Lateral Ankle Sprain Rehab
The ankle is the most commonly injured joint in soccer and most other sports. Ankle injuries make up 11-23% of all injuries recorded during FIFA competitions. The rate of ankle injuries in recreational, amateur players, and children is even higher, representing 35% of all injuries. Most ankle injuries involve a sprain of the lateral ligament complex on the outside of your ankle.
Lateral ligament sprains and peroneal tendon injuries generally occur after an ankle inversion injury or rolled ankle. This may occur when planting to shoot, tackling, cutting, playing on a slippery or lumpy field, or with contact from an opponent. Deltoid ligament injuries involving the inside or medial part of your ankle, and high ankle sprains (syndesmosis injuries) are covered in separate posts.
It has been estimated that the reinjury rate following an inversion ankle sprain may be as high as 80%, which is why it is important to fully rehab the injury prior to returning to play.
Grade 1: Stretching or slight tearing of the ligament with mild tenderness, swelling and stiffness. The ankle feels stable and it is usually possible to walk with minimal pain.
Grade 2: A more severe sprain, but incomplete tear with moderate pain, swelling and bruising. Although it feels somewhat stable, the damaged areas are tender to the touch and walking is painful.
Grade 3: This is a complete tear of the affected ligament(s) with severe swelling and bruising. The ankle is unstable and walking is likely not possible because the ankle gives out and there is intense pain.
Higher grade sprains will typically take more time and intensive rehab to recover.
The vast majority of all ankle ligament injuries will be managed without surgery.
(There is some controversy regarding the management of lateral ligament injuries with grade 3 sprains. A recent Cochrane review did not find any evidence to favor surgery for these injuries. Current research favors a three month period of conservative treatment for all levels of athlete.)
When should you get an x-ray?
The Ottawa Ankle Rules determine the need for x-rays with acute ankle injuries. This screening tool is very effective in ruling out patients who do not have a fracture and is useful for avoiding unnecessary imaging. A patient who presents with none of these symptoms is less than 1% likely to have a fracture.
Ottawa Ankle Rules
X-rays if you have pain in ankle region and
Bone tenderness at the posterior edge of the medial/lateral malleolus (see picture), or
Inability to put weight on your foot right after the injury for 4 steps
X-rays if you have pain in the midfoot and
Bone tenderness at the base of the 5th or navicular bone (see picture), or
Inability to put weight on your foot right after the injury for 4 steps
If you have excessive swelling after the injury it may be wise to get it checked out.
If you are unsure at all, use crutches and go see a healthcare professional.
Risk Factors
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This is the biggest risk factor/predictor of future injury. This applies to most injuries including hamstring strain, ACL tear, etc.
The risk increases with the number of previous injuries and is the highest during the first 6 months after injury.
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There are many studies showing a link between increased BMI and ankle sprain. One study found that overweight players who had a previous ankle sprain were 19x more likely to sustain an ankle sprain compared to a normal weight player with no history of ankle sprains.
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Athletes who are fully or even partially compliant with warm up and proprioceptive training programs have substantially reduced risk of lower limb injuries.
I recommend completing some sort of warm up before all training sessions and matches. The Fifa 11+ is a good start.
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These along with high arches and asymmetrical ROM/strength may increase risk of ankle sprain.
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One study found reduced hip strength (≤33.8% body weight) more than doubled the risk of noncontact lateral ankle sprains in male soccer players.
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There is very likely a fatigue risk factor, as there are more injuries later in each half of a game.
One study found that >50% of injuries were sustained during the last third of each half of the match.
Make sure not to neglect endurance training in your ankle rehabilitation program.
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There is some evidence for increased risk with poor field conditions, artificial grass, or improper footwear.
Footwear Recommendations
AG/conical studs on artificial grass surfaces to avoid cleats sticking in the turf.
FG for natural grass.
SG for soft, wet surfaces to improve traction and reduce slipping.
I have found the Anti-Clog technology in Nike cleats works very well in preventing grass/mud from sticking to the bottom of the cleats.
Here is a picture of my SG anti-clog cleats right after playing on a wet, muddy field.
Rehab and return to play
Many players return to play far too soon after a sprain. There is strong evidence that athletes have a twofold risk for re-injury after ankle sprain, especially during the first year post-injury. We will cover the different phases of recovery below.
Phase 1 - Acute Phase (0-3 weeks)
(Exercises should be performed at least 2x/week, ideally more often in the early phases. These are general guidelines, rehab protocols are never one size fits all. Some athletes will progress much faster and others more slowly. If you have a low grade sprain or these exercises become too easy, move onto the next phase.)
Goals for this stage:
Reduce swelling/pain
Normal walking/weight bearing
Restore motion
Begin strengthening
Protect the ankle
Reduce swelling
Movement - this is most important at this stage. If you have excessive swelling, you may ice, compress, elevate, etc.
Ice as needed for pain
Compression wrap/sock
Elevate above the heart
Normal weight bearing and walking
Early motion and weight bearing for acute ankle sprains has been shown to significantly increase ankle range of motion and decrease pain and swelling sooner than immobilization.
Carry on with normal activities such as walking, using stairs, and squatting as long as the pain is not severe.
Try to avoid activities that excessively aggravate symptoms at this time, which could include running, jumping, cutting, uneven ground, etc.
Restore motion
Strengthening
(I prefer multiple sets with higher reps at this stage. Whatever set/rep range you choose, make sure you are challenging the muscles enough and going near failure.)
Ankle band exercises
Strengthen all directions, especially the peroneal tendons on the outside of your ankle that provide dynamic ankle stability.
Make sure to perform eversion/inversion with toes pointed down as well. The ankle is less stable here and this is typically the position where sprains occur.
Protect the ankle
While you do want to begin moving again as soon as possible, you should still try to avoid higher level activities in the acute phase if they are aggravating.
Most athletes will not need a walking boot, but you may use crutches initially and weight bear as tolerated.
In most cases I recommend wearing a brace if you are going to be walking on uneven ground or if the ankle feels unstable.
Should you brace or tape your ankle?
Taping and bracing the ankle following injury has been shown to reduce the risk of repeated sprains in many studies. The injured ligament can take up to a year to fully heal but athletes will typically return to sport far before this. Therefore I recommend taping or bracing your ankle for 6-12 months following your injury, especially if you have had multiple sprains in the past.
More and more research is showing that taping and bracing provide a proprioceptive effect, improving postural control and the ability of the ankle to react quickly to inversion stress (rolling the ankle). The actual mechanical support is minimal and we see that tape loosens within 10 minutes.
I would not recommend bracing or taping if you have not sprained your ankle in the past. There is no convincing evidence showing that bracing or taping reduces injury in athletes who have never sprained their ankle before.
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Common types of tape
White athletic tape
KT or Kinesio tape
Leukotape
KT tape is the most elastic and fairly easy to apply. Normal athletic tape is cheaper and more rigid, but does not stick nearly as well in my experience. Leukotape is the most rigid and I prefer this type of tape for high ankle sprains.
Benefits of tape
No difficulty fitting in cleats
Does not add any discernible bulk or weight
Unlikely to affect your touch
Unfortunately as mentioned above, tape tends to loosen within just 10 minutes, and it can be costly if you are taping your ankle for every training session and game.
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There are many different braces on the market now, ranging from bulky to more minimalist.
One time cost may save you money in the long run compared to taping.
Braces will provide more padding and compression to the area.
Most braces will be more bulky and heavier. Some may be difficult to fit in your cleats.
Some braces will restrict your motion much more. This can be beneficial in some scenarios but may not be ideal, especially on your dominant foot.
There are many affordable braces online and they may be covered by your health insurance. I would recommend trying both taping and bracing and find what works best for you. You may want to start with the brace initially and transition to tape later on.
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If you’re in the US, this is usually the brace they will have at the doctor’s office. It’s very affordable and probably more appropriate for the acute injury. The brace is more rigid with lace up and Velcro support. Most of these take awhile to get on unless you get the speed lacer model. The fabric is not the most comfortable and they don’t fit well in soccer cleats. I would usually recommend a different brace once you start field training again. ($25)
This is a hinged brace that allows very minimal lateral ankle movement. I do not recommend wearing this brace while playing soccer, but it may be appropriate in the acute stage or with other sports. ($40)
I believe this is the brace Steph Curry wears. This has very rigid lateral support. It is a bit pricier and I don’t usually recommend it for soccer, but it may work well for other sports or if you have a high ankle sprain. ($70)
Several models with various levels of support. Lower profile than the ASO brace with a better fit in cleats. ($40)
Shock doctor ultra knit/stabilizer
Similar to the McDavid models. ($25-$45)
Bauerfeind malleotrain plus/sports ankle support
Bauerfeind braces tend to be preferred by most players due to the low profile and comfort in soccer cleats. They provide a good mix of compression and stability without restricting motion excessively and messing with your touch. They are also easy to take on/off.
Easily the most expensive on the list ranging from around $70-$135 for various models. However, if you plan on wearing a brace for a season or more it may be worth it.
These can be good for compression and may be all you need once you are ready to return to play. They likely work just as well as tape or better and are very affordable. There are a bunch of different models you can choose from. ($10-$20)
Phase 2 - Intermediate (3-6 weeks)
Stationary bike/Jogging (15-45 minutes)
Continue endurance training, you may be able to start jogging at this point.
Begin balance with soccer drills (try to do these without letting your foot touch down)
Sole rolls, passing, volley pass, juggling.
Including single-leg balance with perturbations or on unstable surfaces has been shown to reduce re-injury risk following ankle sprains.
If you are able to perform all of the above without pain, begin basic field drills and move on to the next phase.
Phase 3 - Advanced (6-12 weeks)
Continue to progress strengthening and aerobic training.
Ball drills
Passing
Shooting
Jumping for headers
Sprints
Hopping drills/plyometrics (see video)
Agility/cutting drills (see video)
Full training and scrimmage
Return to play
You can begin training sessions with your team once you have fully rehabbed the ankle and have full strength and motion, minimal swelling, and little to no pain with activity. Injuries are more likely to occur during a match than in training and the majority of these injuries are contact rather than noncontact. I recommend going through several full training sessions without discomfort prior to playing in a competitive match. Keep in mind that even if you feel 100%, full ligamentous strength and healing may not be regained for several months or longer after the injury.
Summary
The ankle is the most commonly injured joint in soccer.
Re-injury rates are also very high.
Performing early motion and weight bearing after spraining your ankle can significantly increase ankle ROM and decrease pain and swelling.
Rehab should consist of stretching and mobility, progressive ankle strengthening, plyometrics, and single-leg balance activities with perturbations/on unstable surfaces.
Taping or bracing your ankle can be helpful for the first 6-12 months after injury.
References
D’Hooghe P, Kerkhoffs G. The Ankle in Football. 1st ed. Springer; 2014.
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Orchard JW, Powell JW. Risk of knee and ankle sprains under various weather conditions in American football. Med Sci Sports Exerc. 2003 Jul;35(7):1118-23.
Hupperets MD, Verhagen EA, van Mechelen W. The 2BFit study: is an unsupervised proprioceptive balance board training programme, given in addition to usual care, effective in preventing ankle sprain recurrences? Design of a randomized controlled trial. BMC Musculoskelet Disord. 2008 May 20;9:71.
Whitman JM, Cleland JA, Mintken PE, Keirns M, Bieniek ML, Albin SR, Magel J, McPoil TG. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther. 2009 Mar;39(3):188-200.
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Kolokotsios S, Drousia G, Koukoulithras I, Plexousakis M. Ankle Injuries in Soccer Players: A Narrative Review. Cureus. 2021 Aug 16;13(8).