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A Comprehensive Guide to Managing Lateral Ankle Sprains: Prevention, Treatment, and Rehabilitation

A Comprehensive Guide to Managing Lateral Ankle Sprains: Prevention, Treatment, and Rehabilitation

With lateral ankle sprains making up the majority of all sports related injuries, having a specific treatment approach to prevent the onset of chronic ankle instability is crucial. In this article we will look at specific science-based rehabilitation protocols to treat a chronically unstable ankle.

This article will be structured as follows:

  1. Introduction
  2. Causes and Symptoms
  3. Diagnosis and specific tests
  4. Prevention of Lateral ankle sprains (Primary prevention)
  5. Acute treatment of ankle sprains
  6. Rehabilitation of an ankle sprain (Secondary prevention) - The rehab approach
  7. Training programme for ankle rehabilitation
  8. Conclusion
  9. Literature

1. Introduction


We will begin by looking at the definition and some numbers regarding lateral ankle sprains (LAS) chronic ankle instability (CAI):

Ankle injuries are the most common sports related injuries (Wang et al., 2020), making up approximately 25% of all injuries across different sports with chances of recurrence as high 70% (Kaminski et al., 2019). Acute ankle sprains occur at high rates in a variety of sports (especially in football and basketball), as well as military personnel and can also happen unrelated to sporting activities (Herzog et al., 2019).

In addition, after just one ankle sprain, people will have increased risk of post-traumatic osteoarthritis (Kaminski et al., 2019). And up to 40 - 70% of them will develop chronic ankle instability (CAI)(Hoch et al., 2023, Kaminski et al., 2019).
A premature return to sports might be a risk factor for such a high recurrence rate, as Picot states in his narrative review (Picot et al., 2022).
This means that people should take their ankle sprains more seriously and undergo evidence-based rehabilitation. Because the longer an instability (and therefore suboptimal loading) exists, the greater the cartilage degeneration, and the higher the risk for osteoarthritis (Wang et al., 2020).

Lateral ankle sprains and its rehabilitation will be the main focus of this article because failure to provide a patient will adequate treatment after an acute ankle sprain will increase the chances of them developing CAI (Al-Mohrej & Al-Kenani, 2016).

2 Causes and Symptoms


This section focuses on what happens after a lateral ankle sprain, that leads to CAI development:

Definition of CAI:
Chronic ankle instability is defined as having a subjective feeling of the ankle "giving way" (instability) and having functional disability >12 months after the trauma (Donovan & Hertel, 2012). As well as ongoing pain and recurrent injuries which can lead to a decline in quality of life throughout the lifetime (Hoch et al., 2023).

Causes:
After an acute lateral ankle sprain, the lateral ligaments will either overstretch (lengthen), partially tear or completely tear. The injury initially induces sensorimotor changes through inflammatory and pain mediators, leading to specific impairments in sensory perception and motor behaviour. These factors will lead to disruptions in proprioceptive feedback to the brain, which means, that there will be misunderstandings in the perception of the brain of where it thinks the foot is positioned versus how it is actually positioned. This is also called "deafferentation". Meaning that local trauma can have effects on the feedback mechanisms of the central nervous system. This is proposed to be one of the primary mechanisms involved in CAI (Kaminski et al., 2019).

The loss of stability after a lateral ankle sprain, which leads to functional deficits, may well be due to neuromechanical defects (as changes in the brain have been detected) (Needle et al., 2017). Understanding these neuromechanical alterations will help in designing secondary prevention programs.
These changes lead to deficits in somatosensation, a decreased ability to activate surrounding muscles, putting a greater toll on the central nervous system to guard the joint. This has then impact on popriocetption, strength and postural control. And a likely decreased ability of the nervous system to react to unanticipated movements (this would explain the high recurrence rate).

The substantial theory behind this is a combination of two concepts:

  1. Injury to the sensory receptors within the ligament can impair joint proprioception and the capacity to reactively stabilize the joint.
  2. Motor dysfunction occurs due to reflexive inhibition of the muscles surrounding an injured joint.

How to improve this sensomotory state of dysfunction:

Joint mobilisations and massage will stimulate capsuloligamentous, cutaneous, and musculotendinous receptors and could thereby influence cortical function, as they have effects on the cortex (Sliz et al., 2012). As well as simple exercises such as balance training and strengthening about the ankle joint will improve nervous system excitability. Especially when it comes to balance training, where improvements in postural stability have been noted (Taube et al., 2007).

There exists an interplay between mechanical (such as muscle, bone or ligament damage), neurological (disturbed feedback mechanisms) and cognitive impairments in people with CAI.
Therefore, a thorough rehabilitation plan will need to address all these factors in order to be successful.

Key Points:

  • Feedback from nerves and other receptors at the foot running to the brain is disrupted.
  • Musculoskeletal injuries have neuromechanical effects that lead to motor dysfunction.
  • A combination of joint mobilisations, massage, balance and strengthening exercises have been shown to improve these neuromechanical faults.

3 Diagnosis and Risk Factors

Different risk factors exist for putting someone at risk of sustaining a lateral ankle sprain (LAS) and they can be categorised as either intrinsic or extrinsic.

Intrinsic risk factors: (modifiable)

  • limited ankle mobility (dorsiflexion) (Drewes et al., 2009)
  • impaired proprioception (Willems et al., 2002)
  • reduced dynamic stability (Donovan & Hertel, 2012)
  • strength deficits (especially at the foot and hip) (Munn et al., 2003)
  • decreased peroneal muscle activity

Non-modifiable intrinsic risk factors are being of female sex (Vuurberg et al., 2018).

Extrinsic risk factors: (modifiable)

  • Type of sport (basketball, volleyball, climbing) due to increased risk after landing from a jump (when landing on a teammates foot in plantarflexion)
  • Wearing high-heels heightens the risk of LAS

Non modifiable extrinsic risk factors are only being of male sex (in competition, being a male puts you at greater risk) (Vuurberg et al., 2018).

Diagnosis:

Making the diagnosis is one of, if not the most important step in treating any condition. Therefore we will provide you with a list of specific tests to detect the deficits that need correction:

The most common mechanism for injury is a combination of plantarflexion with inversion and lower leg external rotation. So asking how the injury came to place can prove to be helpful in determining the injured structures (Donovan & Hertel, 2012).

Patients with CAI do have delays / misinterpretations of foot positioning. Their static and more especially dynamic balance will be negatively affected and needs to be tested.
Restrictions in static stability are subtle but become more apparent the more complex a task is, like having them close their eyes during single-leg stance will more likely show abnormalities (Rosen et al., 2017).

Using the Identification of Functional Ankle Instability Questionnaire is also helpful in determining the degree of dysfunction.

Specific tests:

The following test are useful to detect during which tasks or motions your patients restrictions.

Dynamic stability:

1. Star excursion balance test (SEBT):

The Star Excursion Balance Test (SEBT) will be utilized as a clinical assessment to evaluate dynamic postural control. During the test, patients will stand on one leg with hands on hips and reach with the opposite leg in three directions: anterior, posteromedial, and posterolateral. Trials will be discarded and repeated if balance is lost, the heel is lifted, hands are removed from hips, weight is placed on the reaching limb during toe touch, or the starting position is not regained. Each patient will perform four practice and three analysis trials in each direction on both legs. The average reach distance from the collection trials will be normalized to leg length, with longer distances indicating better dynamic postural control.
A recent analysis found that the postero-medial direction is key in distinguishing people with CAI from healthy individuals. A suggested cut-off score of 91% applies to this direction. Players who did not achieve 94% of the lower limb length faced a threefold higher injury risk (Rosen et al., 2019).

2. Single leg stance:

Derived from the Balance Error Scoring System (BESS) that usually comprises three stances, only the single leg stance is used here. The patient is standing a firm surface with closed eyes, with errors tallied during a 20-second trial. An error is recorded when participants open their eyes, lift their hands off their hips, step, stumble, or fall out of position, lift the forefoot or heel, abduct the hip by more than 30°, or fail to return to the starting position within 5 seconds. During the 20-second trial, count errors from the correct stance. Start counting errors after the individual assumes the proper testing position. If multiple errors happen simultaneously, only one is counted. Having more than 3 errors counted during the 20 sec trial, increased CAI likelihood (Picot et al., 2022).

  1. Side Hop Test

Individuals with Chronic Ankle Instability (CAI) typically exhibit poorer performance in the Side Hop Test (SHT) on their injured limb compared to their uninjured limb. The patient is instructed to hop 10 times laterally and medially as quickly as possible over a 30 cm distance (for a total of 20 jumps), requiring significant activation of the peroneus longus muscle. Patients are instructed to complete at least two trials of the test with a practice trial beforehand, separated by a 1-minute rest period. The perceived ankle instability during the SHT is also considered important. The shortest time until completion is noted. 10 seconds is seen as the cut-off score for people with CAI and healthy individuals (Picot et al., 2022)

  1. Figure-of-8 Hop Test

The Figure-of-8 Hop Test involves hopping on one limb in a Figure 8 pattern between two cones 5 meters apart, completing two laps (total distance of 20 m) as quickly as possible. Control subjects in a previous study had a mean time of 11.0 ± 0.4 s, suggesting this value as a target for clinicians. CAI groups typically score above 13 s initially but approach the proposed threshold of <12 s or perform better after rehabilitation. This test can be used throughout rehabilitation to monitor progress (Picot et al., 2022).

Mobility:

Knee to wall test:

The Knee to Wall Test is a clinical assessment used to evaluate ankle dorsiflexion range of motion. During the test, the patient stands facing a wall with one foot positioned a certain distance away from the wall. Keeping the heel on the ground, the patient attempts to touch the knee of the leg closest to the wall to the wall itself by leaning forward. The distance between the wall and the big toe of the foot closest to the wall is measured. A distance of 10 - 12 cm should be overcome for a healthy individual (1 cm accounting for 3-4 degrees of dorsiflexion).
It is crucial to ask a patient for the whereabouts of their restriction. They will either feel tension around their achilles tendon (suggesting tension in the calf musculature) or pressure in the front of the ankle (suggesting the tibia pushing against the talus). The latter indicating the need for joint mobilisations, while the former needs muscle stretching (Clanton et al., 2012).

Mechanical damage:

Anterolateral drawer test:

The Anterolateral Drawer Test for the ankle is a clinical assessment used to evaluate the integrity of the anterior talofibular ligament (ATFL), one of the major ligaments on the lateral aspect of the ankle joint. During the test, the patient is positioned sitting or lying down with the knee flexed to 90 degrees. The examiner stabilizes the lower leg while grasping the heel with one hand and applying an anterior force to the calcaneus with the other hand, attempting to translate the talus anteriorly relative to the tibia. Excessive anterior translation of the talus compared to the uninjured side or a soft endpoint is indicative of a positive test and suggests ATFL laxity or injury.

Strength:

Single-Leg Heel Raise Test:

The single-leg heel raise test assesses ankle function and strength. To perform the test, stand on one leg and lift the heel off the ground as high as possible, using only the calf muscles. The number of repetitions one should be able to do can vary depending on factors such as age, fitness level, and any previous ankle injuries. However, typically, being able to perform 25 repetitions without losing form or balance is considered good ankle strength for people younger than 40 years of age (Bohannon, 2022).


Summary:

The above tests are highly useful in assessing an individuals specific limitations. Especially dynamic tests, which put more demand on the proprioceptive system, are useful to determine the degree of CAI. But always remember, that your aim is to train the athlete, not the test.

4 Prevention of lateral ankle sprains (primary prevention)


Here, we will be looking at different tools that can be of utility in preventing ankle sprains from occurring in the first place:

A thorough prevention programme for ankle sprains in sports can be subdivided into two categories:

  1. Passive Interventions (External Support)
  2. Aktive Interventions (Training)
  1. Passive Interventions (External Support)

The primary aim of an external support is to enhance stability in the ankle joint. This is typically achieved through either taping or bracing methods. Both approaches aim to limit the joint's movement within its physiological range, thereby reducing stress on its static stabilizers (Kaminski et al., 2019).

In terms of preventing ankle sprains, wearing braces during training sessions has proven effective in reducing injury incidence (Janssen et al., 2014). Ankle braces are not only cost-efficient but also time-effective, as they are easy to put on.

While ankle taping is considered slightly less effective than bracing, it still contributes to lowering injury rates in athletic populations. However, over time, the stiffness of the tape tends to decrease, diminishing its effectiveness after approximately 30 minutes.

The effects of bracing and taping are multifaceted, as outlined by Kaminski et al. (2019):

  1. Mechanical support: Preventing extreme ranges of motion.
  2. Neuromuscular effects: Enhancing proprioception through mechanosensor stimulation, improving postural control and enhancing balance.
  3. Psychological effects: Boosting confidence and instilling a sense of ankle joint stability, but excessive reliance on these devices may lead to overconfidence.

In their conclusion, Kaminski et al. (2019) suggested that bracing has minimal impact on performance while providing significant prophylactic benefits against (first time and recurrent) ankle sprains in athletes. The authors reported a remarkable reduction of approximately 70% in ankle sprains when ankle braces were worn. A variety of studies supporting the high efficacy of bracing and even demonstrated that bracing was more effective than training alone in reducing recurrent sprains (Janssen et al., 2014). Semirigid braces are usually used.

Choosing correct foot wear in sports has not been shown impact ankle sprain incidence and it therefore of no relevant concern (Curtis et al., 2008).

  1. Aktive Interventions (Training)

There exist some great protocols, such as the Fifa 11+, that have been demonstrated to reduce overall lower extremity injury incidence in team sports (including ankle sprains) (Nouni-Garcia et al., 2019). But still, specific factors such as limitations in ankle mobility or lower extremity strength and balance should be assessed individually.

Prophylactic training programmes will surely take up more time than simply putting on a brace prior to the workout, but will be able to treat the problem at its cause. Different exercises, such as balance board training (E. Verhagen et al., 2004) or strengthening about the hip and knee joint (Beckman & Buchanan, 1995) have been shown to have prophylactic effects.

For the greatest risk reduction, studies always "incorporated single-limb static balancing with perturbations, often including the use of either perturbation platforms (eg, wobble boards) or a sport-specific task such as catching, throwing, kicking, or dribbling a ball" (Kaminski et al., 2019), showing that giving a variety of stimuli will prove effective.

Also the time difference is important. As bracing has an immediate effect upon ankle stability, but neuromuscular training needs intensive training for at least- 8-10 weeks to show measurable effects. The preventive potential of combining both passive and active prevention techniques is likely to be optimal, as bracing will give immediate stability while training targets to cure the underlying cause. The athlete choosing to simply stay with passive prevention (using a brace) is recommended to stick to that for 1-2 years during sporting activites, for the preventive effects to be given (Verhagen & Bay, 2010).

For best outcomes: a combination of appropriate training and external support is recommended to maximise prophylactic effects.

5 Acute treatment of ankle sprains


Knowing what to do when dealing with an acute ankle sprain is of valuable importance and will have a great impact on recovery time:

When it comes to treating an acute ankle sprain, a variety of treatment approaches exist. Although the spirits are still divided when it comes to choosing the initial treatments, we currently believe in the "PEACE & LOVE" protocol, which lays emphasis on optimal loading, while protecting the joint and not icing it (Dubois & Esculier, 2020). The rationale behind "PEACE & LOVE" is to first Protect the ankle from excessive loading by leaving it unloaded for the first few days, while keeping in in Elevation and Compressing it to reduce joint swelling. Anti-inflammatories should be Avoided if possible, in order not to interfere with the healing process. The patient has the right to know why his ankle hurts, how long recovery will take and what he can do on his own, therefore we must seek to Educate them to our best of knowledge.
Then (after the first few days have passed), gradual Loading is initiated to get the process of mechanotransduction started. In this stage, a strong mindset if of importance and we advise the patient to stay Optimistic. Then an increase of Vascularisation is sought by moving more via an endurance effort, while strengthening the ankle with specific Exercises.

The practitioner is also advised to conduct a gait analysis, as abnormalities during gait are often formed after an acute sprain (Donovan & Hertel, 2012) and correcting them as soon as possible is advantageous.
For pain relief, different therapeutic approaches such as physical therapy, aricast bracing or neuromuscular electrical stimulation are recommended (Ortega-Avila et al., 2020).

We suggests patients take it EASY (external ankle support for 1 year) after a lateral sprain. Wearing an ankle brace for 1 whole year (during activity) after an injury has been shown to be effective in reducing injury recurrence (McKeon & Donovan, 2019). An ankle brace should be worn during activities of daily living in the acute phase (first few weeks) and then only during sporting activites for at least 6 months, but better long-term results come from wearing them for 1 year (Doherty et al., 2017). But as compliance for an external ankle support is quite low, the patient might benefit from some education of its effects in injury reduction and that no interference with normal training effects will occur.

It is recommended to start weight-bearing and rehabilitation as soon as pain subsides, because some evidence suggests, that at the 2 weeks point people should already be able to perform single-led drop landings and a drop vertical jump. Inability or unwillingness to complete these tests led to increased likelihood (by a factor of 2-3) of developing CAI (Doherty et al., 2016). This just goes to show that the sooner you get back on track, the better.

Summary: Initiating with gradual loading as well as wearing an ankle brace as soon as possible is the way to go after an acute ankle injury.

6 Rehabilitation of an ankle sprain (Secondary prevention) - The rehab approach


This section lays its focus on secondary prevention and aims to merge all of the different factors affecting the patients recovery, and create an optimal therapy regime for the individual:

When it comes to creating the rehabilitation protocol, it is very important to focus on actual anomalies or side to side differences that have been identified prior with specific tests (such as dynamic or static balance deficits) in order to create a well tailored programme for an individual.

The following will provide general information on patient treatment.

General guidelines:

Holistic approach:

  • Educate your clients about the pain they are experiencing. Where does it comes from, why does it hurt, how long will it take to see improvements? (explain them their pain!, this will increase compliance)
  • Treating them for symptoms (early on, to reduce pain)

Active Therapy:

  • A mix of coordination, strength, endurance, mobility (divided into 3 stages, see below)

Additional factors:

  • Make use of an external ankle support

Patient Oriented Outcomes:

Psychological aspects should always be included in a comprehensive rehab approach. We suggest that different questionnaires be used (especially in the athletic populations, before their return to sports). As a study on ACL injuries reported, that psychological readiness was a strong predictor of the return to sports rate in athletes (Faleide et al., 2021).
Psychological factors can be easily assessed via injury specific questionnaires.

In his narrative review, Picot suggests using a combination of the Foot and Ankle Ability Measure (FAAM) and the Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) questionnaires in order to evaluate patient functionality regarding CAI (Picot et al., 2022).
Functional tests and specific questionnaires will both help an athlete in his return to sports decision making.

Key Points: Physical and psychological factors need to be assessed for optimal therapy results.

Exercise Therapy:

Exercise programs have been sown to decrease the prevalence of recurring injuries as well decreasing the likelihood of developing functional ankle instability (van der Wees et al., 2006). Therefore, it is advised to start as early as possible with exercise training (as soon as pain subsides).

We will now present a variety of exercise regimes that are evidence-based and have proven successful. These will then lay the foundation of the exercise programme presented in the next section.

STARS-Protocol:

In people with CAI, sensory feedback on the foot is often decreased. The STARS (sensory-targeted ankle rehabilitation strategy) protocol uses a combination of triceps surae stretching, ankle mobilisations and plantar massage. In combining these three modalities, different sources of sensory input are stimulated (musculotendinous receptors, ankle joint receptors, plantar receptors), thereby increasing sensory feedback of the foot, while increasing dorsiflexion ROM.

According to these authors, focusing on potential arthrokinematic restrictions of posterior talar glide, via joint mobilisations, leads to notably greater initial improvement in range of motion. This supports the idea that ankle sprains might cause positional faults of the talus and fibula.
Immediate increases in single-limb balance were observed after plantar massage, suggesting improved sensory pathways. After two weeks of joint mobilizations, the study noted enhanced functional abilities in activities like running, landing, jumping, and lateral movements. These improvements are likely attributed to restored dorsiflexion range of motion and better landing patterns, as seen in individuals with Chronic Ankle Instability (CAI) who received joint mobilization treatments. However, these self-reported function changes were not sustained at the one-month follow-up, suggesting the need for a higher dosage to preserve these functional gains. Notably, joint mobilization led to significant improvements in weight-bearing dorsiflexion, while plantar massage had a more significant effect on single-limb balance (McKeon & Wikstrom, 2016).
A single 5-minute session of plantar massage improved static postural control in those with CAI (same results of rolling on a ball or massage from therapist). Foot massage should immediately prior to static balance training (as no improvements were found on dynamic training) (Wikstrom et al., 2017).

KEY POINT: Initiating a static balance exercise regime with some sort of plantar massage (either self-massage or rolling out on a fascia ball) will increase single-limb balance performance. Combining this with joint mobilisations (by a practitioner or at home with bands) will improve functional outcomes.

Intrinsic Foot Musculature:

It has been suggested, that strengthening the intrinsic foot musculature is as important as training the extrinsic muscles.
To train the intrinsic foot musculature, "the foot core system" has been proposed. Here, a total of 4 exercises will be used, to train the intrinsic foot muscles, that aid in postural control during gait and standing. These are: 1) the short-foot exercise, 2) toes-spread-out exercise, 3) first-toe– extension exercise, and 4) second- to fifth-toe–extension exercise. They have all been shown to activate the intrinsic muscles to a considerable extend (Gooding et al., 2016). With these exercises, fine-tuning is key. For instance, the exercise involving extension of the second to fifth toes is meant to engage the small intrinsic muscles of the foot connected to the big toe. As the participant lifts these toes off the ground, the muscles that control the big toe may also activate to resist its extension, often happening alongside the activation of other toe extensor muscles. However, as a person's motor skills improve, they may be able to perform this task by activating the other toe extensor muscles without engaging the muscles controlling the big toe (McKeon et al., 2015).
The short foot exercise (and all the others) can be advanced through various stages, transitioning from seated to standing on both feet, and eventually to standing on one foot. Functional movements such as squats and single-leg hops can then be integrated. Growing evidence suggests that systematically training the foot core using progressive short foot exercises can lead to improved foot function, particularly enhanced balance. Initial findings indicate that individuals with chronic ankle instability who incorporated short foot positioning into their balance exercises report greater improvements in function compared to those who did not utilize this technique (Drewes, 2009).

KEY POINT: Including intrinsic muscle activation into a training regime has been shown to increase postural stability and foot function. Theses exercises should be conducted barefoot.

Balance, Strength, Proprioception and Cognition:

Treatment for ankle sprains involves addressing strength, balance, proprioception, and cognition. Balance exercises should encompass a range of challenges, including variations in knee and ankle positions, closed-eye exercises, and head movements, to enhance proprioception and neuromuscular control (Donovan & Hertel, 2012). Strengthening the pronator muscles is crucial in preventing lateral ankle sprains, as weakness in these muscles may contribute to foot inversion during gait.

Lower Extremity Strength:

Rehabilitation should involve comprehensive strengthening of the hip and knee musculature (Donovan & Hertel, 2012). This makes sense, as foot instability will demand more stability from above. That's why increased reliance upon hip movement strategies are often seen in this population. And it is speculated to be a main coping strategy of people with CAI (Doherty et al., 2016).
People with CAI have been shown to have significantly decreased hip extension, abduction and external rotation strength compared to healthy individuals (Dejong et al., 2020). And the literature supports strengthening about the hip to improve rehabilitation outcomes (Donovan & Hertel, 2012).
The hamstring musculature should not be neglected, as the literature indicates greater risk for hamstring injury after an ankle sprain (Malliaropoulos et al., 2018).
A correlation between gluteus maximus and gluteus medius strength have been shown in correlation with the reach length of the SEBT test, especially in the lateral and medial directions. As proximal stability is important for distal functioning, a gluteal strength program could improve balance and stability of the ankle, as inadequete foot movements are often compensated by hip abduction or adduction (Raghava Neelapala et al., 2016). Gluteal strengthening should be included for these reasons.

Balance and Proprioception:

Diminished proprioception and neuromuscular control in CAI patients can be addressed through balance training, which has been demonstrated to reduce ankle sprain incidence (Donovan & Hertel, 2012).

As muscle activation surrounding a joint serve as joint stabilizers. Single-leg balance exercises on different surfaces have shown to elicit different responses of muscle activation. Peroneal muscle activity, has been demonstrated to be way higher when balancing on an unstable surface. Ankle inversion-eversion differences and changes are higher on unstable surfaces. With the greatest inversion / eversion variability and muscle activity seen on the Bosu-ball and the most rapid inversion-eversion direction changes seen on the wobble-board. With Bosu-ball being the most challenging variation overall.
Therefore, the findings indicate that sensorimotor training can be advanced in complexity by gradually decreasing the base of support (from floor to Airex, to wobble-board, to Bosu-ball). The authors suggested, that the frequent changes in direction (from the wobble board), involving inversion and eversion, along with the activation of proprioceptors and the protective musculature, may lead to heightened activation of afferent pathways. This, in turn, could contribute to the development of a coordinated motor response and ultimately enhance stability, potentially reducing the risk of reinjury in certain situations. (Strøm et al., 2016). Making a point of including some kind of wobble-board training in the rehabilitation program.

Balance training in combination with the STARS-protocol (although not statistically significant) might slightly increase effectiveness of the training and is recommended (Burcal et al., 2017).

Overall, a recent meta-analysis found that both balance exercises and strengthening exercises led to improvements in daily living and sporting activities in people with CAI (Guo et al., 2024). But balance training demonstrated a more profound effect on the functional ability.

A more recent and critical review on the aspect of proprioceptive training suggested, that active proprioception or active joint positioning sense was not restored from standardised strength and balance exercises. The authors advised exercises that include the reproduction of repeated joint positioning and errors should be adjusted by feedback (Xue et al., 2023). We will include exercises that aim to restore joint positioning sense in the exercise protocol.

Dynamic stability:

In order to improve dynamic stability and functional outcomes, multijoint exercises need to be prescribed to get better as these tasks, because simply strengthening about the ankle has been shown to be insufficient in increasing functional performance (Hall et al., 2015).


Cognition:

Research indicates a linear relationship between stability and attention in individuals with CAI. Neurocognitive training focusing on attentional control may improve outcomes, particularly in tasks requiring divided attention (Rosen et al., 2017). This would include exercises such as single limb balance, while also catching or throwing a ball (=divided attention).

KEY POINT: A variety of exercise protocols have been proven effective and should be included into an exercise therapy programme.

7 Training programme for ankle rehabilitation

In this final section we will put all of the information about exercise mentioned above into an exemplary training programme, that can be utilized as a rough scheme and then tailored for individual needs.
Any rehabilitation programme focusing on CAI should always point out, that training both limbs (not just the injured side) is important. As people with CAI have been shown to exhibit bilateral dynamic postural control deficits compared to others after an LAS (Doherty et al., 2016).

Background info:

Different training frequencies and therapy durations have been suggested. We recommend sticking to a program for 3 months (as neuromuscular adaptations have been shown to take around 10 weeks (Verhagen & Bay, 2010)) and session duration should be around 45 minutes, performed at least 2, optimally 3 times per week (as it was done in a recent protocol (Hoch et al., 2023)).
A meta-analysis on the topic found that the effectiveness of an exercise intervention is improved, if high training doses are prescribed (>900 min of training), which would account for 20 sessions of 45 min of exercise (Doherty et al., 2017).

Sample Exercise selection:

Mobility:

  • Plantar massage (self-massage or fascia ball)
  • Calf stretching (with knee straight or bent)
  • Ankle mobilisations (with bands)
  • Wobble-board circles (unaffected limb stays on the floor)

Balance & Intrinsic Foot work:

  • Single-leg stance (on Bosu-ball, wobble board, Airex, varying hand positions, eye movements, head movements, including cognitive tasks, catching / throwing / kicking)
  • Exercises of the foot core system
  • Ankle repositioning (in front of a mirror) *
  • Banded adduction/abduction/flexion/extension (with the affected leg on the floor and the other leg performing this exercise

*Include Ankle circles: The Patient sits on a chair in front of the mirror and circles his foot clockwise. He imagines a clock and stops at a given time e.g. 3 o'clock. Then he closes his eyes and continues the circle until he feels he is back at exactly 3 o'clock, then he opens his eyes to check in the mirror. If the patient is off, he corrects the angle and repeats. Varying speeds of circling can be applied. The faster, the more difficult.

Dynamic Exercises:

  • Single leg-hops lateral
  • Single leg-hops diagonal
  • Single leg-hops backwards
  • Single leg-hops forward (varying surfaces, different jumping speeds or distances)

Ankle and Lower Limb strengthening:

  • Eccentric strengthening (walking on toes, heels, insides and outsides of the feet)
  • Heel raises (with decline, with external loads, with bands)
  • Tibialis raises (with bands, standing against the wall)
  • Pronation and Supination (bands)
  • Gluteal and hamstring strengthening

Sample Programme:

A typical training session should take 45 minutes and could be split up as follows: 5 min of mobility, 15 min balance & intrinsic foot work, 10 min of dynamic exercises, 15 min ankle and lower limb strengthening.

Simply choose a few exercises from each category and progress or regress them to your specific needs.
To progress or regress banded strengthening exercises simply change up the band resistance, for hops you could reduce jumping length, for the intrinsic foot musculature you can try performing them first seated, then in standing then during single-leg stance and so on.
Progressing strengthening exercises that utilize bands should be done every 2 weeks while adding a 4th set at the second week of using the same band (e.g.: in week 1: 3 sets with blue band, week 2: 4 sets with blue band, week 3: 3 sets with purple (=heavier) band...), this has been proven effective (Hall et al., 2015).

Return to play:

Physical and psychological factors will dictate the return to play of an athlete. No concrete guidelines exist to help with the return to play decision after a lateral ankle sprain yet. But some some recommendations of functional tests that should be included in the decision making process exist (Clanton et al., 2012):

- Adequate ankle dorsiflexion (knee-to-wall test)
- Balance and proprioception (SEBT)
- Vertical jump (Sargent jump test)
- Coordination and the ability to perform rapid direction changes (Agility T-Test)

As stress can increase the likelihood of an injury, the psychological state of an athlete should be assessed. Fearful athletes are at higher risk of reinjury. Therefore, appropriate questionnaires such as the Trait Sport Confidence Inventory should be utilized (Clanton et al., 2012).

Key Point: Evaluating the functional and psychological state of an athlete is necessary to make a safe return to play decision!

8 Conclusion

In conclusion, the management of chronic ankle instability (CAI) resulting from lateral ankle sprains is a multifaceted process that requires a comprehensive approach. This article has provided an in-depth exploration of the causes, symptoms, diagnosis, prevention, acute treatment, and rehabilitation of CAI, drawing upon current evidence-based practices.
Early intervention and appropriate rehabilitation are crucial to prevent the development of chronic instability and associated complications.
Thorough diagnosis using specific tests to identify deficits, implementation of preventive measures such as external support and targeted training programs, and a holistic rehabilitation approach that addresses both physical and psychological aspects of recovery.
Overall, a tailored approach that considers individual patient characteristics, deficits, and goals is essential for successful management of CAI.

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