopedic physician or other health care provider, who may order further tests, such as an x-ray, to confirm the diagnosis and to rule out other damage to the ankle, including a fracture.
 

How Can a Physical Therapist Help?

Physical therapists help people with ankle sprains recover more quickly than they would without treatment. The time it takes to heal an ankle sprain varies, but results can often be achieved in 2 to 8 weeks. Your physical therapist will work with you to design a specific treatment program that meets your needs and goals.

During the first 24 to 48 hours following your diagnosis, your physical therapist may advise you to:

• Rest the area by avoiding any activity that causes pain.
• Apply ice packs to the area for 15 to 20 minutes every 2 hours.
• Consult with a physician for further services, such as medication or diagnostic tests.
• Walk on the affected foot as soon, and as much as you are able, without making the pain or swelling worse.
• Use crutches or other walking aids to help alleviate pain and support balance.
• Wrap your ankle or use an ankle brace for support and to prevent swelling.

These self-treatments will allow you to be as active as possible with the least amount of pain, and will help speed healing.  

Your physical therapist will work with you to:

1. Reduce Pain and Swelling. You will learn how to avoid or modify your daily and sports activities to allow healing to begin. Your physical therapist may use different types of treatments and technologies to control and reduce your pain and swelling, including ice, heat, ultrasound, electrical stimulation, taping, specific exercises, and hands-on therapy, such as specialized massage.
2. Improve Motion. Your physical therapist will choose specific activities and treatments to help restore normal movement in the ankle. These might begin with "passive" motions that the physical therapist performs for you to gently move your ankle and foot, and progress to “active” exercises and stretches that you do yourself.
3. Improve Flexibility. Your physical therapist will determine if any foot, ankle, or lower leg muscles are tight, begin to stretch them, and teach you how to stretch them.
4. Improve Strength. Ankle sprains may be related to weak, injured, or uncoordinated leg muscles. Certain exercises will aid healing at each stage of recovery; your physical therapist will choose and teach you the correct exercises and equipment to use, to steadily and safely restore your strength. These may include using cuff weights, stretch bands, and weight-lifting equipment.
5. Improve Endurance. Regaining your muscular endurance in the ankle and leg is important after an injury. Your physical therapist will teach you exercises to improve endurance, so you can return to your normal activities. Cardio-exercise equipment may be used, such as treadmills or stationary bicycles.
6. Improve Balance. Regaining your sense of balance is important after an injury. Your physical therapist will teach you exercises to improve your balance ability.
7. Restore Agility. Speed and accuracy of leg movement is important in athletics and in many daily activities. Your physical therapist will help you regain these skills in preparation for a return to sports and to your daily routine.
8. Learn a Home Program. Your physical therapist will teach you strengthening and stretching exercises to perform at home. These exercises will be specific for your needs; if you do them as prescribed by your physical therapist, you can speed your recovery.
9. Return to Activities. Your physical therapist will discuss activity goals with you and use them to set your work, sport, and home-life recovery goals. Your treatment program will help you reach your goals in the safest, fastest, and most effective way possible. Your physical therapist will teach you exercises, work retraining activities, and sport-specific techniques and drills to help you achieve your goals.
10. Speed Recovery Time. Your physical therapist is trained and experienced in choosing the best treatments and exercises to help you safely heal, return to your normal lifestyle, and reach your goals faster than you are likely to do on your own.
11. If Surgery Is Necessary. Surgery is not commonly required for ankle sprains. But if surgery is needed, you will follow a recovery program over several weeks, guided by your physical therapist. Your physical therapist will help you minimize pain, regain motion and strength, and return to normal activities in the safest and speediest manner possible.

Can this Injury or Condition be Prevented?

Your physical therapist can recommend a home-exercise program to help prevent ankle sprains. It may include strength, flexibility, and balance exercises. If you have sprained your ankle once, it is at greater risk for reinjury in the future, if the ligaments did not heal properly or if your ankle never returned to its normal strength. And if you return to sports or other activities too soon after injury, your ankle might give you persistent pain or might easily or frequently reinjure.

Possible other factors that may increase someone’s risk of spraining an ankle are body weight, female gender, muscle weakness, balance problems, or foot/ankle problems.

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To help prevent an ankle sprain or a reinjury, your physical therapist may recommend that you:

• Warm up effectively before athletic activities.
• Use footwear that is best for specific activities.
• Use ankle wraps or braces as directed.
• Perform specific balance and strength exercises several times per week for up to a year.
• Maintain a healthy body weight.

Real Life Experiences

Travis is a 13-year-old basketball player who has just made the junior varsity team at his school. Travis is practicing a lot for the upcoming basketball season, shooting for hours at his local playground, and working hard to gain the respect of his new coach and teammates.

During a practice drill this week, while going up for a layup, Travis lands awkwardly on his right foot, and his right ankle rolls outward as he stumbles and falls. He feels a sharp pain on the outer side of the ankle, and when his teammates help him up, he finds that he can’t put weight on the foot or walk on it. His coach has him sit with his right leg up, and applies an ice pack to the ankle. When Travis's parents arrive, his teammates help him to the car. At home, his mom immediately reapplies the ice pack. His father calls his physical therapist.

The next morning, Travis's physical therapist conducts a complete examination, testing his strength, flexibility, walking, and balance. She checks for tenderness and swelling, and asks about his pain level. Travis explains that his first season's basketball games start in 4 weeks, and he doesn’t want to miss any of them.

Travis's physical therapist recommends an x-ray, which his physician orders for him. The results show that, fortunately, there is no fracture. The diagnosis is a moderate (grade 2) sprain of the lateral (outer) ankle. Travis's physical therapist also notes that he has some muscle weakness and tightness in the lower leg, loss of motion, balance problems, and significant swelling.

Travis's physical therapist gently applies specialized massage around the ankle to reduce the swelling, and teaches Travis specific exercises to help regain normal movement in the ankle. She instructs him to stop if he feels any pain. She teaches him some simple exercises that he can do at home. She also gives him crutches, and teaches him how to use them and how to put a little bit of weight on his injured foot, but not enough to increase his pain. She explains that the earlier he can put a bit of weight on his foot and walk on it without increasing his pain, the faster it will heal. To finish his first treatment, she applies electrical stimulation and an ice pack to the ankle. Before Travis leaves the clinic, she wraps his ankle with an elastic wrap to reduce and prevent further swelling.

At his next treatment, Travis is able to add more exercises for stretching and balance. By the end of the second week of treatment, he is able to walk normally and does not need crutches. By the end of the third week, he is able to run for 10 minutes and perform some jumping drills that his physical therapist teaches him. During the fourth week of treatment, Travis performs some cutting drills during his physical therapy session. At the end of the fourth week, wearing an ankle brace that his physical therapist has recommended, he is able to play 1 quarter in his team's first basketball game of the season, without increased pain.

Travis continues with physical therapy treatments to improve his strength and balance, until he does not need to wear the ankle brace to play in his basketball games anymore, and can play a full game pain free.

After he is discharged from physical therapy, Travis continues to use his home program exercises to warm up before games, and to improve his balance to help prevent reinjury. Just this evening, Travis's jump shot at the buzzer wins the first playoff game of the season!

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients who have an ankle sprain. You may want to consider:

• A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with an orthopaedic focus.
• A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopaedics or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

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General tips when you're looking for a physical therapist (or any health care provider):

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with ankle sprain.
• During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for a visit with their health care provider. The following articles provide some of the best scientific evidence related to physical therapy treatment of your condition. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

1. Hung YJ. Neuromuscular control and rehabilitation of the unstable ankle. World J Orthop. 2015;6(5):434–438. Free Article.
2. McCriskin BJ, Cameron KL, Orr JD, Waterman BR Management and prevention of acute and chronic lateral ankle instability in athletic patient populations. World J Orthop. 2015;6(2):161–171. Free Article.
3. Sefton JM, Yarar C, Hicks-Little CA, Berry JW, Cordova ML. Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2011;41(2):81–89. Free Article.
4. Faltstrm A, Oberg U, Hultman K. The effect of early physiotherapy after an acute ankle sprain: advances in physiotherapy. J Orthop Sports Phys Ther. 2010;12(2):65. Article Summary Not Available.
5. Ismail MM, Ibrahim MM, Youssef EF, El Shorbagy KM. Plyometric training versus resistive exercises after acute lateral ankle sprain. Foot Ankle Int. 2010;31(6):523–530. Article Summary on PubMed.
6. van Ochten JM, van Middelkoop M, Meuffels D, Bierma-Zeinstra SM. Chronic complaints after ankle sprains: a systematic review on effectiveness of treatments. J Orthop Sports Phys Ther. 2010;44;(11):862–871. Free Article.
7. Han K, Ricard MD, Fellingham GW. Effects of a 4-week exercise program on balance using elastic tubing as a perturbation force for individuals with a history of ankle sprains. J Orthop Sports Phys Ther. 2009;39(4):246–255. Article Summary in PubMed.

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