Posts in ankle sprains
Athletes With Hip Weakness Experience Twice As Many Ankle Sprains
ankle-sprains-hip-strength-injury-prediction

Ankle sprains remain one of the most common musculoskeletal injuries treated by Physical Therapists.  Our previous blog posts have highlighted the importance of early diagnoses and treatment including manual therapy, as well as, strengthening and balance exercises.  This treatment approach has been proven superior to both R.I.C.E. (rest, ice, compression, and elevation) and usual medical care.  Many ankle sprains become recurrent without treatment secondary to the alterations in agility, balance, and muscle recruitment across the leg.  We often find weakness in both the hip and leg musculature in patients after ankle sprain, but a new study indicates this weakness may have been present before the sprain.

Powers and colleagues in the Journal of Athletic Training followed 210 competitive male soccer players after a preseason clinical examination (2017).  Athletes underwent multiple clinical tests, including a hip strength assessment prior to beginning their competitive season.  Authors report 12% of the soccer athletes sustained a lateral ankle sprain during the season.  Athletes categorized as high risk were unable to produce >34% of their body weight during the hip strength assessment.  These high risk athletes experienced twice as many ankle sprains as their stronger peers.   

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Risk Factors for Ankle Sprain

Ankle sprains are one of the most common sports and orthopedic injuries encountered in Physical Therapy.  In previous blog posts we described the effectiveness of Physical Therapy treatments over other treatments including rest, ice, compression, and elevation (R.I.C.E.).  In addition, we have good evidence supporting the use of Physical Therapy clinical testing to determine which sprains are most likely to develop into chronic symptoms.  A recent review article highlighted the modifiable risk factors, which make patients more likely to sustain a first ankle sprain. 

Authors in the journal Sports Health (Kobayashi et al. 2016) reviewed 8 published articles to determine the ability of risk factors to predict a future ankle sprain.  The authors reported patients have a greater risk of ankle injury with increased weight, weakness in the leg and ankle musculature and limited balance ability.   Recreational and professional athletes are advised to work with a local Physical Therapist to identify and treat these impairments to reduce their risk of future injury.

Predicting Lasting Symptoms After An Initial Ankle Sprain

Ankle sprains are one of the most common orthopedic injuries we see in our Boulder Physical Therapy practice.  These injuries create local pain, swelling, loss of motion, weakness, and balance difficulties.  In past years these injuries were treated with R.I.C.E. (rest, ice, compression, and elevation), but more recent research has demonstrated improved outcomes and faster recovery with a more active approach.  Athletes treated with manual therapy and exercise by a Physical Therapist demonstrate superior outcomes than those treated with R.I.C.E.  The greatest limitation of the R.I.C.E. and wait and see approach involves prolonging treatment which may lead to lasting chronic symptoms throughout the lower extremity.  

A recent article in the American Journal of Sports Medicine attempted to identify predictors of chronic symptoms and balance difficulties among athletes after an ankle sprain (Doherty et al. 2016).  The authors followed 82 patients who sustained a first time ankle sprain.  The athletes were examined at 3 times points: 2 weeks, 6 months, and 12 months post injury.  At 12 months patients with lasting, chronic symptoms were identified and their data was analyzed to determine if prior clinical data could predict their lack of recovery.  The authors noted patients who were unable to complete landing and jumping tasks at 2 weeks post injury and/or were unable to demonstrate balance in multiple planes of movement demonstrated the greatest risk of lasting pain and symptoms.  

Individuals who sustain an ankle sprain are advised to contact their local Physical Therapist as soon as possible to accelerate recovery and prevent chronic symptoms. 

 

Ankle Mobility Techniques

Ankle mobility is essential for both daily walking tasks as well as higher level athletics and sports participation.  In our Physical Therapy practice in Boulder we see a loss of dorsiflexion, bending, among athletes with lower extremity injuries and conditions.  A lack of ankle bend, dorsiflexion, has been associated with many conditions including heel pain, plantar fasciitis, ankle sprains, stress fractures, achilles tendonitis, and ACL injuries.  An example of the impact of ankle mobility on performance can be found with a squat test.  Try to squat as deeply as you can keeping your heels on the ground, then repeat the squat with your heels lifted on a weight plate.  If the latter is easier you may not have the 10-20 degrees of bend required during many athletic tasks, stair climbing, or walking.  

One of the most effective ways of restoring ankle dorsiflexion in our physical therapy practice involves the use of manual therapy.  These interventions allow a Physical Therapist to passive mobilize the areas of restriction decreasing your sensations of tightness and improving your ability to move through a more full range of motion.  Often the squat test is dramatically improved after mobilizing the joints of the foot and ankle to improve ankle bending.  

boulder physical therapy ankle mobility treatments

In our experience, ankle mobility is more quickly restored when these manual therapy techniques are followed by home exercises designed to move through the newly acquired range of motion.  A recent study examined the impact of two exercises designed to restore ankle bending in individuals who lacked the normal amount of motion in their ankle.  Jeon et al. randomized 32 individuals to either a static stretching group or a group performing a similar stretch using a band (J Athletic Training. 2015).  Individuals underwent the stretching protocol (15 reps x 20 second holds) 5 days a week x 3 weeks under the supervision of a Physical Therapist. 

boulder physical therapy ankle mobility with strap

The authors reported both groups improved their ankle range of motion after 3 weeks, but greater improvements were noted in the group utilizing the strap.  The strap may help localize the movement to the area of joint restriction making the exercise more specific to the individual.  To learn more about the examination and treatment of your ankle mobility contact your local Physical Therapist. 

Predicting Future Ankle Sprains

Ankle sprains are one of the most common sports injuries and one of the most common we encounter at Mend Physical Therapy.  These injuries lead to pain, lost practice and games, as well as chronic balance impairments up to 1 year after the injury.  As our manual therapy and exercise treatments have evolved we are seeing athletes return to play faster with less long term implications.  With any athletic injury "an ounce of prevention is worth a pound of cure" and this is true with ankle sprains as well.  In a previous post we discussed the ability to prevent ankle injuries in basketball and this post will discuss emerging evidence on the ability to predict ankle sprains in high school and collegiate football players.

The star excursion balance test (SEBT) is a clinical test used to assess the ability of the athlete to maintain their balance as they move their uninvolved leg in three directions.  The distance this leg travels is recorded and compared against their noninvolved side.  The test requires significant amounts of range of motion, strength, and balance to perform correctly.  Most importantly Physical Therapists are interested in symmetry between sides when determining return to sport and future risk of ankle injury.  Prior researchers have reported a side to side difference is predictive of future lower extremity injury among basketball players (Plisky et al. 2006).  A recent article in the American Journal of Sports Medicine analyzed the predictive value of the SEBT among high school and collegiate football players.  

Gribble and colleagues evaluated >500 football players on the FMS, SEBT, and body mass index and then tracked the number of injuries these athletes sustained over the course of the season.  The authors reported 54 lateral ankle sprains among the athletes with significant differences on BMI and SEBT performance between the injured and non injured groups.  The injured group had significantly higher BMI scores and lower reach distances compared to the uninjured group.  The most powerful predictor was forward reach distance on the SEBT.  Conversely, the pre season FMS did not help differentiate between injured and non injured athletes in season.

Coaches, athletes, and Physical Therapists should consider using the SEBT to help predict future injury among high school athletes.  

Recurrent Ankle Sprains and Ligament Laxity

My approach to treating ankle sprains has changed dramatically since I began working with athletes in the late 1990s.  The PRICE (protection, rest, ice, compression, and elevation) approach has been replaced with a clinically superior movement approach designed to reduce pain and facilitate a return to an exercise program.  The PRICE approach was effective to control the inflammatory and pain processes but did little to reduce the recurrence of ankle injuries.  Research reports up to 70% of individuals who sustain an ankle sprain will have limited function and symptoms up to 6 months after their injury.  When these athletes would return to clinic with a subsequent ankle sprain the trend was to blame this recurrence on the loss of ligament strength secondary to the initial sprain.  This commonly held belief is being challenged by the most recent research on individuals with recurrent ankle sprains.

A recent article on 200 division I collegiate athletes examined the relationship between ligament laxity in the athlete's ankle and a history of ankle sprains (Liu et al. Clin J Sp Med. 2013).  The authors measured ankle displacement and movement to passive forces on an ankle arthrometer.  They reported no relationship between ligament laxity and the number of ankle sprains the athletes sustained.   Although some studies have linked laxity with recurrent sprains (Brown et al. 2015) this study and others indicate more factors are at play in these athletes other than ligament laxity.  

Our body regions gain stability through three areas:

1: Passive structures: joint anatomy, ligaments and other passive supports

2: Active structures: muscles and tendons

3: Neuromuscular structures: communication between the nervous system and the muscles noted in balance and proprioception

Depending on the severity of the injury, an injured ankle likely has an initial reduction in all 3 areas of stability.  An athlete who can "cope" with an ankle sprain and return to full sport activity likely is able to compensate when one of area of stability is compromised.  Unfortunately, many of these athletes with chronic complains demonstrate continued to loss of strength and balance in the lower quarter.  Interestingly, it is common to find bilateral balance impairments among individuals who have sustained a one sided ankle injury (Evans et al. 2004).  Impairments on the non involved side indicate impairments may have a central component due to changes the ability of the central nervous system to control posture on unstable or unpredictable surfaces.   It is currently not known if these changes were a cause or effect of the ankle sprain, but not rehabilitating the muscular and neuromuscular systems likely places the athletes at greater risk.

To reduce your risk of future injury after an ankle sprain work with a Physical Therapist to reduce lower quarter impairments and rehabilitate your proprioceptive control.