Return to Sport Clearance After Ankle Sprain
Athletes should be cleared for sports based on objective functional criteria rather than time alone, though most can return within 12 weeks if they meet specific performance benchmarks including full dorsiflexion, normalized peroneal response, dynamic balance, and successful jumping/landing. 1
Functional Criteria That Must Be Met Before Clearance
Athletes must demonstrate ALL of the following objective measures before returning to sport:
- Full or near-full dorsiflexion range of motion is mandatory, as restricted dorsiflexion significantly increases reinjury risk 1
- Normalized peroneal muscle response time must be achieved, since delayed firing increases instability 1
- Dynamic postural control and balance on both stable and unstable surfaces must be demonstrated 1
- Successful completion of jumping and landing activities is required; inability to perform these within 2 weeks post-injury predicts chronic instability 1
- Pain-free sport participation with minimal pain over the preceding 24 hours 2
- Adequate muscle strength, endurance, and power restoration 2
- Psychological readiness and perceived ankle confidence must be present 2
- Ability to complete sport-specific drills and a full training session without limitations 2
Timeline and Rehabilitation Milestones
The rehabilitation follows a structured progression with specific checkpoints:
Immediate (Day 0-5): Begin supervised exercise therapy immediately with functional treatment and bracing 1. Clinical assessment is most accurate at 4-5 days post-injury (84% sensitivity, 96% specificity for ligament rupture) 1
Early Phase (Weeks 1-2): Initiate range-of-motion exercises and isometric/isotonic strength training 3. Inability to complete jumping/landing by 2 weeks is an unfavorable prognostic sign 1
Intermediate Phase (Weeks 4-6): Reassess ankle strength and stability 1, 4. Incorporate progressive proprioception training exercises 3. Athletes with persistent deficits at 8 weeks face high risk for chronic problems 1
Advanced Phase (Weeks 8-12): Focus on sport-specific activities 3. Most athletes (60-90%) resume sports at pre-injury level by 12 weeks 1
Critical Pitfalls That Increase Reinjury Risk
Never allow premature return based solely on pain resolution:
- Completing the full 4-6 week supervised program is non-negotiable even if pain subsides earlier; discontinuing exercises prematurely dramatically increases reinjury risk 1, 4
- Up to 40% develop chronic ankle instability from incomplete rehabilitation 1
- Premature return leads to 3-34% recurrence rates at 1-4 years and 33-55% report ongoing instability 1
- Young males in high-level sports face particularly elevated risk 1
Protective Equipment During Return
Continue using lace-up ankle braces during the return-to-sport transition:
- Lace-up braces are superior to elastic bandages or tape for providing stability 1, 4, 5
- Semi-rigid or lace-up supports decrease reinjury risk, especially in athletes with prior sprain history 1, 4
- Bracing should be maintained throughout the transition period even after meeting functional criteria 1
Assessment Framework for Clearance Decision
Use the PAASS framework to systematically evaluate readiness 2:
- Pain: Assess during sport participation and over 24 hours
- Ankle impairments: Test ROM, strength, endurance, power
- Athlete perception: Evaluate confidence, stability perception, psychological readiness
- Sensorimotor control: Test proprioception and dynamic balance
- Sport/functional performance: Assess hopping, jumping, agility, sport-specific drills, full training session completion
All five domains must show adequate performance before clearance 2. Self-reported functional measures combined with ambulation status help predict return timeline 6.