Return-to-Play After Ankle Sprain
A 17-year-old netballer sustains a lateral ankle sprain during a landing contest. She is assessed 10 days later. Swelling has reduced but is still visible over the lateral malleolus. She has full range of motion, can hop on one leg 10 times without pain, and reports pain only when pushing off to sprint. Her coach wants her back for a semi-final in four days. The team has no physiotherapist on site but can arrange a referral. She has had two previous ankle sprains on the same side.
1. Using a return-to-play framework, identify which criteria are met and which are not. What is your recommendation for the semi-final?
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A return-to-play framework has several domains: pain, swelling, range of motion, strength, functional tests, sport-specific skills, psychological readiness and re-injury risk.
Met:
- Full range of motion
- Single-leg hop 10 times without pain (a basic functional test)
Not met:
- Residual swelling at day 10, which indicates incomplete tissue healing
- Pain on push-off to sprint, which is a sport-specific demand for netball (acceleration, landing, cutting)
- No assessment of strength (e.g., resisted eversion, single-leg heel raise), balance or change-of-direction ability
- History of two previous sprains on the same side, which substantially raises re-injury risk (recurrent sprains are a strong predictor of future sprains and chronic ankle instability)
Recommendation: she should not play the semi-final. Pain on a sport-specific action plus residual swelling plus a recurrent-sprain history means she has not completed the criteria. Playing a high-intensity semi-final four days later would expose her to re-injury at a critical stage of healing. Arrange a referral for strength, balance and proprioceptive assessment, and set a realistic target of the following fixture if criteria are met.
2. Design a four-day programme that would give her the best chance of meeting criteria, and explain how you would test readiness.
Read the worked answer
Day 1-2: reduce swelling and restore strength.
- Elevation and compression when resting, plus gentle ankle pumps and circles.
- Isometric and then resisted exercises: eversion, inversion, dorsiflexion and plantarflexion, 3 sets of 10-15 at low pain (0-2/10).
- Single-leg balance on firm ground, progressing to eyes-closed or unstable surface if pain allows.
Day 3: functional loading.
- Single-leg heel raises (3 x 15), lateral hops, and a jog-run progression at 50-70% pace.
- Introduce change-of-direction drills (side steps, then cutting at 70%) only if pain stays at or below 2/10.
Day 4: sport-specific test.
- Netball-specific landing and cutting drills at full pace.
- Hop test battery: single-leg hop for distance, triple hop and timed side hops, compared with the uninjured side. A limb symmetry index of at least 90% is a common benchmark.
- Balance test (e.g., single-leg stance with reach) and a resisted strength check.
- Psychological readiness: ask her directly how confident she feels landing and cutting.
Readiness criteria: no swelling, no pain on sprinting, cutting or landing, limb symmetry of at least 90%, and confidence to play. If any criterion fails, she does not play. The programme is a test-and-progress plan, not a guarantee of return, and a physiotherapy referral should be arranged regardless given her recurrent history.