Rehabilitation for a syndesmotic ankle sprain is typically longer and more cautious than for lateral ankle sprains due to the critical role of syndesmotic stability in overall ankle function. The goal is to restore stability, strength, range of motion, and proprioception while preventing re-injury. The protocol will depend on the grade of the sprain.

General Phases of Physiotherapy

• Acute/Protection Phase (Initial 2-4+ weeks):
  • Goals: Reduce pain and swelling, protect the injured ligaments, promote initial healing.
    • R.I.C.E. principles: Rest (often non-weight bearing or partial weight-bearing with crutches/boot), Ice, Compression (compression stocking or elastic bandage), Elevation.
    • Immobilization: A walking boot or cast may be used to provide stability and limit painful movements (especially external rotation and dorsiflexion). The duration depends on severity.
    • Gentle, pain-free range of motion (ROM) exercises for unaffected joints: Maintain mobility in the knee, hip, and toes.
    • Isometric ankle exercises (pain-free): Gentle contractions of ankle muscles without joint movement (e.g., pushing foot gently into a pillow) to maintain muscle tone and circulation, avoiding pain-provoking directions.
    • Upper body and core conditioning: To maintain overall fitness.
• Subacute/Early Mobilization Phase (Weeks 2-8+):
  • Goals: Gradually restore pain-free ankle ROM (especially dorsiflexion and external rotation, which must be managed cautiously), begin light strengthening, improve early proprioception, progress weight-bearing.
    • Manual Therapy:
      • Gentle Joint Mobilizations: Once cleared by the orthopedic surgeon, the physiotherapist will carefully introduce low-grade joint mobilizations (Grade I-II) to the ankle joint (talocrural) and subtalar joint to restore normal joint play and improve overall mobility. Crucially, specific mobilizations to the tibiofibular joint or those that stress the syndesmosis (like excessive dorsiflexion or external rotation) are avoided or performed with extreme caution until later stages of healing. The focus is on mobilizing adjacent joints to reduce compensatory stiffness.
      • Soft Tissue Mobilization: Gentle massage, myofascial release, or instrument-assisted soft tissue mobilization (IASTM) to address muscle guarding, swelling, and any scar tissue formation in the surrounding calf muscles, foot muscles, and along the lower leg. This helps reduce pain and improve tissue flexibility.
      • Lymphatic Drainage Techniques: To help manage persistent swelling.
    • Active and Passive Range of Motion (AROM/PROM): Carefully guided exercises to regain dorsiflexion, plantarflexion, inversion, and eversion, always respecting pain and avoiding forceful end-range external rotation/dorsiflexion.
    • Light Strengthening (non-weight bearing to partial weight-bearing):
      • Theraband exercises: For ankle plantarflexion, inversion, eversion (dorsiflexion with caution).
      • Foot intrinsic muscle exercises: Towel curls, marble pickups.
      • Calf muscle activation: Gentle seated calf raises.
    • Gradual Weight-Bearing Progression: Progressing from non-weight bearing to partial weight-bearing with crutches, then full weight-bearing, often guided by a walking boot initially.
    • Early Proprioception/Balance: Begin with seated or supine balance exercises. Progress to standing balance with support, then single-leg stance on stable surfaces as tolerated.
• Intermediate Strengthening & Proprioception Phase (Weeks 6-12+):
  • Goals: Significantly improve strength, endurance, balance, and prepare for more dynamic activities.
    • Progressive Strengthening:
      • Weight-bearing exercises: Double-leg calf raises (progressing to single-leg), squats, lunges, step-ups.
      • Closed-chain exercises: Focus on functional movements.
      • Eccentric strengthening: For calf muscles (e.g., controlled lowering from a calf raise) to build tendon resilience.
    • Advanced Proprioception/Balance Training:
      • Balance exercises on unstable surfaces (foam pad, wobble board, BOSU ball – carefully, ensuring no syndesmotic stress).
      • Single-leg balance with dynamic movements (e.g., reaching, tossing a ball).
      • Dynamic balance activities (e.g., walking on uneven surfaces, tandem walking, figure-eights).
    • Cardiovascular Fitness: Stationary cycling, swimming, elliptical to maintain fitness without excessive ankle stress.
• Return to Activity/Sport Phase (Weeks 12-24+ or longer):
  • Goals: Achieve full functional return, minimize risk of re-injury, and prepare for specific sport or occupational demands. This phase is crucial and requires patience.
    • Plyometrics: Gradually introduce low-level jumping and hopping drills (double leg to single leg), progressing to multi-directional jumps and bounds, ensuring proper landing mechanics.
    • Agility Drills: Ladder drills, cone drills, cutting, pivoting, and change-of-direction drills. These are introduced slowly and with careful monitoring for pain and stability.
    • Sport-Specific Drills: Gradually integrate movements and skills specific to the patient’s sport or activity.
    • Taping: Syndesmotic taping (high ankle taping) or a specific ankle brace may be used for support during advanced training and return to sport to provide external compression and stability to the distal tibiofibular joint.
    • Gradual Return to Play/Activity Protocol: A structured, progressive return that ensures the ankle can tolerate the demands without pain, swelling, or instability. This often involves specific objective testing (e.g., hop tests, agility tests).