Return to Sport After Ankle Sprain
Athletes can typically return to sport 60-90% of the time within 12 weeks after an ankle sprain, but clearance should be based on objective functional criteria rather than time alone. 1
Functional Criteria for Sport Clearance
Return to sport decisions must be guided by the PAASS framework, which achieved 98% expert consensus and includes five essential domains that must all be satisfied before clearance 2:
Pain Assessment
- Pain during sport-specific activities must be minimal or absent 2
- Pain levels over the preceding 24 hours should be documented 2
- Athletes should not rely on analgesics to mask pain during participation 2
Ankle Impairments
- Full or near-full dorsiflexion range of motion must be restored, as limited dorsiflexion is a significant risk factor for reinjury 1, 2
- Ankle muscle strength, endurance, and power should be symmetrical to the uninjured side 2
- Peroneal muscle response time must be normalized, as delayed response increases instability risk 1
Athlete Perception
- Subjective confidence and perceived ankle stability are critical - athletes must feel reassured about their ankle 2
- Psychological readiness to return must be assessed, as fear of reinjury affects performance 2
- Self-reported functional measures strongly predict successful return (accounting for approximately one-third of variance in return time) 3
Sensorimotor Control
- Proprioception must be restored through supervised training 2
- Dynamic postural control and balance on both stable and unstable surfaces should be demonstrated 1, 2
- Inability to complete jumping and landing within 2 weeks after first-time sprain is an unfavorable prognostic factor for chronic instability 1
Sport/Functional Performance
- Athletes must successfully complete sport-specific drills without compensation 2
- Hopping, jumping, and agility tests should show symmetry between limbs 2
- Ability to complete a full training session at game intensity is mandatory before clearance 2
- Functional performance testing should be the final gate before return 4
Rehabilitation Timeline and Milestones
Early Phase (0-2 Weeks)
- Supervised exercise therapy should begin immediately with functional treatment and bracing 1, 5
- Range of motion exercises and isometric/isotonic strengthening are initiated 6
- Clinical assessment is most accurate 4-5 days post-injury (84% sensitivity, 96% specificity for ligament rupture detection) 5
Intermediate Phase (2-6 Weeks)
- Proprioceptive training using wobble boards and balance exercises becomes the focus 7, 6
- Progressive strengthening of ankle and hip muscles continues 7
- Lace-up or semi-rigid ankle braces should be used during this phase 7, 5
Advanced Phase (6-12 Weeks)
- Sport-specific activities are progressively introduced 6
- Reassessment of ankle strength and stability occurs at 4-6 weeks of therapy 7
- Most athletes (60-90%) resume sports at pre-injury level by 12 weeks 1
Critical Pitfalls to Avoid
Discontinuing exercises once pain subsides dramatically increases reinjury risk - the full 4-6 week supervised program must be completed 7. Up to 40% of individuals develop chronic ankle instability despite initial treatment, often due to incomplete rehabilitation 1.
Time-based clearance alone is inadequate - functional criteria must guide the decision 2, 4. Athletes with persistent deficits in dynamic postural control, altered hip kinematics, or mechanical instability at 8 weeks are at high risk for chronic problems 1.
Premature return increases recurrence risk - 3-34% of patients experience recurrent sprains at 1-4 year follow-up, and 33-55% report ongoing instability 1. Young males participating in high-level sports face particularly elevated risk 1.
Protective Equipment During Return
Lace-up ankle braces are superior to elastic bandages or tape and should be continued during the return-to-sport transition 7, 5. Semi-rigid or lace-up supports decrease reinjury risk, especially in athletes with prior sprain history 7.