Lateral Ankle Sprain Rehab

The purpose of this blog is to discuss the best exercises for a sprained ankle from the time of injury to return to sport.

Looking to improve the strength, range of motion, and stability of your ankles to enhance your function and performance? Check out our Ankle Resilience program!

Lateral Ankle Sprain

A lateral ankle sprain occurs when you twist or roll your ankle inward at a high speed. The ligament usually involved is the anterior talofibular ligament, or ATFL, and sometimes the calcaneofibular ligament, or CFL. Both ligaments attach to the fibula, the bone located on the outer part of your ankle.

Lateral ankle sprains are typically graded on a scale from 1 to 3. Grade 1 is a mild injury with a relatively quick return to activity. Grade 2 is a moderate injury with a slightly longer recovery. Grade 3 is a severe injury that takes the longest to rehabilitate. Generally speaking, a grade 3 injury will also present with the most swelling and bruising.

Additionally, after any traumatic injury to the foot or ankle, the Ottawa Ankle Rules will be used by a healthcare professional to rule out the possibility of a fracture. They’ll assess if you have the ability to walk four steps or have tenderness at specific bones – the lateral malleolus, base of the 5th metatarsal, medial malleolus, and navicular.

Regardless of the degree of injury, proper rehab is crucial. A systematic review by Wikstrom et al in 2021 concluded that “there is strong evidence to support that a previous lateral ankle sprain increases the risk of a subsequent lateral ankle sprain injury.” On top of that, a prospective study by Doherty et al in 2016 found that up to 40% of individuals develop chronic ankle instability (CAI) after a first time ankle sprain.

Early Lateral Ankle Sprain Rehab

In the case of an acute ankle sprain, there are 3 main goals:

1. Minimize swelling
2. Improve ankle function for day-to-day tasks
3. Normalize walking

Minimizing or reducing swelling does not involve complete rest for an extended period of time and constant icing like formerly believed. You do want to protect the injured tissues, especially within the first 1-3 days so they can heal appropriately, but you don’t necessarily need to avoid all movement. A simple rule of thumb is that if walking or specific exercises are significantly increasing your pain or swelling, you’re probably doing too much and need to scale back. 

Crutches might be required early on in some cases if walking without them is not tolerable. Elevation and compression may also be used when you’re lying around to help with swelling. 

The following exercises can be implemented if they do not increase swelling or exacerbate symptoms.

• Active Range of Motion. Start with comfortable ankle pumps by moving your foot up and down. Over time, you can add in ankle circles or ankle ABCs, in which you practice spelling out the alphabet. Feel free to add in movement of the toes as well. All of these can be performed as much as you want throughout the day as long as they’re tolerable.

• Ankle Strengthening. You’ll start by resisting a band into ankle dorsiflexion (bringing your foot up) and plantar flexion (pointing your foot down). Eversion (rotating the sole of your foot outward) will be next. Inversion (rotating the sole of your foot inward) will likely be last because it stresses the ligaments initially injured. 3-4 sets of 20-25 repetitions is a simple starting point for each exercise.

• Single Leg Balance. Whenever you’re ready, you can practice standing on one leg with or without the use of your hands for assistance. You can work up to a few sets of a minute, or build it into your day while brushing your teeth and doing things in the kitchen.

As you increase the time spent on your feet standing or walking, continue to minimize increases in swelling and pain. Squats, step ups, heel raises, and other exercises will gradually be incorporated, and I’ll discuss those within each exercise progression shortly.

Exercise Overview

In 2021, Smith et al introduced the PAASS framework, which is a group of items that the authors recommend assessing after a lateral ankle sprain prior to returning to sport. These items are

• Pain severity 
• Ankle impairments, including range of motion, strength, endurance, and power
• Athlete perception, such as your perceived confidence and readiness
• Sensorimotor control, including proprioception and dynamic balance
• Sport/functional performance, such as hopping, jumping, and sport-specific activities

I’m going to outline a comprehensive program that’s meant to address these items. Within each exercise category, I’ll provide two exercise progressions, so that you have two different workouts that you can follow.

Please understand that this information needs to be tailored to your individual symptoms, function, and goals. Timelines will vary significantly between people, and not everyone will want or need to perform every single exercise that I’m going to describe.

Category 1: Single Leg Strength (Knee Focus)

Option #1: Step Down Progression

Level 1 – Step Up. Use a stair or objects stacked 6-7 inches high. Don’t push off with the back leg. Focus on putting all of your weight through the working leg and just gently tap up and down with your other heel. If it’s too difficult, decrease the height or use your hands for assistance. Aim for 3 sets of 20 reps per leg.

Level 2 – Lateral Step Down. Same exact cues except this movement will allow for a little more knee travel. Aim for 3 sets of 20 reps per leg.

Level 3 – Forward Step Down or Elevated Lateral Step Down. You can either step forward off the step or continue to perform the lateral step down while gradually increasing the height of the step. Aim for 3-4 sets of 8-15 slow and controlled reps per leg.

Option #2: Split Squat Progression

Level 1 – Bodyweight Squat. Gently tap your butt to a chair and stand back up. If it’s too challenging or painful, shorten the range of motion or use your hands for assistance. Aim for 3 sets of 20 repetitions.

Level 2 – Split Squat. Start in a stride stance and lower yourself down so that your back knee taps an egg that you don’t want to crack. If it’s too difficult for your front or back leg, shorten the range of motion or use your hands for assistance. Aim for 3 sets of 15 reps.

Level 3 – Front Foot Elevated Split Squat. Elevate the front leg using a 2-4” object to start. Drive your knee as far forward as tolerable. Aim for 3-4 sets of 8-15 slow and controlled reps. Add weight as needed.

Category 2: Single Leg Strength (Hip Focus)

Option #1: Single Leg RDL

Stand on one leg while keeping a slight bend in both knees, hinge at your hips until your trunk is almost parallel with the ground, and then return to the starting position. Repeat this movement without touching your foot to the ground. If this is too challenging, use your hands to help with balance, shorten the range of motion, or tap your foot to the ground. Aim for 3-4 sets of 8-15 slow and controlled reps. Add weight as needed.

Option #2: Hip Thrust Progression

Level 1 – Double Limb Bridge. Lie on your back, bridge up, squeeze your glutes, lower yourself down, and repeat. Aim for 3 sets of 20 reps.

Level 2 – Single Limb Bridge. Aim for 3 sets of 15 reps.

Level 3 – Single Limb Hip Thrust. Aim for 3-4 sets of 12-15 slow and controlled reps. Add weight as needed.

Category 3: Heel Raises

Option #1: Straight Knee Heel Raise Progression

Level 1 – Double Leg Heel Raises on Flat Ground. Aim for 3 sets of 25 slow and controlled reps. Use your hands for balance as needed.

Level 2 – Single Leg Heel Raises on Flat Ground. Aim for 3 sets of 15 reps.

Level 3 – Single Leg Heel Raises on a Step. Aim for 3-4 sets of 8-15 reps. Over time, you can add weight as needed.

Option #2: Bent Knee Heel Raise Progression

Level 1 – Seated Heel Raises on Flat Ground. Aim for 3 sets of 8-15 slow and controlled reps.

Level 2 – Deficit Seated Heel Raises. Aim for 3-4 sets of 8-15 reps.

You can use a barbell, smith machine, dumbbells, or seated heel raise machine.

Category 4: Dynamic Balance

Option #1: Y Balance

Set up tape, cones, or imagine standing on an upside down Y. Stand on one leg and reach in each direction of the Y. Try not to put any weight through the foot that is tapping the ground. Start with small reaches and gradually increase the distance as your balance improves. Begin with 3 sets of 30 seconds each and work up to 60 seconds.

Option #2: Standing Rotation

Stand on one leg, rotate your torso as far as you can in one direction, and then rotate as far as you can in the other direction. Start with small rotations for 3 sets of 30 seconds each and work up to your full range of motion for sets of 60 seconds. If you master that, you can add in resistance with a band or medicine ball throws in both directions.

Additional Exercise Considerations

Although I’m simplifying the names of the categories, each exercise progression serves multiple purposes. For example, the forward step down will increase hip and knee strength, but it’ll also improve ankle dorsiflexion range of motion and single leg balance.

The exercises up to this point are sufficient for the purposes of many people, but others will need to include plyometrics, or want to include additional mobility and balance options. Therefore, here are 3 more optional exercise categories.

Optional Plyometrics

Option #1: Hopping

Start by hopping in place on 2 legs with your hands on your hips and eyes looking straight ahead. You want to spend as little time on the ground as possible. Progress to hopping forward and backward before moving on to hopping side to side. You’ll then work through the same progression on a single leg. Aim for 3 sets of 30 to 60 seconds per leg. You can make the exercise more challenging by hopping higher or further.

Option #2: Jumping

Start by performing a submaximal jump on 2 legs before progressing to a maximal vertical jump on 2 legs. Do your best to stick the landing. Then work on a submaximal jump on 1 leg before progressing to a maximal vertical jump on 1 leg. You can then practice jumping forward, side to side, and diagonally. Aim for 3 sets of 6-8 reps each.

Optional Ankle Mobility

Option #1: Calf Stretch

As part of a dynamic warmup, you can perform an inchworm by starting in a plank position, slowly walking your feet toward your hands, and driving your heels into the ground so you feel a stretch in your feet, calves, and hamstrings. Reset your position and repeat for a few reps.

If you’re driving your knee forward during the split squats and step downs, and using as much range of motion as possible during the deficit knee bent heel raises, you likely don’t need to add anything extra for dorsiflexion mobility.

Option #2: Plantar Flexion Mobility

Start with quadruped rock backs, progress to tall kneeling rock backs, and end with half kneeling rock backs. Keep them comfortable and stick to 1-3 sets of 10-15 reps each.

Optional Static Balance

If you mastered the single balance mentioned earlier, you can progress the exercise in one of 4 ways:

1. Add an unstable surface
2. Close your eyes
3. Pass a kettlebell back and forth between your hands, toss a tennis ball against the wall, or find another fun challenge
4. Use a combination of the choices

Programming

Assuming you’re out of the very acute phase of rehab, how do you put all of this information together?

Set up your week with two training days with at least 2 days of rest between each workout. On day 1, perform the step downs, single leg RDLs, straight knee heel raises, and Y balance. On day 2, perform the split squats, hip thrusts, bent knee heel raises, and standing rotations. 

If you’re including the optional plyometrics, put them at the start of each workout.

If you’re including the optional static balance exercises, put them at the end of each workout. 

The inchworm can be used as a dynamic warm up and the rock backs can be placed at the beginning or end of a workout.

Although I didn’t list specific progressions for them, you can continue to incorporate dorsiflexion and eversion strengthening with bodyweight, bands, plates, or other equipment.

If you’re an athlete returning to sport, you might include cardiorespiratory exercise, practice, or sport-specific training on some of the other days.

Although I have tried to be as comprehensive as possible with the programming in this blog, remember that you still need to modify this information to fit your individual needs and goals.

Get Walking

In addition to everything I’ve already mentioned, I can’t emphasize enough the importance of walking. It’s not uncommon for general physical activity to significantly decrease after an injury and stay lowered over time. Strive for an eventual goal of at least 30 minutes of dedicated walking per day. It can be helpful to track your steps to see how your step count is trending over the course of weeks and months.

Bracing

A systematic review by Doherty et al in 2017 concluded that “there is strong evidence for exercise therapy and bracing in preventing recurrence of an ankle sprain.” In addition to reducing the risk of an ankle sprain, braces aid in reducing the severity of an injury. Lace-up ankle braces are preferred, and are recommended for a minimum of 6 months and up to 1 year following an ankle sprain.

Summary

In summary, a lateral ankle sprain occurs when you twist or roll your ankle inward at a high speed. The ligament usually involved is the anterior talofibular ligament, and sometimes the calcaneofibular ligament.

In the case of an acute ankle sprain, you want to minimize swelling, improve ankle function for day-to-day tasks, and normalize walking. As you gradually load the area, use a simple rule of thumb – if walking or specific exercises are significantly increasing your pain or swelling, you’re probably doing too much and need to scale back. Crutches and/or bracing may be needed.

As you progress through your rehab, you want to include exercises that address any ankle impairments, including range of motion, strength, endurance, and power, sensorimotor control, such as proprioception and dynamic balance, and sport/functional performance, including hopping, jumping, and sport-specific activities. You also want to have minimal to no pain, good confidence in your ankle, and no feelings of instability before fully returning to sport or your desired activities.

Lastly, don’t underestimate the power of walking. Track your steps and gradually do a little more each week.