Foot and ankle injuries are among the most common reasons athletes miss time in their sport. These usually result from planting, pivoting or even blunt trauma, which can cause overstretching of the ligaments, sometimes to the point of tearing.
Although injuries of this nature usually only cause an athlete to miss less than 7 days, the long term effects and potential for re-injury may impact their lives for years to come.
To prevent these long-term problems, it is vital to go through the stages of rehab with precise order and timing. Being too aggressive too soon or too conservative too late in the healing process can create poor ligament integrity and lead to chronic instability and increased joint wear.
To insure you are on the right track, timing is everything.
Step 1 – P.R.I.C.E.
The first step to recovery starts with the inflammatory phase. At this point, the body feverishly starts producing various healing factors and directs them to the injury site to begin the healing process. This phase of acute inflammation lasts 48-72 hours. It is during this time that Protection, Rest, Ice, Compression and Elevation (PRICE) should be employed in order to control severe pain. If pain is so extreme that walking even a few steps isn't possible, it is best to seek medical care ASAP. If the pain is manageable, along with PRICE, try doing “ankle pumps" forward/back and side to side. Also attempt “drawing" the alphabet with your foot in the air to improve mobility and reduce swelling.
Step 2 –Light Resistance/ Walking/ Basic Balance
Following the initial 72 hours, continue with active range of motion (AROM) exercises and start resistance exercises with a light resistance band for several days as the pain reduces. Over the next 1-2 weeks start working on restoring normal gait mechanics by using external stabilization devices such as an AirCast or a lace up ankle brace if pain limits normal mechanics. These braces can help reduce pain when walking and should be used only as long as they are needed to do just that. Restoring your normal gait helps increase functional independence and also improves the alignment of newly forming collagen fibers along the long axis of the ligament. Once walking becomes easier, focus on single leg balance training work. Begin with standing on one leg for 30-60 seconds, and try doing it barefoot for added difficulty. Other exercises you can add include heel raises on two feet, squats and step-ups. All of these exercises will continue to restore function while limiting the amount of uncontrolled stress to healing tissue. This is the time to also incorporate light cardio equipment like a stationary bike into your workout.
Step 3- Rotational movement/ Progressive Balance
At this point, it will have been approximately 3-4 weeks since the initial injury and you can begin to introduce rotational movements. To begin adding rotational components, try bouncing or throwing a ball while balancing on one foot. Next, try timing yourself on a balance board and then once again add a component of throwing with 1 and 2 hands to increase body rotation over a stationary foot.
These rotational exercises will mimic the typical direction of stress your ankle will encounter during daily activities and athletic pursuits. It will also encourage maturing collagen fibers to align properly. Feel free to also progress cardio to an elliptical cross trainer to move closer to the demands of running.
Step 4 – Dynamic Exercises
You are now 4-6 weeks since the initial injury and collagen fibers are continuing to mature as the ligament gains strength. This is the time to add in more dynamic exercises such as lateral band walks, eccentric step-downs (see below), lunges and light lateral movements like light shuffling and hopping. It is also appropriate to start jogging progressions at this point. This should be done carefully to make sure compensations and bad habits don't form due to limitations in ROM and strength. If you've been guided through the process by a physical therapist, this is the time they may use slow motion video analysis to assess your running progress and fix any issues before they become larger problems. However, if you've been rehabbing this injury on your own, now may be the time to ask for professional help to limit the risk of re-injury.
Beyond the Rehab
Months after an ankle injury, restoring cutting and jumping movements will ensure full function of the ankle in all planes of motion, allowing you to compete at 100%. Begin with lateral single leg hopping and jumping rope. Later you can transition to more intense lateral planting and cutting and using an agility ladder.
It is important to note that there is evidence that even ligaments that have healed continue to have fibers that are weaker than the original. This means that even if you no longer have pain, you may be more likely to sprain your ankle again. Also, a significant percentage of people with ankle sprains continue to have pain and weakness even 1 year after the injury. This again points to the importance of strengthening the muscles around the ankle to improve stability. Losing time in sports to rehab an injury can be frustrating, but it's important to be patient and not rush the healing process. The time you spend rehabbing at the time of the injury and doing preventative strengthening later is surely time well spent.
Hauser, R. A. (2013). Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics. The Open Rehabilitation Journal, (6), 1-20.Anandacoomarasamy, A. Barnsley, A. (2005). Long term outcomes of inversion ankle injuries. Br J Sports Med, (39) 14, 1-4.
About the Author: Alex Shafiro is the director of physical therapy and wellness at Performance Physical Therapy in Westport CT. He is board certified in orthopedics with specializations in strength and conditioning (CSCS), kettlebell training (SFG-1) and functional dry needling (FDN-2). Blending manual therapy with exercise prescription, Alex works with each patient to restore and elevate their level of function based on their fitness and life goals.
