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A Guide to Ankle Sprains: Grades 1, 2, and 3 Rehabilitation and Return to Sport Strategies

Ankle sprains are a common injury in athletes. Understanding the severity of the sprain and the appropriate evaluation and rehabilitation steps is important for a full recovery and to reduce future injuries that can lead to chronic instability.


If you have an acute ankle sprain, the Ottawa Ankle Rules are a good way to determine the next treatment step and rule out a fracture.  Medical professionals developed this screening tool to determine a fast and accurate way to avoid unnecessary imaging.


These rules include

  1. Bony tenderness along distal 6 cm of the posterior edge of the fibula or tip of the lateral (outside ankle bone) malleolus.

  2. Bony tenderness along distal 6 cm of the posterior edge of tibia/tip of the medial (inside ankle bone) malleolus

  3. Bony tenderness at the base of the 5th metatarsal.

  4. Bony tenderness at the navicular.

  5. Inability to bear weight immediately after injury and for 4 steps during initial evaluation.


If there is any pain in the malleolar zone and 1, 2, or 5 are present, an ankle x-ray is warranted.  If there is any midfoot pain and 3, 4, or 5 are present then a foot x-ray is warranted.  If you cannot bear weight, apply ice and compression with an elastic bandage to reduce swelling and use crutches and/or a boot (paid link) to unload your injured ankle.   If all of these rules are negative, imaging is not recommended, and assessing ligament damage is the next step.

Ankle sprains are categorized into three grades based on the extent of ligament damage: Grade 1, Grade 2, and Grade 3 which can occur on the outside or inside of the ankle.  Rest, ice, and compression with an elastic bandage is initially recommended if you can bear weight. 


Grades 1 and 2 Ankle Sprains

Grades 1 and 2 sprains involve mild to moderate damage to the ligament fibers. A Grade 1 sprain includes mild stretching or microscopic tearing, while a Grade 2 sprain involves partial tearing. Symptoms can range from mild pain and slight swelling (Grade 1) to moderate pain, swelling, and bruising (Grade 2).  A grade 1 sprain can take one to three weeks to heal and a grade 2 sprain can take three to six weeks to heal.

 

Rehabilitation Focus: Mobility, Strengthening, and Proprioception


Mobility Exercises:


  • Ankle Pumps: Sit or lie down with your leg extended. Slowly move your ankle up and down 20 – 30 times every couple of hours.

  • Stretch: Gently stretch your calf muscles to prevent them from tightening up.  Hands against wall straight knee calf stretch and bent knee wall stretch.

  • Alphabet Exercise: If there is no pain, spell the alphabet in the air with your foot to encourage range of motion. You may have to wait 3 – 5 days before you start this, based on the severity of your sprain.


Strengthening:


  • Towel Scrunches: Place a towel on the floor and use your toes to scrunch it up towards you.

  • Resistance Band Exercises: Use a resistance band for gentle strengthening exercises like dorsiflexion, plantarflexion, inversion, and eversion.  If it is too painful to move at first then start with isometrics.  Place the band on your injured foot and pull the band in the direction you want to train with your other foot while resisting the movement and not moving your injured foot

  • Calf Raises: Stand on both feet and slowly rise up onto your toes, then lower back down.

  • Toe Raises: Stand on your heels and lift your toes off the ground.

  • Heel-to-toe walking: Walk on your heel with one foot, slowly lower your foot, and then rise on the balls of your feet.


Proprioception:

  • Balance Exercises: Stand on one leg for 30 seconds, gradually increasing the duration. Progress to doing this with eyes closed or on an unstable surface.

  • Wobble Board: Use a wobble board to improve balance and proprioception.

  • Advanced Balance Training: Incorporate single-leg balance on unstable surfaces, such as balance pads or wobble boards.

  • Agility Drills: Once basic proprioception is regained, introduce lateral movements, hopping, and agility ladder drills to simulate sports movements.


Grade 3 Ankle Sprain

A Grade 3 sprain is a complete tear of the ligament. Symptoms include severe pain, significant swelling, bruising, and instability of the ankle. The grade often requires medical evaluation and possible immobilization or surgery.  A grade 3 or high ankle sprain can take up to three to six months to heal.


Follow your medical provider's rehabilitation (mobility, strength, proprioception, gait training) and return to sports protocols.


Return to Sport While Reducing Re-injury Rates: Bracing or Taping

Upon returning to sports, incorporating bracing or taping received an A grade as a treatment protocol to reduce reinjury rates.  This is highly recommended to provide additional support to the healing ligament. This step is important for all grades of sprains to allow time for strength and proprioception to fully return.

  • Bracing: Wearing an ankle brace can provide stability and prevent excessive movement that could lead to a re-injury.

  • Taping: Athletic taping (using the right kind of pre-wrap and athletic tape - I like Mueller) offers similar benefits, providing support and limiting harmful movements during physical activity. (paid links)


Duration: The duration of bracing or taping varies depending on the severity of the sprain and the individual's recovery progress. Generally, it's advised to continue this support for several weeks to months, especially during high-risk activities.


Key Points to Remember

  • Gradual Progression: Start with gentle exercises and gradually increase intensity based on tolerance and recovery stage.

  • Consistency: Regularly performing the exercises is important for recovery and reduction of future injuries.

  • Listen to Your Body: Avoid pushing through pain, which can lead to further injury.


By focusing on mobility, strength, and proprioception tailored to the grade of the sprain, and incorporating bracing or taping upon returning to sports, you can effectively rehabilitate your ankle and reduce the risk of recurrence. Always consider consulting with a healthcare professional or physical therapist for personalized guidance and to ensure you're performing exercises correctly.

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Grade 2 Ankle Sprain

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