Physical Therapy for High Ankle Sprains
Exercise therapy should be started as soon as possible after a high ankle sprain to recover joint functionality, with supervised exercises focusing on proprioception, strength, coordination, and function.1
Understanding High Ankle Sprains
High ankle sprains (syndesmotic sprains) differ from lateral ankle sprains:
- They involve injury to the syndesmosis between the tibia and fibula 1
- Can be detected using the crossed-leg test, where pressure applied to the medial side of the knee produces pain in the syndesmosis area 1
- Often require longer recovery times than lateral ankle sprains 2
Initial Management
The traditional RICE (Rest, Ice, Compression, Elevation) protocol is no longer recommended as a standalone treatment:
- Current evidence indicates that RICE alone has no positive influence on pain, swelling, or patient function 1
- NSAIDs may be used to reduce pain and swelling in the acute phase 1
- Functional support (particularly bracing) is preferred over immobilization 1
Physical Therapy Approach for High Ankle Sprains
Phase 1: Acute Phase (0-7 days)
- Protect the joint while minimizing pain, inflammation, and muscle weakness 2
- Some form of immobilization with weightbearing restrictions is typically recommended 2
- Gentle mobilization and resistance exercises should be initiated to maintain muscle strength 2
- Cryotherapy combined with exercise therapy has shown greater effect on reducing swelling compared to heat application 1
Phase 2: Subacute Phase (1-3 weeks)
- Focus on normalizing range of motion, strength, and function in activities of daily living 2
- Progressive mobilization and strengthening exercises are the hallmarks of this phase 2
- Neuromuscular training should be initiated as a central component of rehabilitation 2
- An accelerated exercise protocol during the first week after ankle sprain has been shown to improve ankle function and activity levels 3
Phase 3: Advanced Training Phase (3+ weeks)
- Prepare the patient for return to sports participation or normal activities 2
- Include perturbation of support surfaces, agility drills, and plyometrics 2
- Sport-specific training should be incorporated for athletes 2
- Supervised exercises with focus on proprioception, strength, coordination, and function are strongly recommended 1
Evidence for Physical Therapy Effectiveness
- Exercise therapy has the strongest evidence (level 1) for effectiveness in ankle sprain rehabilitation 1
- Functional treatment has been shown to help patients return to sports 4.6 days sooner than immobilization 1
- Patients undergoing functional treatment returned to work 7.1 days sooner than those treated with immobilization 1
- Manual mobilization is advised only in combination with other treatment modalities to enhance the treatment effect 1
Common Pitfalls and Considerations
- Inadequate treatment of ankle sprains can lead to chronic problems such as decreased range of motion, pain, and joint instability 1
- Immobilization should be avoided as it shows no benefits compared to functional treatment 1
- Proper diagnosis is crucial - clinical assessment of ligament damage is optimized if delayed for 4-5 days post-injury when swelling has decreased 1
- For recurrent ankle sprains, exercise therapy should be incorporated into regular training activities as much as possible 1
- The effectiveness of some modalities like deep oscillation therapy remains inconclusive compared to standard care 4
Work and Sport Resumption
- Immediate functional treatment and a return-to-work schedule are advised to minimize work absenteeism 1
- For sport resumption, supervised exercises focusing on proprioception, strength, coordination, and function are strongly recommended 1
- A progressive return to activity protocol should be followed to prevent reinjury 2