An ankle sprain often feels like an injury you should simply wait out. Rest it. Ice it. Stay off it for a few days. Start walking again when it hurts less. For many people, that works well enough in the short term. The problem is that an ankle can stop hurting before strength, balance and stability have fully recovered. Research suggests that a substantial percentage of people continue to experience pain, recurrent sprains, reduced function or a sense that the ankle “gives way” long after the original injury.[1-3] That is one reason physical therapists take ankle sprains more seriously than many patients do.
Ankle Sprains Are Common, and Often Undertreated
Ankle sprains are among the most common musculoskeletal injuries. A large systematic review estimated an incidence of roughly 10 ankle sprains per 1,000 people each year.[1] Many never make it into a clinic. Research has suggested that only about half of people with ankle sprains seek professional medical care, and supervised rehabilitation is used in only a minority of cases.[2] That may be because most ankle sprains do improve. Improvement, however, is not always the same thing as complete recovery.
Studies have found that lingering problems can include:
Recurrent ankle sprains
Persistent pain
Reduced strength
Poor balance
A feeling of instability or “giving way”
Difficulty returning fully to sports or exercise
Limitations in everyday activities
An international consensus review concluded that more than 40% of people may develop some degree of chronic ankle instability following a lateral ankle sprain.[3]
Is a Handout Enough?
One practical question researchers have asked is whether patients really need supervised rehabilitation, or whether written instructions and a home exercise program can accomplish the same thing.
Kristin Gustafsson and colleagues studied that question by comparing people with acute ankle sprains who received therapist-supervised rehabilitation with patients who received written instructions for functional rehabilitation.[4] The researchers assessed recovery using the Foot and Ankle Outcome Score, a measure that includes pain, symptoms, daily function, sports and quality of life. At both six weeks and six months, the patients who received only written instructions had significantly worse scores for several outcomes, including physical ability and satisfaction, than those receiving supervised rehabilitation.[4]
That does not mean every ankle sprain requires weeks of in-clinic treatment. It does suggest that simply giving someone exercises to perform may not always produce the same result as having a physical therapist assess the ankle, progress the exercises and respond to what happens during recovery.
Why Do Studies Sometimes Reach Different Conclusions?
Research on ankle sprain rehabilitation can look inconsistent at first.
One large randomized trial published in the BMJ, for example, did not find a clinically important advantage from adding a particular supervised physiotherapy program to usual care for simple ankle sprains.[5] The details matter. Rehabilitation programs vary considerably from study to study. Some begin early. Some start later. Some include only a few supervised sessions. Others provide substantially more treatment. Programs also differ in how much they emphasize strength, mobility, balance, joint movement and progressively challenging activity.
That may explain why simply asking whether “physical therapy works” is not very informative.
The more useful question is “what kind of rehabilitation is being provided, when it begins and whether it addresses the problems that make ankle sprains likely to recur.”
Balance Training Is a Big Part of Ankle Rehabilitation
One of the most important pieces of ankle rehabilitation is something many people would never think to work on after a sprain: proprioception. Proprioception is your body’s ability to sense where a joint is and what it is doing without looking at it. After an ankle sprain, that system can be impaired. A person may have enough strength to walk normally but still react too slowly when stepping on an uneven surface, landing from a jump or suddenly changing direction.
Physical therapists often use progressively challenging balance exercises to retrain this system. That might begin with standing on one leg and eventually progress to unstable surfaces, reaching activities, jumping, landing and sport-specific movements. Research reviews have found that exercise programs incorporating balance and neuromuscular training can reduce the risk of recurrent ankle sprains.[6]
Early Movement May Also Be Helpful
For many uncomplicated grade I and grade II ankle sprains, rehabilitation can begin surprisingly early. Research has supported early functional movement and progressive loading rather than prolonged immobilization for many lateral ankle sprains.[7,8] Early treatment does not mean ignoring the injury. The amount of weight bearing, movement and exercise should be appropriate for the severity of the sprain. More serious injuries may require protection, bracing or additional medical evaluation. For an uncomplicated sprain, however, complete inactivity is usually not the long-term goal. A physical therapist may work on restoring ankle motion, strength and normal walking while gradually increasing the amount of stress the healing ankle can tolerate.
The Goal Is to Keep It From Becoming “That Ankle”
Almost everyone knows someone who says, “I always roll this ankle.” Often, the story began with a sprain years earlier. The pain eventually disappeared, daily walking became comfortable, and rehabilitation stopped there. Some remaining combination of weakness, reduced mobility and impaired balance then made future sprains easier. A good ankle rehabilitation program aims beyond making the pain disappear. The goal is to restore enough mobility, strength, balance and control that the ankle is prepared for the person’s actual life, whether that means walking across a yard, working on their feet, hiking, running or returning to competitive sports.
When Should You Consider Physical Therapy?
An ankle sprain deserves professional evaluation when pain or swelling is substantial, walking is difficult, symptoms are not improving as expected, or you are uncertain whether the injury may be more serious than a sprain. Physical therapy can also be valuable when the ankle is beginning to feel better but has not regained normal strength, mobility or confidence. That may be the most important time to remember that pain is only one measure of recovery.
An ankle that no longer hurts can still have work left to do.
Sources
Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med. 2014;44(1):123-140.
Feger MA, Herb CC, Fraser JJ, Glaviano N, Hertel J. Supervised rehabilitation versus home exercise in the treatment of acute ankle sprains: a systematic review. Clin Sports Med. 2015;34(2):329-346.
Gribble PA, Bleakley CM, Caulfield BM, et al. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med. 2016.
Gustafsson K, Fältström A, Öberg U, Kammerlind AS. Written instructions versus physiotherapist-supervised rehabilitation after acute ankle sprain. Eur J Physiother. 2017;19(2):76-83.
Brison RJ, Day AG, Pelland L, et al. Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. BMJ. 2016;355:i5650.
Doherty C, Bleakley C, Delahunt E, Holden S. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. Br J Sports Med. 2017;51(2):113-125.
Karlsson J, Lundin O, Lind K, Styf J. Early mobilization versus immobilization after ankle ligament stabilization. Scand J Med Sci Sports. 1999;9:299-303.
Dettori JR, Pearson BD, Basmania CJ, Lednar WM. Early ankle mobilization. Part I: the immediate effect on acute lateral ankle sprains. Mil Med. 1994;159:15-20.
