Ankle injuries are one of the most commonly seen conditions among athletes and physically active individuals. Whether they come from an acute injury like a sprain or a chronic issue such as tendinopathy or instability, ankle pain can have a large impact on performance and activities of daily living. Athletic therapists play a crucial role in managing ankle pain through prevention, assessment, rehabilitation, and education. Their approach integrates evidence-based practice, functional movement analysis, and individualized rehabilitation to restore mobility, strength, and stability while preventing re-injury.
Anatomy and Function of the Ankle
The ankle is a complex joint that supports body weight, absorbs shock, and provides mobility during walking, running, and jumping. It primarily consists of three bones: the tibia, fibula, and talus. These form the talocrural joint, which allows dorsiflexion (bringing the toes upward) and plantarflexion (pointing the toes downward). Below this lies the subtalar joint, involving the talus and calcaneus (heel bone), which facilitates inversion (rolling in) and eversion (rolling out) movements of the foot and ankle.
The ankle is stabilized by several key ligaments on both the lateral and medial sides of the joint. The lateral (outside) ligaments include the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). This complex prevents excessive inversion of the ankle, which is the most common mechanism how people experience sprains. The medial (inside) ligament is called the deltoid ligament, preventing excessive inversion. There are also important muscles through the lower leg that contribute to the dynamic stability of the ankle: peroneals, tibialis anterior, tibialis posterior, gastrocnemius, and soleus.
Because of the joint’s complex structure and its role in weight-bearing and movement, it is particularly susceptible to injury, especially during high-impact or pivoting activities. Athletic therapists must therefore have a detailed understanding of this anatomy to accurately assess and treat ankle pain.
Common Causes of Ankle Pain
Ankle pain can result from acute or sudden injuries, chronic overuse, or biomechanical dysfunction. There are a variety of conditions or injuries the ankle can experience; understanding these causes helps athletic therapists determine the best course of treatment.
Ankle Sprains
Ankle sprains, particularly lateral/inversion ankle sprains, are among the most frequent injuries treated by athletic therapists. They typically occur when the foot rolls inward, stretching or tearing the ligaments on the outside of the ankle, especially the ATFL. Symptoms include pain, swelling, bruising, and instability. Recurrent sprains can lead to long-term or chronic ankle instability, which is characterized by weakness, proprioceptive deficits, and repeated episodes of the ankle giving way.
Syndesmotic sprains, better known as high ankle sprains, are also frequently seen in the athletic population. These result from having the ankle dorsiflexed and externally rotated (turned out) when planted. Many symptoms are similar to inversion sprains; however, this type of injury involves the ligaments between the tibia and fibula and has a longer healing time compared to a typical ankle sprain.
Tendinopathies
Overuse or repetitive strain can lead to tendinopathies, which are represented by degenerative changes in the tendons. Common areas affected by this type of injury include the achilles, peroneal, and posterior tibial tendons. These conditions typically cause localized pain, inflammation, stiffness, anticipated morning stiffness, and tenderness that worsens with activity.
Fractures and Impingement Syndromes
The malleoli are located at the bottom of the tibia and the fibula on either side of the ankle. They are easily identified as the bony points just above the ankle. Fractures of the malleoli, talus, or calcaneus may accompany severe sprains or trauma. Anterior ankle impingement, caused by repetitive dorsiflexion, and posterior impingement, from plantarflexion overload, can also result in chronic pain and restricted motion.
Biomechanical and Postural Issues
Poor foot biomechanics, such as overpronation or supination, can lead to uneven load distribution and chronic stress on ankle structures. Weakness or tightness in the lower body, particularly the calves, hips, or core, can further contribute to ankle dysfunction. Athletic therapists address these biomechanical factors to ensure long-term recovery and prevention.
Assessment and Diagnosis in Athletic Therapy
Accurate assessment is the foundation of effective treatment. Athletic therapists begin with a comprehensive history, gathering details about the mechanism of injury, duration of pain, activity level, and previous ankle problems. They then perform a physical examination that includes observation, palpation, range-of-motion testing, strength assessment, and special tests.
Observation
When athletic therapists observe the ankle near the start of their assessment, they are looking for swelling, bruising, or deformities. If the therapist notices anything of sinister concern, they will refer you to a medical doctor for further investigation.
Functional Movement Assessment
Athletic therapists often employ movement screens like gait analysis, squats, lunges, or single-leg balance tests to assess the ankle’s role in overall movement patterns. This holistic approach ensures that rehabilitation addresses the root cause rather than just symptoms. If there are any deficiencies, the therapist will be sure to address these in your individualized plan of care.
Range of Motion and Strength Tests
Active range of motion testing provides objective numbers, movement limitations, and pain indicators of your condition, while passive range of motion tests help determine how the joint responds to relaxed movement. Manual muscle testing evaluates strength and pain during contraction. Comparing the injured ankle to the uninjured side provides valuable reference points.
Special Tests
Specific orthopedic tests, such as the anterior drawer test and/or talar tilt test for lateral ligament integrity help confirm ligamentous injury. Klieger’s test is used to confirm a syndesmotic sprain. For chronic instability or suspected impingement, functional and balance assessments are used, but can also involve tests for acute injuries as mentioned above.
Palpation
Near the end of the physical assessment, therapists will palpate or touch associated bones, ligaments, tendons, and muscles to localize tenderness and identify potential tissue damage.
Treatment and Rehabilitation Strategies
Athletic therapy for ankle pain follows a progressive and individualized approach, focusing on reducing pain, restoring function, and preventing recurrence. Treatment typically proceeds through four stages: acute care, recovery, strengthening, and return to activity.
In the first 24-72 hours post-injury, the priority is to manage pain and inflammation. Athletic therapists often use the PEACE and LOVE principle.
The PEACE phase stands for protection, elevation, avoid anti-inflammatories, compression, and elevation.
· Protection: reduce or restrict movement and load on the injured area, which could involve using a brace or crutches. Avoiding complete inactivity is crucial, but the amount of movement should be guided by pain levels.
· Elevation: elevate the injured limb above the level of your heart as much as possible to aid in reducing swelling by the use of gravity.
· Avoid anti-inflammatories: avoid non-steroidal anti-inflammatory drugs (better known as NSAIDs) and ice. Inflammation is a natural part of the healing process.
· Compression: use an elastic bandage or taping to help control excessive swelling, ensuring it is not too tight and restricting blood flow.
· Education: learn about your injury and its specific recovery process. A healthcare professional, such as an athletic therapist, can guide you through an active recovery process and help you avoid further injury.
After the first 72 hours, the LOVE principle begins, focusing on long-term recovery and rehabilitation.
· Load: gradually reintroduce movement and normal activities as tolerated within pain limits. This helps restore strength and promotes healing.
· Optimism: keep a positive mindset. Psychological fears can delay recovery so it is important to believe in yourself and your body’s capacity to heal. You are more resilient than you think!
· Vascularization: start light cardiovascular activities such as stationary cycling, swimming, or gentle walking. This will increase blood flow to the injured area, improve overall function, and reduce the need for pain management.
· Exercise: follow your home exercise program provided to you by your athletic therapist to further restore strength, mobility, and balance, thus reducing your risk of re-injury and a safe return to activity.
Once pain and swelling subside, the focus shifts to restoring the full range of motion and improving neuromuscular control. Therapists introduce mobility exercises like ankle circles, alphabet writing, and gentle stretches for the calf and Achilles tendon. Proprioceptive training, such as balancing on one leg or using wobble boards, helps retrain the body’s awareness of joint position, which is essential for preventing future injuries.
In the strengthening phase, the athletic therapist designs a program targeting both local and global musculature. Exercises may include:
- Resistance band strengthening for inversion, eversion, dorsiflexion, and plantarflexion.
- Calf raises, step-downs, and lateral hops for lower-limb strength.
- Closed kinetic chain exercises (squats, lunges) to restore coordination across joints.
This phase often incorporates plyometric and agility drills to mimic sport-specific demands, preparing the ankle for real-life movements such as cutting, jumping, or sprinting.
The final stage involves progressive reintroduction to sport or physical activity. Athletic therapists use functional testing, such as hop tests or shuttle runs, to assess readiness. They also educate clients on footwear selection, taping techniques, and proper warm-up routines. Preventive programs may include continued balance training, dynamic stretching, and maintenance exercises to ensure long-term ankle health.
The Role of Education and Patient Empowerment
A key component of athletic therapy is client education. Therapists teach individuals about the mechanisms of their injury, how to manage symptoms, and how to modify activity levels safely. Empowering clients with knowledge promotes self-efficacy and adherence to rehabilitation programs. Athletic therapists also emphasize lifestyle factors such as nutrition, sleep, hydration, and recovery habits that influence tissue healing and overall performance.
The Important of Prevent and Long-Term Management
Prevention is a defining feature of athletic therapy. For ankle pain, preventive strategies may include:
- Balance and proprioceptive exercises to enhance stability.
- Strengthening of peroneal and calf muscles for dynamic support.
- Proper footwear assessment to ensure alignment and shock absorption.
- Taping or bracing during high-risk activities for additional protection.
By addressing biomechanical deficiencies and movement inefficiencies, athletic therapists not only treat ankle pain but also reduce its recurrence, supporting long-term performance and well-being.
Conclusion
Athletic therapy provides an evidence-based, functional, and client-centred approach to managing ankle pain. Through detailed assessment, individualized rehabilitation, and ongoing education, athletic therapists guide individuals from injury to full recovery while emphasizing prevention and performance optimization. Their expertise in musculoskeletal health, movement mechanics, and active rehabilitation enables them to treat not just the symptoms but the underlying causes of ankle dysfunction. Whether working with elite athletes or active individuals, athletic therapists play a vital role in helping people move confidently and pain-free. In addressing ankle pain, they embody the essence of the profession: restoring motion, enhancing performance, and preventing future injury through knowledge, movement, and care.
About Kate Wiens:
Kate pursued Athletic Therapy after growing up playing sports (primarily hockey and softball) and became interested in the field after seeing a wide range of injuries and how they could be managed. She has spent the last 8 years working with hockey teams (3 years working AAA through university & 5 years in the MJHL). During her time in hockey, she has seen a variety of injuries and have gotten to channel her creativity with therapeutic rehabilitation, alongside utilizing her first responder skills. Growing up on a farm, she always loved being outside and decided to recently take up golf as a summer activity. In her free time, she enjoys spending time with friends and family (as well as her dog), going to the gym, and exploring the outdoors!
