About 25,000 people sprain their ankle every day, and in most of these incidents, sports are involved. Ankle sprains represent the most common injury in sports, as they account for a whopping 45% of all sports–related injuries. But this risk varies widely between sports, with football, basketball, and soccer being associated with the highest rates of ankle sprains because they involve high speeds and frequent changes in direction. In football, for example, ankle sprains occur at a rate of 1/1,000 hours, meaning that one ankle sprain occurs for every 1,000 hours of participation.

These statistics may seem daunting, but a recently published review has shown, most ankle sprains can be effectively treated with a conservative treatment program that involves evidence–based rehabilitation.

Ankle anatomy and grading system

Ankle sprains involve the ligaments of the ankle joint, which are flexible bands of tissue that connect one bone to another. Ligaments are elastic and can be stretched to a certain length and then return to their original position, but they have a limit. When any ankle ligament is stretched beyond its maximum range of motion, damage will occur, and the result is an ankle sprain. Ankle sprains are generally categorized into the following three groups:

• Grade 1 (mild): ligament(s) stretched but there is no tear; symptoms involve mild pain and tenderness, some swelling and stiffness
• Grade 2 (moderate): most common type of sprain; ligament(s) partially torn; symptoms include significant swelling and bruising, moderate pain, and trouble walking
• Grade 3 (severe): ligament(s) completely torn; symptoms involve severe swelling and pain, especially while walking, instability of joint, extreme loss of motion, possible difficulty bearing weight on foot

Depending on its location in the ankle, a sprain can be further categorized as either lateral, medial, or high. Lateral ankle sprains take place on the outside part of the ankle, which is the most common site for a sprain (about 80% of all sprains). High ankle sprains are less common (up to 15% of sprains) and are often seen in football, downhill skiing, and other field sports, while medial sprains are the least common (about 6%).

Most patients will make a complete recovery after sustaining an initial ankle sprain, but up to 70% of those who experience a lateral ankle sprain will go on to develop chronic ankle instability. Patients with this condition experience changes in the function of their nervous system that may lead to decreased postural control, joint position awareness, and more ankle instability. The combined result of these changes is an increased risk for recurring pain and other symptoms, as well as greater odds for sustaining a second ankle. And with each additional sprain, the risk continues to rise.

Appropriate rehabilitation is key to successful outcomes

This underlines the importance of proper treatment after the first ankle sprain, which can significantly reduce the risk for chronic ankle instability. Fortunately, most ankle sprains can be effectively treated with conservative (nonsurgical) interventions, and patients can expect to experience good to excellent outcomes when following this approach. One of the only possible exceptions is grade 3 lateral ankle sprains, as surgery may be beneficial for some elite athletes dealing with this injury to accelerate their recovery; however, conservative treatment is still preferred over surgery in most cases.

Physical therapy is generally regarded as the best way to deliver conservative treatment to patients, since therapists utilize individualized and evidence–based rehabilitation programs to achieve the highest level of care. Ankle sprain rehabilitation typically begins with alleviating swelling and further injury during the initial inflammatory phase of recovery, which is achieved with the POLICE (protect, optimal loading, ice, compression, elevation) protocol for the first 2–7 days. Short–term immobilization with a removable cast or boot may also be helpful for severe ankle sprains during this period. After inflammation has subsided, patients are advised to wear an ankle brace and will begin an exercise therapy program, which typically includes early active range of motion exercises, followed by strengthening exercises, proprioceptive training, and functional exercises. Exercises should simulate the physical demands of the patient’s sport and become more challenging as the program progresses.

After an ankle sprain, the top concern of most patients is when they will be able to return to their respective sport. But unfortunately, this decision is often difficult, as returning a player too soon can lead to residual disability and additional injuries in the future. Therefore, it is the physical therapist’s responsibility to ensure that athletes do not return too soon by ensuring that certain functional markers are met.

There are currently no formal criteria to clearly determine when an athlete is ready to return to sports, but several tests can be used to assist in this decision. When analyzing patients, therapists must ensure that all functional limitations from the sprain have been restored, cardiovascular fitness is equal to or greater than pre–injury status, and that there is no apprehension from the athlete or other members of the rehabilitation team concerning their safety. For patients with a history of ankle sprain, extra caution is required since the risk for chronic ankle instability is higher.

All patients must also recognize that although an extended recovery can be frustrating, taking the adequate time to heal and recover will increase their chances of long–term success. We will work to manage your expectations and ensure that you’re getting back to the field or court as quickly, but also as safely, as possible