Medial Ankle Sprain - Rehab
The ankle is the most commonly injured joint in soccer as well as most other sports. Ankle injuries make up 11-23% of all injuries recorded during FIFA competitions. The vast majority (~85%) of ankle sprains involve the lateral ligament complex. Medial or eversion ankle sprains involving the deltoid ligament are much less common and only account for about 5% of all ankle sprains. These sprains typically occur as a contact injury when another player tackles or steps on the outside of your ankle, rolling the ankle inward. They may also occur when cutting, landing awkwardly when shooting or jumping, or playing on a lumpy or sticky/turf field. Pain is typically felt on the inside of the ankle and you may have bruising or swelling here or down into the foot. Football along with men’s and women’s soccer have the highest incidence of deltoid ligament sprains.
There is not nearly as much research on medial ankle sprains compared to high and lateral sprains as they are far less common. However, we do know they tend to take longer to recover from, potentially even twice as long as a lateral ankle sprain. As a result, we must be more patient with the rehab process and may need to progress more slowly.
Ankle Sprain Grades
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.
(Due to the substantial amount of force required to sprain this ligament, these injuries are rarely isolated and may occur in conjunction with ankle fractures. In a study of 288 acute ankle fractures, 39.6% involved the deltoid ligament. If you have had an ankle fracture make sure to have the deltoid ligament assessed at some point along the recovery.)
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 implicating increased BMI with the risk of ankle sprain. One study found that overweight players who had a previous ankle sprain were 19 times more likely to sustain an ankle sprain than a normal weight player with no history of ankle sprains.
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There is evidence that reduced hip strength increases the risk of noncontact lateral ankle sprains. This may also increase the risk of medial ankle sprains, but this is less clear.
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There may be a greater risk of eversion ankle sprain in athletes with flat feet, increased pronation, or limited dorsiflexion range of motion.
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There is some evidence for increased risk with poor field conditions, artificial grass, or improper footwear.
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. Rehab in general for a medial sprain is going to be very similar to lateral. There are a few differences and likely a more extended rehab timeline.
Phase 1 - Acute Phase (0-4 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
Protect the ankle from further injury
Normal walking/weight bearing
Restore motion and strength
Reduce swelling
Movement is most important. Ice, elevate, compress as needed.
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.
A walking boot and crutches may be needed for the first 3 weeks.
Orthotics with medial support can be helpful as well to prevent stressing the deltoid ligament further.
Eventually transition from the boot to a brace/tape.
If you can go up and down stairs and walk outside without much discomfort, you are likely ready for full weight bearing and can stop using crutches.
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.
Try to avoid activities that excessively aggravate symptoms at this time, which could include running, jumping, cutting, uneven ground, etc.
Restore motion and strength
(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.)
Should you brace or tape your medial 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.
Due to the slower recovery and healing with deltoid ligament sprains, I recommend starting out wearing a fairly rigid brace and potentially supportive orthotics as well.
There are many affordable braces online and they may be covered by your health insurance. See dropdown below.
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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)
Progress to the next phase when you are able to walk at a normal speed without limping, go up and down stairs, and perform all exercises with minimal discomfort.
Phase 2 - Intermediate (4-8 weeks)
Continue to progress strengthening and aerobic training.
You may begin jogging when you are able to balance on one foot, walk, and use stairs with no discomfort.
Trial inside of the foot passing when you are able to run pain free.
Sprinting, cutting, and agility training may begin later in this phase.
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 exercises without pain, begin basic field drills and move on to the next phase.
Phase 3 - Advanced (8-16 weeks)
Continue progressing strengthening, aerobic training, plyometrics, and agility.
Re-introduce shooting with the inside of the foot and instep, gradually increase power.
This may need to be delayed due to the stress on the deltoid ligament.
You should be able to shoot at full power before playing returning to play.
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. You may want to wear a brace initially when you return to sport.
Key Takeaways:
Medial or eversion ankle sprains only account for about 5% of all ankle sprains. They typically occur as a contact injury.
These tend to take longer to recover from, potentially even twice as long as a lateral ankle sprain.
A walking boot and crutches may be necessary for the first 3 weeks.
Once you can go up/down stairs and walk outside without much discomfort, you are likely ready for full weight bearing and can stop using crutches.
Shooting with the instep may need to be delayed due to the stress on the deltoid ligament.
You may want to brace/tape initially when you return to sport.
References
D’Hooghe P, Kerkhoffs G. The Ankle in Football. 1st ed. Springer; 2014.
Dutton M. Dutton’s Orthopaedic: Examination, Evaluation, and Intervention. 5th ed. McGraw Hill; 2019.
Waterman BR, Belmont PJ Jr, Cameron KL, Svoboda SJ, Alitz CJ, Owens BD. . Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med. 2011; 39 5: 992– 998.
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.
Kofotolis ND, Kellis E, Vlachopoulos SP. . Ankle sprain injuries and risk factors in amateur soccer players during a 2-year period. Am J Sports Med. 2007; 35 3: 458– 466.
Kopec TJ, Hibberd EE, Roos KG, Djoko A, Dompier TP, Kerr ZY. The Epidemiology of Deltoid Ligament Sprains in 25 National Collegiate Athletic Association Sports, 2009-2010 Through 2014-2015 Academic Years. J Athl Train. 2017 Apr;52(4):350-359.
Reider B, Davies GJ, Provencher MT. Orthopaedic Rehabilitation of the Athlete: Getting Back in the Game. Elsevier/Saunders; 2015.
Hintermann B, Regazzoni P, Lampert C, Stutz G, Gachter A. . Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br. 2000; 82 3: 345– 351.
Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Intrinsic risk factors for acute ankle injuries among male soccer players: a prospective cohort study. Scandinavian journal of medicine & science in sports. 2010;20(3):403-410.
Fousekis K, Tsepis E, Vagenas G. Intrinsic risk factors of noncontact ankle sprains in soccer: a prospective study on 100 professional players. Am J Sports Med. 2012 Aug;40(8):1842-50.
Tyler TF, McHugh MP, Mirabella MR, Mullaney MJ, Nicholas SJ. Risk factors for noncontact ankle sprains in high school football players: the role of previous ankle sprains and body mass index. Am J Sports Med. 2006 Mar;34(3):471-5.
Powers CM, Ghoddosi N, Straub RK, Khayambashi K. Hip Strength as a Predictor of Ankle Sprains in Male Soccer Players: A Prospective Study. J Athl Train. 2017 Nov;52(11):1048-1055.
Soligard T, Nilstad A, Steffen K, et al.. Compliance with a comprehensive warm-up programme to prevent injuries in youth football. Br J Sports Med. 2010; 44 11: 787– 793.
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.
Savage-Elliott I, Murawski CD, Smyth NA, Golano P, Kennedy JG. The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies. Knee Surg Sports Traumatol Arthrosc. 2013; 21 6: 1316– 1327.
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.
Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. . A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007; 37 1: 73– 94.
Kolokotsios S, Drousia G, Koukoulithras I, Plexousakis M. Ankle Injuries in Soccer Players: A Narrative Review. Cureus. 2021 Aug 16;13(8).
Huang PY, Chen WL, Lin CF, Lee HJ. . Lower extremity biomechanics in athletes with ankle instability after a 6-week integrated training program. J Athl Train. 2014; 49 2: 163– 172.