Ankle Sprain

Rehabilitation for ankle inversion injuries

by Physiotherapist Jake Robinson

Acute ankle inversion injury is one of the most prevalent musculoskeletal injuries. Ankle sprains are the most frequent injury sustained in sports

What is it?

A sprained ankle is an injury that occurs when you roll, twist or turn your ankle in an awkward way. Ankle ligaments, which help hold your ankle bones together, can be stretched or torn by this type of injury.

Ligaments help stabilize joints by preventing excessive movement. Sprained ankles occur when the ligaments are forced past their range of motion. Sprained ankles are usually caused by injuries to the ligaments on the outer side of the ankle.

Symptoms may include:

  • Pain, especially when you bear weight on the affected foot

  • Tenderness when you touch the ankle

  • Swelling

  • Bruising

  • Restricted range of motion

  • Instability in the ankle

  • Popping sensation or sound at the time of injury

Causes

A sprain occurs when your ankle is forced to move out of its normal position, which can cause one or more of the ankle's ligaments to stretch, partially tear or tear completely.

Causes of a sprained ankle might include:

  • A fall that causes your ankle to twist

  • Landing awkwardly on your foot after jumping or pivoting

  • Walking or exercising on an uneven surface

  • Another person stepping or landing on your foot during a sports activity

Risk factors

Poor athletic conditioning. Strenuous athletic activities may cause ankle ligaments and muscles to sprain or strain if individuals are not sufficiently prepared, such as through regular calf and ankle stretching and strengthening exercises.

 

Muscle and ligament fatigue. If people "push through" fatigued muscles and ligaments near the end of a vigorous activity, they run a greater risk of injury than if they rest. A marathon runner may be at risk of ankle sprains or strains during the last few miles of the race, for instance.

 

Not warming up before activity. Athletes who immediately start vigorous activity without a gradual warmup, such as a gentle stretching session and a walk before a sprint, suffer ankle sprains and strains at a higher risk. As a result of not warming up before your workout, your muscles and ligaments will be tight, and your flexibility will be reduced, which means you're more likely to sprain or tear your muscles.

 

Carrying excess weight. Walking, running, and jumping with excess weight places higher impact loads on the joints. As a result, ligaments and/or muscles may be stretched or torn during activity. Some studies indicate that males with more weight are more likely than females to sustain ankle sprains or strains.

 

Inappropriate footwear. Ankle sprains and strains can develop if you're not wearing supportive footwear designed for the type of surface being used. In certain situations, such as walking on an uneven or icy surface wearing high-heeled shoes, or when playing basketball wearing low-tops instead of high-tops.

 

Prior history of sprains or strains. A person who has suffered an ankle sprain or strain in the past is more likely to sustain the same type of injury again than someone who has never sustained an ankle sprain or strain

Relevant anatomy

There are three ligaments that make up the lateral or outside of the ankle. The anterior talofibular (ATFL), the calcaneofibular (CFL), and posterior talofibular (PTFL). The anterior talofibular ligament is the most frequently injured of these three ligaments. Approximately 70% of lateral ankle sprains involve this ligament alone along with a mechanism of plantar flexion (The toes pointing down) and inversion (Rolling the ankle inwards). Injuries to the CFL occur more commonly during dorsiflexion (Pointing the toes up) and inversion. Of all the lateral ligaments, the posterior talofibular ligament is the least commonly injured.

The medial or inside of the ankle is home to the deltoid ligament which is the strongest ankle ligament. The deltoid ligament tends to be injured with eversion (Rolling the ankle outwards) injuries. It is rare for a deltoid ligament injury to occur in isolation

Grading

A sprained ankle's severity determines both the prognosis and the approach to treatment.

As a rough time guide sprains of Grade I heal within a few weeks. Grade II tears may require three months or more. It will take months to regain normal muscle function after you have had surgery for a Grade III sprain. 

Grade I - In this case, structural damage is only on a microscopic level, there is slight local tenderness, and there is no joint instability.

Grade II - There is a partial tear (rupture) of the ligament, visible swelling and tenderness, but there is none or slight joint instability present.

Grade III - This is a severe sprain where the ligament is completely ruptured accompanied by swelling and joint instability.

 
 

Treatment

Peace and love

Initially when an injury occurs, we want to provide the soft tissue structures with PEACE, for the first 1-3 days

 

P-PROTECT:

Unload area, restrict movement, but minimize full rest.

Protecting the area with the above, will reduce bleeding and prevent further reaggravation.

 

E – ELEVATE:

Placing effected limb above the position of their heart.

This reduces the build-up of fluid around the injury.

 

A – AVOID ANTI-INFLAMMATORY MEDICATION

When taken in high quantities, anti-inflammatory medications can inhibit the body's natural inflammatory processes, which can be harmful to long-term healing of injuries.

Ice is also questionable, while many people use ice to numb the pain and decrease inflammation, there is poor research to suggest that it may help heal or fast-track recovery, and instead there is many new papers suggesting it could potentially impair recovery and tissue repair.

 

C – COMPRESSION:

Taping or bandages to compress the area may help in the decrease in swelling of the injury.

 

E – EDUCATION:

Therapists should educate patients about the benefits of an active approach to recovery. With this education, the patient will have a better understanding of their injury, will prevent overuse and overtreatment, and will learn the expected tissue healing times for their injury.

 

Once PEACE is achieved, following the first few days of recovery, soft tissues need LOVE –

 

L – LOAD:

It is possible to promote injury recovery and tissue tolerance if you use active movement and exercise that involves optimal loading (without increasing pain).

Normal activities should be performed once symptoms allow it

 

O – OPTIMISM:

There are numerous psychological factors that are known to affect recovery, including catastrophizing, fear, depression, all of which are known to affect treatment outcomes and management.

Optimism still needs to be realistic.

 

V – VASCULARISATION:

To increase blood flow to the injured area, pain free cardiovascular exercise is introduced.

This increases the likelihood of improvement to function, return to work/sport, and reduces need of pain medications.

 

E – EXERCISE:

Incorporate exercise to assist the return to work or sport after the above is accomplished. Pain-free exercise is essential to further healing and preventing recurrence.

A gradual increase in exercise intensity and difficulty shall promote optimal repair by restoring strength, mobility and function the affected area.

 

 

 

Pain

Pain during exercise

Aim to stay in the green or amber boxes. The exercises can be modified if you fall into the red zone by reducing the amount of movement during the exercise, reducing the repetitions, adjusting the weight, reducing your speed, or extending rest periods between sets.

Pain After Exercise

You should be able to return to your pre-exercise baseline within 30 minutes of exercising. After exercising, you should not experience pain or stiffness that lasts longer than 60 minutes in the morning.

Early rehab - Phase 1

ROM exercises: You should begin ROM rehabilitation and weight-bearing as soon as the pain allows. In the early stages of rehabilitation, it is better to minimize inversions and eversions.

 

Active Dorsiflexion

Tap your toes by pulling your foot towards your shin then back down again.

Active Plantarflexion

Point your toes away from you to stretch the front of the ankle.

Knee to wall stretch

Stand with your toes a few cm’s away from a wall then push your knee forward to touch the wall.

 

Early rehab - Phase 2 range of movement

When the tenderness over the ligament decreases, inversion and eversion exercises can be added. These exercises should be performed slowly, without pain, and with high repetitions.

 

Active Eversion

Actively turn your feet outwards, as if you were to walk on the inside edge of your foot.

Active Inversion

Actively turn your feet inwards, as if you were to walk on the outside edge of your foot.

Active rotations

Circle your feet in both direction, try drawing letters of the alphabet with your big toe. Just move your foot in all planes of movement.

 

Early rehab - Phase 2 isometrics

When the tenderness over the ligament decreases, inversion and eversion exercises can be added. These exercises should be performed slowly, without pain, and with high repetitions.

 

Isometric Inversion

Actively pull your foot in against a heavy resistance band or immovable object. You should feel this working the muscles on the inside of your shin.

Isometric Eversion

Actively push your foot out against a heavy resistance band or immovable object. You should feel this working the muscles on the outside of your shin

Isometric heel raise

Push up onto your tip toes and hold this position. Start with 2 legs then progress to a single leg.

 

 Mid rehab

Neuromuscular and proprioceptive training may be carried out next to restore balance and postural control and reduce subjective instability, improve functional outcome measures, and decrease the likelihood of recurrence after rehabilitation.

 Late rehab

Sport-specific training is the last phase of the rehabilitation process. For volleyball players, it may be plyometric training with jumping maneuvers, while for soccer players it would be running and cutting drills. During the early stages of sport-specific training, a brace or tape may be appropriate.This phase of the training program should simulate as closely as possible the demands the athlete would be under if they were to return to sport.

When to return to sport

It is ideal for athletes to return to play once their range of motion is full and their strength is restored. The athlete should be able to perform sport-specific activities without recurrent symptoms. It may take 6-12 weeks for ligaments to heal, but the amount of time it takes to return to sport varies considerably

Future prevention

Bracing and taping

Recurrent ankle sprains can be prevented with non-rigid bracing and prophylactic taping. These may reduce the risk of ankle sprains by 50% to 70% in those with a history of ankle sprains. Researchers have shown that ankle braces (especially non-rigid lace-up braces) are effective at preventing acute sprains in soccer, basketball, volleyball, and American football. The existing evidence recommends using lace up braces or tape after ankle sprains for one year to prevent recurrences.

 

 

 

 

Neuromuscular exercise programs often include proprioception and balance exercises with repeated involuntary or voluntary destabilizations. The programs are designed to improve functional outcome scores, joint proprioception, and muscle reaction time. Using them, an athlete with an ankle sprain who suffers an acute sprain can reduce recurrence rates up to 12 months following the injury and should consider them as early as tolerated after a sprain.

Summary main takeaways

1.                 Peace & Love

2.                 Allow pain to dictate progression

3.                 Allow full recovery before return to sport

4.                 Prevention is just as important as rehabilitation

 References

1.    Chen, E., McInnis, K., & Borg-Stein, J. (2019). Ankle Sprains: Evaluation, Rehabilitation, and Prevention. Current Sports Medicine Reports, 18(6), 217-223. https://doi.org/10.1249/jsr.0000000000000603

2.    Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World Journal Of Orthopedics, 11(12), 534-558. https://doi.org/10.5312/wjo.v11.i12.534

3.    Melanson, S., & Shuman, V. (2022). Acute Ankle Sprain. Ncbi.nlm.nih.gov. Retrieved 16 May 2022, from https://www.ncbi.nlm.nih.gov/books/NBK459212/.

4.    Elnaggar, S. (2022). High Ankle Sprain | Online Physical Therapy - [P]rehab. [P]rehab. Retrieved 16 May 2022, from https://theprehabguys.com/high-ankle-sprain/.

5.    NHS. (2021). Sprains and strains. nhs.uk. Retrieved 16 May 2022, from https://www.nhs.uk/conditions/sprains-and-strains/.

6.    Kemler, E., van de Port, I., Backx, F., & van Dijk, C. (2011). A Systematic Review on the Treatment of Acute Ankle Sprain. Sports Medicine, 41(3), 185-197. https://doi.org/10.2165/11584370-000000000-00000