Ankle Sprain Rehabilitation Guideline

This rehabilitation program is designed to return the individual to their activities as quickly and safely as possible. It is
designed for rehabilitation following Ankle Sprain. Modifications to this guideline may be necessary dependent on physician
specific instruction, specific tissue healing timeline, chronicity of injury, and other contributing impairments that need to be
addressed. This evidence-based Ankle Sprain Guideline is criterion-based; time frames and visits in each phase will vary
depending on many factors including patient demographics, goals, and individual progress. This guideline is designed
to progress the individual through rehabilitation to full sport/activity participation. The therapist may modify the program
appropriately depending on the individual’s goals for activity following Ankle Sprain. This guideline is intended to provide
the treating clinician a frame of reference for rehabilitation. It is not intended to substitute clinical judgment regarding the
patient’s post injury care, based on exam/treatment findings, individual progress, and/or the presence of concomitant injuries
or complications. If the clinician should have questions regarding progressions, they should contact the referring physician.

General Guidelines/ Precautions:

General healing timeline is variable but can expect 2-6 week time frame on average
During the acute phase, avoid activities that stress the ligaments on the
lateral or medial surface of the foot (depending on MOI)
1. Laterally (most commonly injured): Anterior Talofibular Ligament, Posterior Talofibular Ligament, Calcaneofibular ligament
2. Medially (less commonly injured): Superficial and Deep Deltoid Ligaments
3. Syndesmotic: See “High Ankle Sprain” rehabilitation guideline
General ROM/strength present at the beginning of rehabilitation is highly variable
Patient is at risk for recurrent ankle sprains and development of chronic ankle instability
Rule out fracture and/or need for further imaging through utilization of the Ottawa
Ankle Rules (exclude children under 6 or pregnant women)
1. Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
2. Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
3. Bone tenderness at the base of the fifth metatarsal and/or navicular
4. An inability to bear weight both immediately and in the emergency department for four steps
Avoid activities which increase pain and/or swelling

Sanford Total Ankle Arthroplasty Physical Therapy Post-Operative Guidelines

WEEK SUGESSETED INTERVENTIONS GOALS

Phase I Discuss: Goals of Phase:

Protection Phase Anatomy, existing pathology, rehab schedule, and expected progressions. 1. Diminish pain and inflammation
Specific Instructions: Do not perform activities that increase pain and/or 2. Improve flexibility and range of motion
swelling

0-2 Suggested Treatments: Criteria to Advance

Weeks • Modalities as indicated: Ice, compression, elevation, electrical stimulation to Next Phase:
• ROM: PROM, AAROM, AROM within pain free range 1. Normal gait pattern without
use of assistive device
• Protection: Protect ligaments from further trauma through use of taping,
splinting, orthotics, braces, or casts in severe instances based on clinical 2. Edema reduction with comparable
judgement and patient presentation circumferential measurements
+- 1-3 cm to opposite extremity
• WBAT: Utilize assistive device as deemed appropriate for normalization of
gait pattern
 WEEK SUGESSETED INTERVENTIONS GOALS

0-4 Expected Exercise Examples:

Sanford Total Ankle Arthroplasty Physical Therapy Post-Operative Guidelines
Visits • Ankle alphabet
• PROM in all ankle planes
• Gastroc/soleus stretching
• Gait training with various AD’s progressing to no AD based on pain level
• Modalities for pain relief and edema control
Other Activities:
May perform core, hip, and knee strengthening exercises for proximal stabilization if
deemed appropriate

Phase II Specific Instructions: Goals of Phase:

Progressive Do not perform exercises that increase pain and/or swelling 1. Improve muscular strength
ROM and Early Suggested Treatments: and endurance
Strengthening 2. Progress to full active
and passive ROM
3. Improve total body
proprioception and control

1-3 Weeks Modalities as indicated: Edema and pain controlling treatments Criteria to Advance to Next Phase:
1. Normal gait pattern without
ROM: AROM Strengthening: Isometric, eccentric, or concentric exercises in pain free
2-6 Expected use of assistive device
range with/without weight bearing as deemed appropriate
Visits 2. Edema reduction with comparable
Manual therapy: talocrural and subtalar joint glides for improved DF/PF and general
ankle mobility circumferential measurements
+- 1-3 cm to opposite extremity
Exercise Examples:
• DF/PF/Inv/Ev theraband exercises in pain free range
• Foot intrinsic strengthening
• Ankle Isometrics
• Squats stable surface
• Lunges stable surface
• Calf Raises
• Toe Raises
• Single leg stance with stable/unstable surface and eyes open/eyes closed
• BAPS board (*utilize seated if not able to tolerate standing)
• Rocker board
• Treadmill walking
• Biking
• Pool Program
Other Activities: Progress core, hip, and knee strengthening exercises with focus on
stabilization if deemed appropriate

Phase III Specific Instructions: Goals of Phase:

Advanced Continue with previous exercise program; ensure core/hip stability; symmetrical 1. Return to strength training with
Strengthening & strength of 5/5 should be present in both hip abductors and extensors appropriate modifications
Neuromuscular Modalities only as needed 2. Improve muscular power, speed,
control agility, and neuromuscular control
If no sport to return to, consider option of independent
program after completion of this phase 3. Improve proper body mechanics
and movement patterns
2-6 Weeks Suggested Treatments:
Manual Therapy: Soft tissue work, talocrural and 4. Increase overall proximal stability
4-16 Expected subtalar glides for improved ankle mobility. Criteria to Advance to the Next Phase:
visits Exercises: Strengthening, proprioceptive, and beginner agility/power exercises 1. Ankle strength within 90%
of uninvolved ankle with
Exercise Examples:
pain free ankle eversion
• Standing BAPs board
on resisted isometric
• Treadmill running with varying inclines
2. Able to perform light running
• Resisted side stepping with no gait abnormalities
• BOSU squats 3. Able to SLS for 1 minute without
• BOSU lunges loss of balance on involved limb
• Front/side plank with progressions
• Bridging with progressions
• Double leg hopping forward, backward, sideways
• Dry land jogging/running
Other Activities: Begin practice with sport activity in controlled environment
with additional support as deemed necessary (ex. Taping, braces)
 WEEK SUGESSETED INTERVENTIONS GOALS

Phase IV Specific Instructions: Goals of Phase:

Return to Sport • Continue previous exercise program 1. Progression of agility and
Suggested Treatments: strengthening exercises to more
3-8 Weeks Modalities: Relief of exercise related muscle soreness through e-stim and cryotherapy closely replicate movements
performed during sport activity
Manual Therapy: Soft tissue work, talocrural and subtalar glides
6-12 Expected 2. Development of individualized
visits Exercises: High level strengthening, power, and agility based exercises
maintenance program in
Exercise Examples: preparation for discontinuation
• Single leg hopping forward, backward, sideways of formal rehabilitation
• Single leg and double leg dot drills with various patterns 3. Eliminate possible fear of
• Agility ladder exercises movement and/or re-injury through
use of graded introduction of higher
• Box jumps
level agility and power exercises
• Depth jumps over obstacle/hurdle
Criteria for Return to Sport:
• Single leg bounding
1. Demonstration of safe
• Unstable surface landing strategies movement patterns and
• Sprinting, shuffling, backwards running neuromuscular control with
• Sport specific agility/plyometric training higher level agility exercises
Other Activities: Return to sport practice in more unpredictable environment in a 2. Pain free completion of exercise
graded manner with additional support as deemed necessary (ex. Taping, braces) program with no observed
episodes of instability

REFERENCES:
1. Garrick JG. The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am J Sports Med. 1977;5:241-242.
2. Hockenbury, RT, Sammarco, GJ. Evaluation and treatment of ankle sprains: Clinical recommendations for a positive outcome. The Physician and Sportsmedicine [online].
2001;29(2).
3. Hubbard TJ, Cordova M. Mechanical instability after an acute lateral ankle sprain. Arch Phys Med Rehabil. 2009;90:1142-1146.
4. Willems T, Witvrouw E, Verstuyft J, Vaes P, De Clercq D. Proprioception and muscle strength in subjects with a history of ankle sprains and chronic instability. J Athl Train.
2002;37:487-493.
5. Van Os AG, Bierma-Zeinstra SM, Verhagen AP, de Bie RA, Luijsterburg PA, Koes BW. Comparison of conventional treatment and supervised rehabilitation for treatment of acute
lateral ankle sprains: A systematic review of the literature. J Orthop Sports Phys Ther. 2005;35:95-105.
6. Bullock-Saxton JE. Local sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther. 1994;74:17-28; discussion 28-31.
7. Johnston EC HS. Tension neuropathy of the superficial peroneal nerve: Associated conditions and results of release. Foot and Ankle International. 1999;20(9):576.
8. Docherty CL, Moore JH, Arnold BL. Effects of strength training on strength development and joint position sense in functionally unstable ankles. J Athl Train. 1998;33:310-314.
9. Rozzi SL, Lephart SM, Sterner R, Kuligowski L. Balance training for persons with functionally unstable ankles. J Orthop Sports Phys Ther. 1999;29:478-486.
10. Wester JU, Jespersen SM, Nielsen KD, Neumann L. Wobble board training after partial sprains of the lateral ligaments of the ankle: A prospective randomized study. J Orthop
Sports Phys Ther. 1996;23:332-336.
11. Willems T, Witvrouw E, Verstuyft J, Vaes P, De Clercq D. Proprioception and muscle strength in subjects with a history of ankle sprains and chronic instability. J Athl Train.
2002;37:487-493.12. Zoch C, Fialka-Moser V, Quittan M. Rehabilitation of ligamentous ankle injuries: A review of recent studies. Br J Sports Med. 2003;37:291-295.

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