Ankle sprain: conservative protocol
Conservative pathway based on early protected loading, peroneal strengthening and proprioceptive retraining, with objective return-to-sport criteria and prevention of chronic instability.
Return to sport: 2-8 weeks for grades I-II, longer for grade III and syndesmotic injuries
This protocol is part of the post-operative pathway and must be adapted to the surgeon’s instructions and to the individual clinical response.
These documents are protocol templates for information and education only: they do not replace the rehabilitation prescription for the individual case. Timing, loading and progressions must always be adapted to the patient, the lesion pattern, the surgical technique used and the clinical course, in collaboration between orthopaedic surgeon, physiotherapist and, where appropriate, physiatrist. Progression is driven by objective criteria, not by the calendar alone.
At a glance
- Acute phase
- PEACE & LOVE: protect, elevate, compress, educate; then progressive loading, optimism, vascularisation, exercise. Anti-inflammatory drugs are used only on medical advice and never to mask pain in order to load earlier.
- Loading
- Early and protected, as tolerated: prolonged immobilisation is discouraged.
- Brace / taping
- Semi-rigid brace or taping in the first weeks and in high-risk sports for the first 6-12 months.
- Proprioception
- Started early, continued for at least 6-8 weeks including after return to sport.
- Running
- When walking and single-leg hopping are pain-free and dorsiflexion is symmetrical.
- Return to sport
- 2-8 weeks in mild-moderate grades; always with functional criteria met.
- Days 0-3Compression, weight bearing as tolerated, early motion
- Days 3-14Normal gait, dorsiflexion recovery
- Weeks 2-6Strength, proprioception, running
- Weeks 4-8Agility and return to sport
- 6-12 monthsPreventive programme maintained
Ankle sprain is the most common musculoskeletal injury in youth sport. It is considered trivial, but it is far from harmless: a very high proportion of patients develop persistent symptoms or chronic instability when rehabilitation is incomplete or return to sport is early and not criteria-based.
Step by step
Each phase lists the goals, what to do and the exercises for that exact moment: do not anticipate them. Dosage is indicative and must be adapted by your physiotherapist.
Phase 1 — Acute: protection and optimal loading
Indicative timing: Days 0-3
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Control pain and swelling
- •Protect tissues without prolonged immobilisation
- •Start loading as tolerated
What to do
- •Elastic compression and elevation, relative offloading with crutches if gait is antalgic
- •Semi-rigid brace or taping
- •Active unloaded ankle mobility (foot alphabet) within pain limits
- •Education: the ankle should be moved and loaded, not fully rested
Restrictions and precautions
- •Avoid heat, deep massage and alcohol in the first 48 hours
- •Avoid running, jumping and uneven surfaces
Exercises for this phase
1. Ankle alphabetFrom the first days, offloaded
- •Sitting or lying, leg elevated and foot free in the air.
- •Draw the letters of the alphabet with the big toe, moving only the ankle.
- •Slow, wide movements, within pain limits.
Dosage: Full alphabet, 3-4 times a day
Ready for the next phase when
- ☐Decreasing swelling
- ☐Walking possible with partial or full weight bearing, with or without brace
- ☐Pain controlled at rest
Phase 2 — Subacute: mobility and activation
Indicative timing: Days 3-14
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Restore dorsiflexion
- •Normal gait without aids
- •Activate peroneals and tibialis posterior
What to do
- •Active mobility in all directions, dorsiflexion mobilisation (knee-to-wall)
- •Isometric then elastic-band strengthening in 4 directions, emphasis on eversion
- •Single-leg balance on a stable surface, eyes open then closed
- •Cycling and walking in water
Restrictions and precautions
- •No jumping, no running, no fully loaded unstable surfaces while pain is uncontrolled
Exercises for this phase
2. Knee-to-wall (dorsiflexion)From the loading phase
- •Stand facing a wall, operated foot forward, heel firmly on the ground.
- •Push the knee forward towards the wall without lifting the heel.
- •Measure the toe-to-wall distance and compare with the healthy side: target difference <2 cm.
Dosage: 3 sets of 10 pushes, twice a day
3. Four-direction band workFrom week 3-4
- •Sitting with the leg extended and a band around the forefoot.
- •Move in four directions: up, down, inwards, outwards.
- •Move slowly over 2 seconds, return under control over 3 seconds.
Dosage: 3 sets of 15 per direction, daily
Ready for the next phase when
- ☐Symmetrical gait without aids or limping
- ☐Weight-bearing lunge test within a few centimetres of the healthy side
- ☐Single-leg balance held for 30 seconds
Note for the physiotherapist
Limited dorsiflexion is one of the strongest predictors of recurrence: measure it with the weight-bearing lunge test and treat it specifically, not only with passive stretching.
Phase 3 — Functional: strength and proprioception
Indicative timing: Weeks 2-6
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Symmetrical peroneal and calf strength
- •Proprioceptive control on unstable surfaces
- •Return to running and light jumping
What to do
- •Progressive band and bodyweight strengthening: double-leg then single-leg calf raises
- •Proprioception on wobble board, cushion and unstable surfaces, progressing to eyes closed and dual-task
- •Star Excursion / Y-balance as both exercise and measure
- •Progressive straight-line running, then hopping and light plyometrics
Restrictions and precautions
- •Cutting and sport-specific skills only in the next phase
Exercises for this phase
4. Calf raiseFrom full weight bearing
- •Standing with hands on a wall, rise onto the toes with both feet.
- •When easy, lower slowly on one leg only (3-second eccentric).
- •Final target: 25 full single-leg repetitions.
Dosage: 3 sets of 15, 4-5 times a week
5. Single-leg balanceFrom the full weight-bearing phase
- •Stand on one leg, knee slightly bent, looking ahead.
- •Progress: eyes open → eyes closed → soft surface → catching a ball.
- •The pelvis must stay level: if it drops on one side, the gluteus medius is weak.
Dosage: 3 x 30 seconds per side, daily
6. Proprioception on an unstable surfaceFrom week 2-3
- •Stand on a cushion or wobble board on one leg.
- •Hold the position with the knee slightly bent and the pelvis level.
- •Progressively add eyes closed, ball throwing and light perturbations.
Dosage: 3 x 30 seconds, daily
Ready for the next phase when
- ☐Repeated single-leg calf raise, pain-free and symmetrical
- ☐Star Excursion Balance Test asymmetry <4 cm
- ☐Pain-free continuous running
- ☐No swelling after sessions
Phase 4 — Return to sport and prevention
Indicative timing: Weeks 4-8 and beyond
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Safe agility, cutting and sport-specific skills
- •Confidence in the ankle
- •Recurrence prevention
What to do
- •Progressive agility: shuttles, figure-of-8, cutting, decelerations
- •Simulation of sport-specific gestures and graded return to training
- •Ongoing neuromuscular prevention programme (FIFA 11+ or equivalent), taping/bracing in high-risk sports
Exercises for this phase
7. Progressive plyometricsImpact phase
- •Start with two-foot hops on the spot, landing softly with bent knees.
- •Progress to front-back and lateral hops, then single-leg.
- •Landings must be silent: noise means insufficient shock absorption.
Dosage: 2-3 sets of 10-20 contacts, 2-3 times a week
8. Agility and change of directionPre-return-to-sport phase
- •Shuttle runs, figure-of-8, cone slaloms: wide turns first, then sharper cuts.
- •Add unanticipated (cued) direction changes only at the end.
- •No drill should be performed with pain or a feeling of an unsafe knee.
Dosage: 2 sessions a week, within training
Ready for the next phase when
- ☐Agility and cutting performed without pain or a feeling of instability
- ☐No swelling after the most demanding sessions
- ☐Sport-specific training tolerated progressively
- ☐The tests and questionnaires required for clearance are listed in the return-to-sport section
If symptoms appear after a progression
If persistent pain, effusion or swelling, or loss of movement appears after moving to a new phase or increasing load, temporarily reduce load and volume and have the situation reassessed by the surgeon or physiotherapist before progressing again. This document is informative for families and physiotherapists and does not replace individual clinical assessment.
Return to sport / full activity
2-8 weeks for grades I-II; longer for grade III, syndesmotic injuries and osteochondral lesions.
- ☐Hop tests (single-leg hop, figure-of-8) with LSI ≥90-95%
- ☐No reported functional instability (no giving way in daily or sporting activities)
- ☐Return to daily and sporting activities without pain or limitations reported by child and family
- ☐Star Excursion Balance Test asymmetry <4 cm
- ☐Symmetrical dorsiflexion on weight-bearing lunge test, no residual swelling or pain
- ☐Sport-specific functional tests passed without compensation
The neuromuscular programme should continue after return to sport: it is the intervention with the largest documented effect on recurrence. Bracing or taping in high-risk sports is reasonable for the first 6-12 months. The Limb Symmetry Index has known limitations: on its own it is not sufficient, because the uninjured side may also be deconditioned; it should be combined with absolute strength values, movement quality and sport-specific demands.
Red flags: stop and contact us
- •Inability to bear weight or tenderness over the malleoli or base of the 5th metatarsal (criteria indicating that an X-ray should be requested)
- •Pain high on the ankle with a positive squeeze test (suspected syndesmotic injury)
- •Deep pain, locking or catching (suspected osteochondral lesion)
- •Swelling that does not settle or pain persisting beyond 6 weeks
- •Repeated giving way despite rehabilitation (chronic instability)
- •In children with open physes: focal tenderness over the distal fibular or tibial physis after trauma (possible physeal injury, even with normal radiographs)
Written and reviewed by Dott. Daniele Priano, Paediatric Orthopaedics. Last review: August 2026.
Timings are indicative: progression depends on clinical and functional criteria and on the surgeon’s indications.
Frequent questions
Is it true that the ankle should be rested?
No: prolonged rest worsens outcomes. Current guidance (PEACE & LOVE) recommends early loading and movement within pain limits, with protection in the first days, because tissue heals better with graded loading.
Why does the ankle keep giving way months later?
Because the sprain also damages the receptors that inform the brain about foot position. Without specific proprioceptive work, chronic functional instability can develop; it is treated with balance, peroneal strength and dorsiflexion recovery, not with rest.
In-depth content (full introduction, technique comparison, FAQ, references) at ortopediaevolutiva.com/en/rehabilitation/ankle-sprain
Ankle sprain: conservative protocol — Dott. Daniele Priano, Pediatric Orthopaedics · Information document: it does not replace an in-person assessment.
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Email: daniele.priano@ortopediaevolutiva.com