Ankle Sprains

This article will present some research-based advice on how to recover after the most common type of ankle sprain, the inversion sprain. It will also cover some rehab exercises to help reduce the chances of it happening again. Inversion sprains happen when the ankle rolls inwards, stretching and/or tearing the stabilising ligaments on the outside of the joint. 

The first 24-72 hours

If you have a severe amount of pain and swelling after your ankle sprain and can’t put any weight on your ankle at all, you should seek medical advice to establish if you need an x-ray. This will rule out more serious damage like fractures to the leg or foot bones.

The following information is for people who have ruled out these more serious problems. The vast majority (over 95%) of ankle sprains can be treated successfully without surgery, and the rest, ice, compression and elevation (‘RICE’) model should be followed for the first 24-72 hours.

I now recommend that the use of ice should be confined to the day of the injury. This is because recent research has shown that using ice beyond 12 hours post-injury may interfere with tissue healing and regeneration.

If you want to use ice on your ankle, it's generally recommended to apply ice packs for between 10 to 20 minutes at a time. You can repeat this every 1 to 2 hours as needed. Make sure to wrap the ice pack in a cloth or towel to protect your skin from frostbite. If you experience excessive discomfort or numbness, remove the ice pack immediately. 

Non-steroidal anti-inflammatories (NSAIDs) like ibuprofen are still often recommended to relieve the pain of ligament injuries. Whilst they do usually provide pain relief, studies have shown that NSAIDs can also interfere with collagen production, leading to poorer healing and weaker ligaments. 

As a result, researchers recommended using NSAIDS for the shortest period of time (if at all). As an alternative, paracetamol is just as effective for pain relief without the adverse impact on tissue repair. 
Other considerations

There are other factors to consider that might further optimise your healing. 

Red Light Therapy - There is strong evidence that using red light on injured tissues promotes wound healing and tissue repair. I’ve talked about the science behind red light therapy in a previous blog here. You can either purchase your own red light device or find a practitioner (like me) who uses one. Although cheaper models are freely available, I use a hand-held light from this company as well as a larger machine from this company.

Nutrition - To make sure your body has the vitamins and minerals it needs to repair and replace the injured muscle you should consider taking a quality supplement that contains the following, all of which have a role in collagen synthesis.

Vitamin C, Vitamin D3, Vitamin A, Vitamins B6 and B12, copper, zinc, magnesium.

In addition, collagen powder is worth considering. The body initially patches up your injured muscle with type 3 collagen and then as healing progresses it replaces it with type 1 collagen. There is some evidence that supplementing with collagen peptide powder can help with tissue  repair. My preferred product, which I have been using for years, is this one, which contains both type 1 and 3 collagen

Initial Recovery Phase

Research has shown that the quicker you can resume some weight-bearing activity after an ankle sprain the better, but a short period of immobilisation of the ankle may be necessary to stop your ankle from rolling over again and causing further damage. This usually means having the ankle in a cast, or some kind of brace that firmly holds the ankle in position. 

How long in a brace, & which type?

A recent  paper in 2023 recommended no more than 5-10 days of initial immobilisation.  Remember, you are looking to start putting some weight on the ankle as soon as it feels safe to do so. 

If the injured ankle is held rigidly for too long, it’s been shown that the scar tissue being laid down is not well-formed and strong. The new ligament tissue is thought to start maturing 10-21 days after the initial injury, so if possible, you should introduce some controlled weight bearing exercises before this period is over.

As for the type of brace to use, the gold-standard is the semi-rigid brace like this one  shown below which is used by the NHS . They have been shown to be better than simple tubular compression braces. 

Please note that this type of brace is sold in left or right ankle versions, so make sure you order the correct one!

These braces are a bit pricey, so if you are on a budget or can’t get one through the NHS, I would get a tight-fitting neoprene or elasticated ankle brace that holds your ankle as firmly as possible.

So what would this short period of immobilisation look like? 

I would be wearing the brace when I’m on my feet and moving around during the day, but taking it off at night and when sitting for any length of time. 

When sitting or laying down, as long as pain permits,  I would be performing gentle non-weight bearing mobilisation exercises with the injured ankle, like ankle pumping, ankle circles, or the alphabet exercise. 

See the short videos below showing you how to perform the exercises.

Ankle Pumps

Ankle Circles

Ankle Alphabet Exercise

Secondary Recovery Phase

This phase is important. If you skimp on it, you may get ongoing problems with your ankle.  Research has shown that ankle rehab is often ineffective and that many patients have lingering problems for up to 18 months after their injury.

During this phase you should gradually reduce the amount of time spent wearing the ankle brace and also start some controlled weight-bearing balance and muscle strengthening exercises for the injured ankle. 

For videos detailing how to do these exercises click the image below or here.

When should you go back to sport?

Like a previous article I wrote about hamstring injuries, there is evidence that athletes are returning to sport too soon after ankle sprains. A study looking at pro footballers showed that they were back playing football on average 16 days after the injury, and that 17% of them then went on to injure the same ankle again. 

Considering most people don’t have access to the medical support of a professional footballer, I believe you shouldn’t really be returning to sport earlier than 16 days after your injury. 

As research has shown that collagen can still be forming and maturing in the scar tissue up to 3 weeks after the injury, for me, 3 weeks seems like a more sensible minimum return to play timescale. Three weeks would also allow for more balance and strengthening exercises to take place. 

Should you wear an ankle brace when you return to sport?

Like a lot of the research around ankle sprains, there’s no definitive advice about this. Some research has recommended that athletes returning to sport following an ankle sprain should wear some type of ankle brace for both matches and training for at least 6-12 months after the injury. Other research has been less supportive of the ongoing use of braces after the initial rehab period. 

From a physiological perspective, studies have shown that damaged ankle ligaments are still recovering their stability for up to 3 months post the injury, and other research has shown that 31% of people still have clinical ankle instability 6 months after an ankle sprain.

Ultimately, it’s a personal decision which will depend on a number of factors, including how successful your rehab has been, how stable you feel your ankle has become and the nature of your sport.

Based on the healing timeline above, there’s an argument for wearing some light ankle support (like an elasticated brace) when playing sport for at least 6 months after the injury. However, I would certainly look to phase out an ankle brace long-term by working on the rehab exercises to stabilse the ankle effectively.

Osteopathy

Finally, there is a role for osteopathic treatment in the ankle sprain rehab process, particularly when it comes to trying to prevent repeat strains.

I like to assess what is going on bio-mechanically with patients who have had ankle sprains, particularly what’s happening in the ankle joint and within the affected foot. Several of the small bones in the foot can become malpositioned or misaligned following ankle sprains and may need treatment. 

In addition, it’s important to assess the  mobility and function of the lower back, hips, knees and feet, as they can all have an effect on ankle function.

If you live in the East Grinstead or Forest Row area and have suffered an ankle sprain, and want help getting back to sport, then book an appointment to see me at Osteo Studio.

Cliff Russell, Registered Osteopath