Physiotherapy Blog

Ft. The Ottawa Ankle Rules

My name is Dominic Ko, I’m a physiotherapist from Toronto, Ontario. I acquired my Master’s of Science in Physical therapy at Queen’s University. When I am not busy working in the sports clinic or at the hospital, you will find me backpacking across the world. Just before the pandemic I had the opportunity to backpack and hike in Rwanda,Uganda, Mexico, Chile and Argentina! As an avid global hiker and a runner, I’m dedicating this blog post to talk about ankle sprains and what you should do when you sprain your ankle.
The most common ankle sprain is called an inversion sprain. Whether it’s from running, walking, stepping onto uneven ground or down a curb…I’m sure most of us have twisted our ankles this way!
My biggest take away from this post is to empower you to know if an ankle sprain is potentially an ankle fracture. I will let you in on our secret to determine when you need an x-ray and give you tips on when to seek advice from a medical professional or have the confidence to manage your ankle sprain from home.

Ft. The Ottawa Ankle Rules

Last summer my co-worker convinced me to start running with her to get our “summer bod” ready. With good intentions but unfortunate luck, she rolled her ankle coming off the sidewalk curb. She fell to the ground and SCREAMED in pain. My physio checklist kicked in and the first thing I asked her was, “are you able to walk on it?”.
  • She was unable to walk even after resting on the ground for 5 minutes. This set off alarms in my head and I knew it was a serious injury.
  • The next thing I did was look to see if there was any swelling or signs of bruising.
  • I started to press on the back areas around her ankle and she had extreme pain on the outside ankle bone.
  • I drove her to the hospital. Stay tuned.
I used the Ottawa Ankle Rules (shout out to us Canadians!) to quickly screen her for a potential fracture. This is a life saver and a secret that many health care providers are familiar with. The OAR suggests that an X-ray is required to rule out a fracture.
In my co-workers case, I had to be the bearer of bad news and let her know that the “summer bod” may have to wait till summer of 2020. Little did we know we would be in a pandemic…so now it’s looking more like 2021!
The X-ray showed a small hairline fracture in her ankle which required her to wear a cast for 6 weeks. The takeaway from this extreme incident is to recognize the key features to know when to seek medical attention. If you are ever uncertain, contact a physiotherapist to err on the side of caution so that you don’t cause any irreversible damage.

CASE #2 What Does A Real Sprained Ankle Look Like?

Another friend of mine rolled their ankle (I swear I’m not an unlucky guy)! They were still able to weight bear by limping and walking on it even though there was pain. There was no pain when pressing on the bony areas, just tenderness on the sprained ligament itself. In this case, I’m not too concerned and recommended to treat this conservatively.
“With a normal ankle sprain, you may find that there is pain when you turn your heel inwards, decreased movement in the ankle, swelling and difficulty walking”.


Now I have to be the bearer of bad news- again. It’s going to be worse before it gets better so buckle in! In the first 4 to 6 days the pain may get worse because your body is going through the healing process. Usually after that time, the pain will get better as long as you follow these recommendations immediately and take caution to not re-injure it.
Follow the RICE principle (basmati or jasmine works best!) but jokes aside…
R- Rest, as in don’t over stress the ankle, give it time to rest and heal.
I – Ice within the first 24 to 48 hours, every 2 hours.
C- Compression using a tensor bandage. This will also assist in reducing the swelling.
E -Elevate. Position the ankle up onto a pillow where the ankle is above the level of the heart. This will assist in flushing out the swelling in the foot.
You also want to protect the ankle by keeping it in a neutral position, which means the ankle should be kept at 90 degrees where the toes point to the sky (if you’re lying down). The overall goal for the next 4 to 6 days is to reduce the swelling, pain and prevent re-injury. If the pain is really severe when walking, I would suggest partially weight bearing using crutches to reduce the stress onto the ankle and foot. If your symptoms get worse or don’t get better after 4 to 6 days, please seek advice from a physiotherapist.

Exercises for Acute Care (Weeks 1 & 2)

Now there are exercises you can perform to prevent complications of being immobile. All exercises should not increase the pain or swelling and should be performed minimum 3 times a day.

Toe scrunches with a towel or toe curls: 10 reps, 3 sets.

Picking up a marble with your toes and placing it in a cup: 10 reps, 3 sets.

Dorsiflexion (foot up), plantarflexion (foot down) and eversion (foot outward) range of motion exercises: 10 reps per direction, 3 sets.

Avoid any stretching of the ligament (picture on the right) or strengthening exercises at this time as it may cause more pain and swelling – which can delay healing.

Strengthening Exercises for a Sprained Ankle (Weeks 2 & 3)

Depending on the severity of your sprain, your sprained ankle should be almost healed at 2 to 3 weeks. If pain and swelling are no longer an issue and the range of motion has returned, strengthening exercises should be initiated with caution. It is not recommended to return to running or sport because chances of re-injury are still high.
In rehab, I always remember one physio always telling me that when we get injured,
“We break sh*t down and build sh*t back up”.
Now it’s time to “build sh*t back up”! Normally, after 2-3 weeks you will have decreased range of movement, strength and balance from your ankle injury. Here are some key rehab exercises to start with:

Calf stretch: 1-2 minutes, 2-3 times a day. Keep the back knee straight to feel a stretch!

Calf raises: 8-10 reps, 2-3 times a day. Start with two feet and aim for equal weight bearing. When you're able to complete this exercise with ease, progress to a single leg calf raise.

Eversion (foot outwards) and dorsiflexion (foot up) exercises with resistance band: 8-10 reps, 2-3 times a day.

Single leg balance with support: 30 seconds, 3 times a day. If able, challenge yourself without support (picture below)!

These exercises should not cause any pain or swelling after performing them. If this occurs, you may be too aggressive with your exercises or not ready to start strengthening yet. If you are ever uncertain, please seek advice from a physiotherapist. They can help guide you to progressively load your ankle safely. If you crushed these exercises without breaking a sweat, congrats!
The next step (around 4-6 weeks after the injury), would be to begin an exercise program that is more specific to your activity. A physiotherapist can give you the right recommendations and exercises to suit the demands of your activity. This way you are able to build resilience in the ankle to prevent re-injury.
If you have read this far, I hope you were able to take something of value from this post. Thanks for reading and share this blog post to educate your friends and family about the Ottawa Ankle Rules!
Lastly, protect those ankles, keep on moving and kiss a llama.
Note: no ankles were injured during this 4-day hike to Machu Picchu with my four friends!
Written By: Dominic Ko, PT

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