Wednesday, March 2, 2016

Rehabilitation for Ankle Sprains

by David Piskulic, DPT, SCS, ATC/L
St Louis Children's Hospital Physical Therapy

     Ankle sprains are one of the most common injuries in sports participation.  In fact, the ankle accounts for about 1/3rd of all sport-related injuries.  In their lifetime, 1 in 5 individuals who are physically active will sustain a lateral ankle sprain, which is when the foot turns in and the ligaments on the outside of the ankle are either damaged or torn.  Incidence of these ankle sprains is highest in our young athletes, between 15-19 years.  While the incidence of these injuries is well known, proper rehabilitation of the injury and knowing when to get back to sports participation can be difficult to determine.

How Do I Start Care for an Ankle Sprain?

     After your athlete sustains an ankle injury, observe for common signs and symptoms: localized pain, swelling that builds up and may lead to discoloration, a popping sound during the injury, and difficulty moving the ankle or foot.  Be especially aware of difficulty bearing weight on the leg or even difficulty walking, as this may be a sign of a more severe ankle sprain or fracture.  If you suspect a severe injury, follow-up with your physician for a full evaluation.

     Once an ankle sprain is determined, the old method of rest, ice, compression, and elevation (often referred to as “R.I.C.E.”) still stands tried and true.  The athlete should rest from activity, ice the area of pain for up to 15-20 minutes, maintain compression with a wrap, and elevate the ankle above the level of the heart.  All of these initial treatments will help with overall circulation and decrease excessive swelling.  More severe sprains may require use of a boot or air-cast that can be acquired from and applied by your physician.

Figure 1 : Examples of wraps and bracing to treat ankle sprains.

When Can I Move My Ankle?

      While you initially want to protect the injured ankle ligaments and restrict ankle movement to let them heal, light range of motion exercises can help prevent stiffness and improve circulation to allow proper blood flow for healing and reduction of swelling.  Some simple exercises are completing the “ankle alphabet”.  The athlete will “draw” letters of the alphabet with their big toe, moving their ankle through pain-free range of motion.  This can be accomplished by starting with small letters and gradually making bigger letters once pain improves.

Figure 2 : Examples of "ankle alphabet" exercises
When Can I Walk?

     Early weight bearing has been linked to improved outcomes in rehabilitation of ankle sprains.  It is important for the athlete to “normalize” their walking pattern and to have their heel touch the ground first with their toes forward, then roll through their step and gently push off from their toes.  If use of a larger boot or brace limits ankle mobility, have the athlete roll through their step with their toes forward as much as possible.  If the athlete is having difficulty pushing off from their toes during walking, they may benefit from completing a heel raise exercise.  The athlete can complete the exercise on both legs at the same time and then progress to single leg heel raises as their strength improves.
Figure 3 : Example of proper walking mechanics at the foot and ankle

Figure 4 : Example of a heel raise exercise with heels elevated

     In addition to the athlete having a normalized walking pattern, they should also work on balance exercises to assist with stabilizing the ankle.  Several studies have been done on specific types of exercises, use of equipment and special supplies, but the main conclusion these studies have is that any type of exercises that challenge an athlete’s single leg balance, such as balancing on uneven surfaces, promote improvement in overall stability of the ankle joint.  This can be accomplished by having the athlete balance on 1 leg on a flat surface while pain free for up to 30 seconds.  When the athlete reports no pain with these exercises, they can start single leg balancing on uneven surfaces, such as thick carpeting or a couch cushion, and practice sport specific drills, such as throwing and catching a ball.  These types of balances programs are even recommended as a pre-season work-out and have been correlated to decreased incidence of injuries among athletes.

When Can I Play Sports Again?

     This is usually the most important question asked after sustaining an injury, not only by the patient but by the parents as well.  And don’t worry, parents, clinicians want your young athlete to return to their sport or activity as soon as possible!  We just want to make sure they’re safe and healthy to do so.
     Some tests to complete with the athlete are single leg balancing, pain-free walking and running without favoring their injured leg, performance of sport specific skills without any form of contact from other players or teammates, and equal performance of jumping and hopping on each leg.  Your rehabilitation specialist of choice should be able to help your athlete in finding exercises and activities for them to complete to properly train their injured ankle and get them fully prepared to return to their sport.

How Do I Keep From Getting Injured Again?

     In a perfect world, everyone would be able to participate in their own sport or activity free from aches, pains, and injuries.  However injuries are very much a part of the sports world and unfortunately will continue to occur despite our best efforts.  That being said, there are still many things to do to avoid a higher incidence of future injury.  This includes several aspects of sports training, including continued training in balance exercises throughout sports participation, completion of a thorough return to sports test with your medical provider, and continued use of ankle support with use of a functional lace-up ankle brace or taping.  These have been found to reduce the incidence of ankle sprains when returning to sports following injury.  Consult your physician, physical therapist, or athletic trainer for their recommendations on functional bracing and for assistance with application of ankle taping.

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