BraceLab Clinical Clues

August 2020 No. 17

Ankle Sprain Treatment for Athletes - Seize the Evidence!

Jerry Ditz, DPT, Dip. Osteopractic, Cert. SMT, Cert. DN


Because half of ankle sprains occur during sports play and 40% of those ankle sprains lead to re-injury or chronic instability, clinicians often treat athletes more than once for the same ankle injury. When treating the same patient again, reviewing relevant evidence to update the treatment plan may be efficacious.

A 22-year-old male collegiate baseball player (S. T.) who had sustained a grade 2 lateral ankle sprain 18 months earlier returned to physical therapy with the complaint of 1 to 4 episodes of non-painful ankle instability (giving away) per month for the last three months. Interestingly, his instability only occurred during training but not during competition.

Most recent MRI and x-rays were consistent with his previous grade 2 ankle sprain without indication of a new injury. Six months earlier S. T. had discontinued the use of his ankle brace after having worn it for 12 months post injury.

Dumbbell Step Up

His just completed sophomore baseball season had been his most productive, suggesting no performance limitations. S. T. had only one week before he was to begin summer workouts, so therapy was limited to two visits.

Manual muscle testing and range of motion showed no deficits, so a functional return-to-sport ankle exam1 was completed because of his high functional level. Surprisingly, he scored 98% on comparative measures for this exam! Since the examination did not expose impairments for S.T., it was thought recent literature might offer some innovative treatment approaches.

Two systematic reviews suggested that knee and hip strength deficits are common after ankle injury.2-4 Could his athletic ability be masking an underlying hip or knee weakness? Because manual muscle testing did not identify any weakness, strength was assessed using Olympic weightlifting testing protocols.5

Animated Dumbbell Step Ups

An article by Simenz suggested a loaded step-up exercise with variations would allow assessment of multiple movement planes that require hip and knee muscles to be the primary movers. Because S.T.’s ankle instability was only occurring while training, it was important to test both his maximum strength (ability to produce the highest level of muscle force) and his endurance strength (ability to maintain a muscle contraction for a time period.)

To test his maximum strength, S.T. performed a one repetition max test5 while holding dumbbells for the loaded step-up exercise and its variations. To test his endurance strength, S.T. worked to achieve the highest number of repetitions possible in one minute of the same step up exercise, without the dumbbells.

The one repetition max test revealed S.T. had a 15% lower score on his injured side than on his uninjured side, while the bodyweight step-up test showed only a 2% lower score than the uninjured side. This testing determined S.T.’s strength deficit was only present during heavy resistance activities, which indicated it would be beneficial to investigate his current strength training regime. A phone review with S.T.’s strength and conditioning coach identified S.T. could benefit from increasing his single-leg exercises with heavier weight (load) at low repetitions (5 or under).

When treating the same patient for the same injury it is easy to use the same approach. In this case, a literature perusal created a focus on the importance of heavy resistance single leg hip and knee strengthening exercises and highlighted that high-level athletes may need nontraditional testing to identify impairments. Additionally, it was a useful reminder of the importance of working with other sports medicine team members to reach a maximum functional outcome.


1. Clanton TO, Matheny LM, Jarvis HC, Jeronimus AB. Return to play in athletes following ankle injuries. Sports Health. 2012;4(6):471-474.

2. Khalaj N, Vicenzino B, Heales LJ, et al. Is chronic ankle instability associated with impaired muscle strength? Ankle, knee, and hip muscle strength in individuals with chronic ankle instability: a systematic review with meta-analysis. Brit Jour Sports Med 2020;54:839-847.

3. Simenz CJ, Garceau LR, Lutsch BN, et al. Electromyographical Analysis of Lower Extremity Muscle Activation During Variations of the Loaded Step-Up Exercise, J Strength Cond Res. 2012;26(12):3398-3405.

4. Neto WK, Soares EG, Vieira TL, et al. Gluteus Maximus Activation during Common Strength and Hypertrophy Exercises: A Systematic Review. J Sports Sci Med. 2020;19(1):195-203.

5. Ratamess N. ACSM's Foundations of Strength Training and Conditioning. Philadelphia, PA: Lippincott, Williams and Wilkins, 2012


Download Clinical Clues No. 17, Ankle Sprain Treatment for Athletes - Seize the Evidence!; August 2020

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Disclaimer: BraceLab Clinical Clues are intended to be an informal sharing of practical clinical ideas; not formal evidence-based conclusions of fact.

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