The Clinical Coach: Ankle Rehabilitation for Acute and Chronic Sprains

Happy Fourth of July .

Before you get to them, you’ll want to save this issue as this is one of the most common complaints you’ll see in the summer if you are working with runner, hybrid athletes or college students.

What is… acute/chronic ankle sprains?

If you remember from your time in my myofascial course.

Sprains are injuries to ligaments. In this case to the ligaments of the ankle.

Typically caused by a sudden twist or rolling motion of the foot.

Sprains, just like strains, are graded.

Ankle sprains are classified into three grades based on the extent of ligament damage.

• Grade 1 (mild): Stretching or slight tear of the ligament with minor pain and swelling

• Grade 2 (moderate): Partial tear of the ligament with moderate pain, swelling and difficulty with weight-bearing.

• Grade 3 (severe): Complete tear of the ligament with significant pain, swelling, and instability.

Most Common Treatment

Most patients tend to simply ignore their ankles rolls, unless it’s really bad and they are unable to load it at.

Thinking it might be broken, they rush to the doc and get some x-rays.

They’ll soon come out with an outrageous bill and a simple, and quite frank absurd, treatment plan.

Pain pills, and RICE.

If you are familiar with the rest, ice, compress, elevate protocol. It’s been almost 10 years since the original authors of that protocol came out to say they were not supportive about that “Rest” mentality anymore.

Instead they recommended methods like POLICE:

• Protect

• Optimal Loading

• Ice

• Compression

• Elevation

It holds to be a more robust approach helping patients return to activities faster, with actually better outcomes than before.

Why?

Well there are a couple of reasons.

• Patient’s aren’t deconditioning because of resting the injury

• Patient’s move their ankle more often than the latter option of rest

• Patient’s get introduced to better loading and rehab through the early stages.

In my experience. Patient’s who follow the POLICE method tend to require less ICE overall and spend about 50% less out of their activities.

Assessing the Ankle

As any good clinician your assessment should include the testing of:

• Gastrocnemius/Soleous

• Anterior/Posterior Tibialis

• Extensor Hallucis

• Flexor Hallucis

• Plantar Fascia

• Walking gait

• Deltoid ligament

• PTFL

• ATFL

• CFL

What are we looking at here?

From the muscle assessment, we are looking for good muscle strength, non-painful movements of the ankle, and non-painful muscles during all ranges of motion at the ankle. Preferably we’d like to see pain during our passive assessments.

During walking gait, we are looking for foot mechanics. I’m not nearly as concerned with the knee or hip just yet. While they may be involved in some compensation mechanics, during acute ankle sprains, correcting and emphasizing safe patterns at the ankle will most likely change the kinetic chain upwards, affecting the knee and hip.

What specifically are we looking in ankle mechanics? We are looking at how your patient lifts their foot, and how it lands. Can they balance in one foot with minimal pain?

The 3-Phase Ankle Rehab Formula

In my opinion, there’s no one size fits all rehab program.

Sure there are overlaps in the system or formula, but seldomly should patients have the exact same program.

This is the exact 6-week framework we use to help runners and trail runners bounce back with stronger ankles broken down in phases.

Not every patient will follow the timeline exactly, some overlap between phases might be needed.

Phase 1: RESET (Weeks 0–2)

Goal: Reduce pain, swelling, and restore mobility

Priorities:

• Control swelling: compression, elevation, active movement

• Restore dorsiflexion and eversion

• Light weight-bearing as tolerated

Weekly Focus:

• ✅ Ankle pumps – 3x/day, 20 reps

• ✅ Alphabet with toes – 2x/day

• ✅ Banded ankle mobility (dorsiflexion) – 2x/day

• ✅ Heel-toe rocking (tall stance weight shifts)

• ✅ Isometrics (towel curls, resistance band holds)

• ✅ Walking with short strides inside shoes or hiking boots

Phase 2: REBUILD (Weeks 3–5)

Goal: Rebuild balance, control, and ankle-specific strength

Priorities:

Proprioception (awareness and balance)

Lateral and rotational stability

Strengthen peroneals, tibialis posterior, and intrinsic foot muscles

Weekly Focus:

✅ Single-leg balance (eyes open → eyes closed)

✅ Banded ankle strengthening – all 4 directions

✅ Heel raises (double → single leg)

✅ Step-downs and eccentric calf lowering

✅ Toe walks + heel walks for 30s x 3 sets

✅ Mini-hikes or incline treadmill walking (progress terrain)

Phase 3: RELOAD (Week 6+)

Goal: Prepare for return to running/hiking with full function and trust

Priorities:

Restore power, reactivity, and load tolerance

Simulate real-world terrain demands

Reinforce joint integrity under fatigue

Weekly Focus:

✅ Single-leg hops (forward/side-to-side)

✅ Skater bounds + deceleration drills

✅ Trail-specific strength: step-ups, split squats, weighted carries

✅ Return-to-run program (walk/run intervals)

✅ Trail preview sessions: hike inclines/descents + loose footing

✅ Plyometric ladder work (if trail running is their sport)

Expect Outcomes Upon Completion

• Full return to running, squatting, and hybrid training by week 12

• Better strength, mobility and endurance symmetry

• More resilient, pain-free capacity

Anything else?

Yes.

If you suspect your patient may have a hidden stress fracture or have any of the following symptoms:

• ankle catching, locking or swelling post movement

• pain persists at night or worsens with rest

• no improvement after 4 weeks of rehab

Order imaging.

Clinical Pearls

Tissue remodeling, tissue capacity, and tissue adaptations only occur through adequate stressors. In those cases your best progressions are based on volume, load, intensity and frequency of the stimulus. Start conservative and build.

Every patient is unique.

Make sure you take the time to understand them.

Until our next issue!

In health and strength,

P.S. If you have questions or comments, feel free to respond to this email. I reply to all emails personally.

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