Are you a football player with a recently sprained ankle? Chances are you’re not alone. Ankle sprains are very common amongst football players, with numerous studies indicating high injury rates. An analysis of English academy players with ages ranging from U9 to U16 revealed a rate of 1 ankle injury per year per player. A similar study was conducted on professional players across Europe, revealing an average rate of ankle sprains that equated to 7 injuries per team each season. Child, teenagers and adults - ankle sprains are a threat to competitive players of all ages. If you want to secure a swift and safe return to playing football after an ankle sprain, understanding the importance of effective rehab will be essential.
Step 1 - The Acute Phase
The first step of rehab will be visiting our physiotherapist, who will help us determine the sprain’s level of severity. This is commonly done by assigning a grade from I to III based on the amount of damage to the ligament(s). From here you will be given a timeframe for a return to sport, allowing time for healing and also an exercise program that will improve the physical capabilities of the ankle.
The first stage of recovery is known as the acute phase, in which pain and swelling are highest during the first few days following the injury. For ankle sprains, the main focus at this stage is to manage swelling and return to pain-free gentle activities (eg walking).
Following the PEACE & LOVE acronym is a helpful way to ensure best healing (as pictured below). PEACE applies to the first few days in which elevation for swelling management and avoiding aggravating movements is our priority. LOVE involves participation in healthy movements and exercises once our symptoms settle. The key is to gradually return to movement at a rate that does not aggravate pain.
Step 2 - Understanding Rehabilitation Exercise Program Structure
After the acute phase is over and your ankle is less irritable, your structured exercise program can begin. These can be designed using periodisation, which is essentially a process that divides a rehabilitation period (macrocycle) into smaller blocks (mesocycles). Each mesocycle has different treatment priorities for exercise prescription based on what is relevant for that stage of recovery. In the case of an ankle sprain, our 4 main target areas for exercises are:
Muscle strength
Power (rate of force development)
Sensorimotor abilities - specifically the ability of the ankle muscles to maintain stability in response to sensory information concerning joint position (proprioception)
Sports specific activities (performance sensorimotor abilities)
For example, let's say your ankle sprain requires a 12 week rehabilitation period before returning to play, the exercise plan would then be broken into three 4-week mesocycles. As demonstrated by the graph below, the focus of the 1st mesocycle would be on muscle strength and sensorimotor abilities (stability), the 2nd would be a balance of all 4 areas, and the 3rd on rate of force development (power) and performance sensorimotor abilities (sport specific activities).
Step 3 - Ankle Strength + Stability Exercises
Now that we know how the program can be effectively structured, let's focus on these first 2 early priorities of strength and ankle stability.
Training the muscles at the ankle is important because they are considered the ‘active stabilisers’ of the joint, meaning it is their contractions that help prevent injuries. If your injury is a lateral sprain, then the ankle evertors (located on the outer side) are a priority to train. Similarly for a medial sprain, the ankle inverters (located on the inner side) are important. This is because these muscles perform the opposite action to the movement that causes either type of sprain. Dorsiflexion (front of ankle) and plantar flexion (calves) strength is also helpful. Ankle strengthening can be performed using therabands, as shown in the diagram below. Please note that calf raises are preferable for plantarflexion, provided they do not exacerbate your ankle pain.
Next up is ankle stability exercises. Ankle sprains unfortunately cause a decrease in stability, partially due to the ligament becoming less tight after healing (imagine a rope becoming more slack), but also due to their proprioceptive function being impaired after injury. Thankfully, studies have shown that balance and stability training can help decrease the chance of recurrent ankle sprains. A simple, early exercise is single leg balance (static balance), which can be made more difficult with eyes closed and/or foam surfaces. The following exercises can further train your stability:
Single Leg balance on BOSU board (reactive balance)
Tightrope walk over rolled towel (dynamic balance)
4 square hop (dynamic balance, multiple directions of movement)
Step 3 Power and Sport Specific Exercises
Finally, let’s focus on the later stage priorities of power and sports specific activities.
Plyometric exercises, such as box jumps or squat jumps, improve both jump height and time taken to reach the jump’s apex. Both improvements are beneficial for winning headers in a football match, which is especially important if your position is centreback or striker. Explosive sprinting exercises over short distances, such as 35m sprints or hill sprints, aim to increase muscular power to achieve top speeds quickly. This is important in a footballing context during counter attacking plays, especially if you are a winger or fullback who needs to be able to transition from offence to defence rapidly.
The natural way to perform football-specific exercises would be to return to training, however your ankle will also need additional help to prepare for the quick changes of direction involved in football. To help prepare your ankle for return to play, additional agility exercises will greatly help. Running + cutting is a helpful exercise that can be performed in a variety of directions + distances using markers. Additionally, agility ladders help focus on rapid direction changes, while a box drill agility exercise (diagram below) incorporates back peddles, forward sprints and side shuffles into one exercise.
While ankle sprains can be discouraging at first, the good news is that rehab can help. Through the general overview we just covered, we can see how a well-structured plan can not only reduce the chance of reinjury but also improve physical performance upon your return to sport.
References:
Cloke, D., Spencer, S., Hodson, A., & Deehan, D. (2008). The epidemiology of ankle injuries occurring in English Football Association academies. British Journal Of Sports Medicine, 43(14), 1119-1125.
D’Hooghe, P., Cruz, F., & Alkhelaifi, K. (2020). Return to Play After a Lateral Ligament Ankle Sprain. Current Reviews In Musculoskeletal Medicine, 13(3), 281-288.
Dubois, B., & Esculier, J.F. (2020). Soft- tissue injuries simply need PEACE and LOVE.
British Journal of Sports Medicine. 54,72-73.
Minshull, C. (2019). Periodisation and Rehabilitation [Blog]. Retrieved from https://getbacktosport.com/latest-news/periodisation-and-rehabilitation/
Vriend, I., Gouttebarge, V., van Mechelen, W., & Verhagen, E. (2016). Neuromuscular training is effective to prevent ankle sprains in a sporting population: a meta-analysis translating evidence into optimal prevention strategies. Journal Of ISAKOS, 1(4), 202-213.
Waldén, M., Hägglund, M., & Ekstrand, J. (2013). Time-trends and circumstances surrounding ankle injuries in men's professional football: an 11-year follow-up of the UEFA Champions League injury study. British Journal Of Sports Medicine, 47(12), 748-753.
Wood, B. (2008), "Box Drill Fitness Test." Topend Sports Website,
https://www.topendsports.com/testing/tests/box-drill.htm, Accessed 12 May 2022
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