Ankle Sprain Rehab and Recurrence

Ankle Sprain Rehab: Why Healed Ankles Keep Rolling

Ankle sprains get treated like a nuisance. You roll it stepping off a curb or landing wrong on a basketball court, ice it, limp for a week, and then one day it stops hurting and you go back to what you were doing. Most people never see anyone about it, and few do anything that looks like rehab.

The problem is that an ankle usually stops hurting well before it’s ready, and the gap between those two points is where a lot of second and third sprains happen. Lateral ankle sprains are among the most common injuries in physically active people, and the recurrence rates are high enough that a large share of people who sprain an ankle once go on to develop ongoing problems with it (1). One estimate puts the share who develop chronic ankle instability at up to 40 percent after a first sprain (2).

Why a healed sprain comes back

Chronic ankle instability describes an ankle that, more than a year after the first sprain, is still prone to re-spraining or the feeling of giving way, often with some lingering pain or swelling (2). It’s common enough that it’s worth assuming it’s a risk for anyone who has rolled an ankle and never trained it back.

When a ligament gets stretched or torn, the injury reaches past the tissue itself. The updated model of chronic ankle instability describes mechanical changes in the joint feeding into changes in how the ankle senses its own position and how the person moves afterward (2). That’s a useful frame, because it explains why rest alone tends to fall short. Rest lets the tissue settle, and the sensing and movement pieces still need to be trained back.

What a sprain changes besides the ligament

Position sense is usually the first casualty. Ligaments and the joint capsule carry receptors that feed position and movement information to the nervous system. After a sprain, that signal gets less reliable, and the muscles that protect the ankle can react a beat too late when the foot lands on something uneven.

Range takes a hit too. Many people come out of a sprain with less dorsiflexion (the shin moving forward over the foot) than they had before. A stiff ankle changes how you land and squat, and it tends to push load somewhere else. If you’ve ever been told you have tight calves, it’s worth knowing that what looks like a calf problem is sometimes something else in the ankle, which we break down in this video on tight calves versus ankle eversion.

Then there’s control at the edges of the range. Most sprains happen when the foot rolls inward past where the ankle can manage. Strength in eversion (turning the sole of the foot outward) and control near the end of inversion are what catch the ankle before it goes too far. After a sprain, both tend to be weaker than people realize, because nothing in daily walking asks for them.

Why landing is where it goes wrong

Walking on flat ground barely tests any of this, and landing tests all of it. When you jump and come down, step off a curb without looking, or cut sideways on a court, the ankle has a fraction of a second to sense the surface and organize itself. If position sense is dulled and control at end range is weak, the foot keeps rolling.

That’s why someone can feel completely fine for months and then re-sprain the ankle the first time they play a pickup game or hike a rocky section of the Greenbelt. The ankle was never tested under those conditions after the first injury. Training those conditions on purpose, in a controlled way, is what return-to-activity work is for.

What training an ankle back looks like

The goal is an ankle with its range back, enough control to own that range, and the reactivity to handle an unpredictable landing.

Range and control come first. Ankle CARs (slow, controlled circles of the ankle through its full range) give you a daily read on how the joint is moving and gently work all of its directions. From there, PAILs and RAILs for dorsiflexion and eversion build strength at the ends of the range, which is where a sprain happens. The video below walks through the kind of ankle work we use in KINSTRETCH classes, and the full post on ankle mobility foundations explains why we start new members at the ankle.

Single-leg stability comes next. Standing on the injured leg, then adding head turns, eyes closed, reaching, or an unstable surface, retrains the ankle to sense and correct. A review of treatment research found moderate evidence that this kind of neuromuscular training reduces the risk of re-spraining an ankle (3).

Landing comes last. Start with small hops in place, progress to hops forward and sideways, and eventually step down off a low box, with attention on a quiet, controlled landing. The height and speed go up only as the ankle handles the level below it. Most people skip this stage, and it’s the one that looks most like how sprains happen.

The calf and Achilles also need to be strong enough to absorb load, which overlaps with what we covered in Achilles tendon loading. And spending more time barefoot, on surfaces where the foot has to work, can help rebuild the sensing side of the ankle, which is part of why we think barefoot training is underrated.

When it isn’t a training problem

Some ankle injuries need imaging or a medical evaluation before any of this. If you couldn’t take four steps right after the injury, have pain directly on the bone around the ankle or the outside of the midfoot, have pain higher up between the shin bones (a high ankle sprain), or the ankle feels loose and unstable well after the swelling has gone down, see a physician or physical therapist first. If you’ve already been through physical therapy and were discharged before you felt ready, that’s a situation we see often, and training after physical therapy covers how that handoff should work.

Common questions

How long does a sprained ankle take to heal?

Pain and swelling from a mild to moderate sprain usually settle within a few weeks, though the ligament keeps remodeling for months after that. The more useful question is how long it takes before the ankle can land and cut with confidence, which depends on the sprain and on the training. Many people feel normal well before the ankle is ready for sport.

When can I run or play sports again?

When you can hop on the injured leg, land quietly, change direction without hesitation, and the ankle feels as trustworthy as the other one. Time alone is a poor guide, and someone who trains the ankle can often return sooner and with less risk than someone who waits it out.

Should I keep wearing a brace?

Bracing has strong evidence for reducing the risk of re-spraining an ankle (3). A brace can be a reasonable tool during a return to sport or for high-risk activities. It works best alongside training, since position sense and strength still have to be rebuilt.

Why does my ankle keep rolling?

Repeated sprains usually point to position sense and end-range control that never fully came back after the first injury. If it keeps happening, get it assessed; an ankle that rolls often needs more than another round of rest and ice.

If your ankle has been giving you trouble since the last time you rolled it, we can take a look and build a plan from what we find.

References

Written by

Brian Murray, FRA, FRSC

Founder of Motive Training

Motive Training is a coaching studio in South Austin built around assessment, joint health, and strength you can use. Train with us in the studio, come to a KINSTRETCH class, or work through the progressions in KINSTRETCH Online.

Ankle Sprain Rehab: Why Healed Ankles Keep Rolling