Ankle sprain injury can occur both sides of the ankle, when the ankle is twisted or turned in awkward ways either lateral or medial side during any sports activities or ADL 1, 2. Prevalence and incidences of ankle sprain was reported higher in females compared to males (13.6 vs 6.94 per 1000 exposure). Also, higher incidence and prevalence was reported among children ((2.85 per 1000 exposure) than adolescents (1.94 per 1000 exposure), and higher in adolescents (1.94 per 1000 exposure) than adults (0.72 per 1000 exposure) 3. During sports, the incidence of ankle injury is even higher, accounting for 16%-40% among the causes of sports related trauma 4. Almost 85% of ankle sprain occurs at the lateral ankle ligaments in which 65% involves (ATFL) anterior talofibular ligament, 20% involves both ATFL and calcaneofibular ligament (CFL) injury and remaining 15% involves medial ankle sprain 5.

In ankle sprain one or more ligaments of the ankle are partially or completely torn 6. Mechanical instability and neuromuscular impairment are the primary cause for chronic ankle instability (CAI) 7. Lateral ankle sprain commonly occurs in sports involving higher lower limb momentum 8. Ankle sprains are localized with pain at the site of the injury with clinical presentation of ligament laxity, muscular weakness, impaired joint proprioception, stability, inflammatory reaction, restricted joint movement mainly dorsiflexion at the ankle 9, 10.

The ATFL, CFL and posterior talofibular ligaments (PTFL) provides stability against ankle joint inversion 11, 12. ATFL is commonly injured in the lateral ligament complex with 85% prevalence. While CFL 35% cases and PTFL in 12 % cases during ankle sprain 12, 13. The deltoid ligament complex posterior tibiotalar (PTTL), tibiocalcaneal (TCL), tibionavicular (TNL) and anterior tibiotalar ligaments (ATTL) injured during vigorous pronation and supination of hindfoot. The common causes leading to ankle sprain are a fall with ankle twist, awkward landing on foot while running/jumping/ sports, excessive plantar or dorsi flexion of the foot, wearing improper footwear and use of High heels 14, 15, 16.

The risk of ankle sprain includes history of ankle sprain, sports participation in amateurs, activities on uneven platforms, poor posture, balance and muscle weakness, improper shoes, carrying excessive weight, lack of warm up before the sports participation 4, 7. Clinical features of ankle sprain includes severe pain during standing or weight bearing, swelling, tenderness around the sprained ankle, limited mobility, strength and instability of the ankle joint 4, 17.

Ankle sprains on lateral aspect commonly occur during speedy shift of body’s center of mass on weight-bearing foot 13. Excessive ankle Inversion and plantarflexion on the lateral side, affects ATFL, CFL and PTFL. Due to excessive eversion on the medial aspect of ankle, PTTL, TCL, TNL and ATTL are affected 18, 19. Complication includes recurrent ankle sprain due to lack of ligament resilience, joint instability, peroneal tendon injuries, arthritis, and functional performance deficit 20, 21. Research reported early return to sports before complete recovery or rehabilitation in ankle sprain resulted in poor recovery of ligaments properties. Reviews reported high chances of ankle sprain with excessive plantar flexion. Recurrence of ankle sprain can be limited by supervised rehab protocol, tapping, bracing, customized shoes and by reducing the intensity of the activity.

Preventive parameters like proper warm up exercises before sports, cautiousness while walking or running on uneven surfaces, avoiding or minimizing high heeled shoes, use of an ankle brace on weak or previously injured ankle and practicing or training sport with safety gears can reduce the occurrence of ankle sprain 22, 23.

This narrative review included articles from PubMed between 2017 – 2022. Full text articles RCT, systematic reviews, Meta-analysis were included. Key terms used for literature search were Ankle sprain AND physiotherapy, ankle instability, exercises. Abstract and other languages articles were excluded. The quality of the study was analyzed using PEDro quality rating scale. The rating showed that all the studies were in fair and above of which 2 of the included studies were in excellent and one in good category rating (Table 1) .

Table 1

Sl. No	PEDro Criterion	Sierra- guzman	Cruz- diaz	Huang p-y	Hall EA	Cain MS	Feland JB
1	Eligibility criteria	0	1	1	0	1	0
2	Random allocation	1	1	1	1	1	1
3	Concealed allocation	1	1	1	0	0	0
4	Baseline comparability	1	1	1	1	1	1
5	Blind subjects	0	0	0	0	0	0
6	Blind therapists	0	0	0	0	0	0
7	Blind assessors	0	1	0	0	0	0
8	Adequate follow-up	1	1	1	1	0	0
9	Intension- to- treat analysis	0	0	1	0	0	0
10	Between- group comparisons	1	1	1	1	1	1
11	Point estimates and variability	1	1	1	1	1	1
	TOTAL	6	8	8	5	5	4

Figure 1

The literature included for this study from PubMed was critically appraised as follows

This review studied the recent advances in physiotherapy management for ankle sprain. The common symptoms of ankle sprain in acute cases include tenderness over the tip of lateral malleolus or medial malleolus, inability to weight bear immediately after the injury 5. In case of chronic ankle sprain severe pain with ankle joint instability resulting in deficit of functional performance and reduced ankle range of motion are reported 5, 15. The literature reviewed reported that the ankle sprain is common in both men and women aged 17 years to 35 years. We observed that chronic joint instability was commonly reported in amateur and recreational players. Further lack of supervised sport training can lead to structural and functional rearrangements. Physiotherapy interventions reported in quality research targeted training of structures enhancing stability, mobility and functional components involving the ankle complex. To achieve these parameters, cause of clinical symptom with evidence based therapeutic techniques and protocols through robust research methods are warranted. With these objectives the reviewed literatures reported combination of exercises ranging from stretching, strengthening and balance exercises during the initial setting phase and progressively advancing to plyometric and agility exercises for sports specific training. The summary of evidenced exercises are as follows. The conservative approach of RICE is a standard method used for any soft tissue injury and also in ankle sprain condition. With the reduction of pain, swelling and the inflammation symptoms, the exercise regimen reported in the literature includes multicomponent exercises like static stretching, strengthening and mobilization, balance exercises, and advance exercises like unilateral balance training with vibration, self-mobilization and cross-fit training, whole body vibration and progressive hop-to-stabilization balance program.

Progressive strengthening exercises with self-mobilization improved dorsiflexion & plantarflexion ROM, dynamic postural control and decreased perceived ankle instability. The recommended training protocol was twice/thrice per week for 6-12 weeks, with 3 sets x 10 repetitions.

Unilateral balance training with Static stretching for calf muscles reported ROM improvements, increased blood flow, changes in the viscoelastic characteristics of muscles and better relaxation of sensory afferents. Protocol of 3-5 seconds hold for 10-15 repetition with duration of 3 times per week for a total of 4 week 28.

Single limb balance exercise including kicking / ball toss, single limb-hop to stabilization with reach 3 times a week for 4 week reported significant improvement in joint position sense, balance and ankle activities of ADL 27. The physiological changes reported were enhanced muscle spindle activity and excitability of motoneurons, decreased reaction time of the ankle-stabilizing muscles and motor-unit recruitment thresholds 27.

Cross fit training with a warm up period for 21 repetitions × 3 sets, a training phase including band pull, ankle joint mobilization with a resistance band, and kettlebell dorsiflexion for 10 repetitions with 3 sets twice a week for a total of 12 weeks reported improved plantar flexion and dorsiflexion followed by cool down period 2.

Advanced training protocol included Unilateral balance training program on vibration platform like biodex balance system, progressive Unilateral balance training with vibration on BOSU balance trainer incorporating 1-leg stance, crossed-legged sway, runner’s pose, catching and throwing a volleyball against the wall reported significant improvement in balance parameters and stability in antero-posterior and medial-lateral index 24

6 articles related to the recent advances for improving functional activities of ankle sprain were selected and reviewed. Self-mobilization and cross fit protocol shown to have significant effectiveness in treating ankle sprain, followed by single limb balance and progressive hop-to-stabilization balance program. It can be concluded that based on the clinical presentations, structures involved and severity of structures damaged, client specific evidence-based physiotherapy interventions needs to be planned. Treating the pain and inflammatory response with RICE and protective gears are basic & standard methods of practice. To further enhance movements, strength and endurance of the structures around ankle complex, stretching and strengthening exercises with self-mobilization techniques are reported to have significant functional outcomes. Followed by balance and functional training with unilateral limb balance program with vibration, cross fit training, hop-to-stabilization exercise training supported with good quality RCTs can be implemented in the clinical practice with causation of ethic and geographical variations to prevent ankle injuries and instability in the athletes requiring excellent strength, endurance and flexibility in ankle and related functions. Further good quality RCTs in Indian population might be helpful for the implementation of such protocols in our context. As well as systematic reviews on protocols are indicated for getting gold standard evidence for decision-making.