Posts tagged ankle sprains
Treatment and Prevention of Acute and Recurrent Ankle Sprains
ankle sprain-treatments-prevention-physical therapy

Ankle sprains remain one of the most common orthopedic injuries seen in both physician and Physical Therapy offices.  The majority of these injuries occur when the foot and ankle roll inward under the shin.  Previously, a program of P.R.I.C.E. (protection, rest, ice, compression, and elevation) was prescribed but new research has shown this strategy may help in the short term but may contribute to the high rates of chronic symptoms in this injury group.  The key missing component from the P.R.I.C.E. approach is the absence of manual therapy and focused exercise treatments designed to accelerate the healing progress and return of function.

Recently, a review article of the available evidence was published in the British Journal of Sports Medicine describing the most effective treatments and prevention strategies on ankle sprains (Doherty et al. 2017).  The authors compiled data from 46 previous research papers and found strong evidence supporting early mobilization with manual therapy and exercise after an ankle sprain injury.  Further, the authors reported strong evidence for bracing and moderate evidence for balance and proprioception training in the prevention of future injury.  Patients and athletes are advised to work with a local Physical Therapist to both accelerate their recovery from ankle sprains and reduce their risk of injury recurrence. 

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.

 

Ankle Sprains and Physical Therapy Interventions
Ankle Sprains, Injury and Physical Therapy

Ankle Sprain Injuries

Ankle sprains are one of the most common orthopedic injuries with an annual incidence of 7 sprains per 1000 individuals(1).

Lateral ankle sprains involving the outside of the ankle account for 85% of these sprains (see picture) and involve flexed and inverted foot(2).

Authors reports up to 72% of individuals who sustain an ankle sprain will report symptoms at 6 month follow up(4).

Grade I and II injuries, the least severe on a 3 point scale, are most likely to reoccur and may lead to chronic symptoms of instability(5). 

Lateral Ankle Sprain

Physical Therapy Interventions

Physical Therapy clinical practice guidelines promote the utilization of early protection and controlled motion following acute ankle sprains.

Patients with ankle sprain often demonstrate reduced hip motor performance which may increase their risk to future injuries. PT aims to correct these imbalances throughout the lower quarter to return clients to their prior levels of activity.

Authors recommend a multimodal treatment program consisting of early weight bearing, manual therapy, exercise and balance interventions to reduce pain and improve function(15). 

Physical Therapy Evidence

Manual Physical Therapy Ankle Mobilization

Evidence supports the implementation of weight bearing, with or without assistive devices, following ankle sprains over non weight bearing(13).

Research has reported the utilization of R.I.C.E. (rest, ice, compression, and elevation) may be inferior to a Physical Therapy approach consisting of manual therapy and R.I.C.E interventions6.

A more effective treatment program designed to reduce pain, disability, and prevent recurrence of ankle injuries consists of manual therapy, balance/proprioceptive training, and return to sport exercise prescription(15).

Whitman et al. conducted a prospective study of 85 patients with acute ankle sprains and noted 75% of patients demonstrated an immediate improvement in symptoms and function in the first week of a manual therapy (see picture above) and exercise approach provided by Physical Therapists(8).

A recent systematic review demonstrated improved pain, improved motion, and decreased disability following manual therapy interventions in patients with ankle sprains(12).

Researchers reported restoring range of motion and decreasing pain processing from joints of the lower extremity may facilitate an earlier return to an exercise program.

Cleland et al. reported a formal Physical Therapy program consisting of manual therapy and exercise was more effective and efficient than a home program for patients with ankle sprain at both 4 weeks and 6 months after their sprain(10).

Balance training programs designed to reduce postural sway, improve joint stability and function, and prevent reoccurrence are prescribed following acute ankle sprains(14) 

Single Leg Balance. Physical Therapy Proprioception Exercise

When to Schedule an Appointment

Patients should seek out Physical Therapy services following acute ankle injuries to be effectively screened for the aforementioned interventions. Appropriate candidates will be treated effectively with manual therapy, exercise and balance training, sport specific exercise interventions to facilitate return to sport and to prevent recurrence.

References

1. Almeida SA et al. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sp Ex. 1999;31:1176-1182

2. Ferran NA, Maffulli N. Epidemiology of sprains of the lateral ankle ligament complex. Foot Ankle Clin. 2006;11:659-662.

3. Bachmann, L. et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid foot. A systematic review. BMJ. 2003;326:417

4. Braun, BL. Et al. Effects of ankle sprain in a general clinic population 6-18 months after medical evaluation. Arch Fam Med. 1999;8:143-149.

5. Malliaropoulos N, Ntessalen M, Papacostas E, Longo UG, Maffulli N. Reinjury after acute lateral ankle sprains in elite track and field athletes. Am J Sports Med. 2009;37:1755-1761.

6. Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001;81:984-994

7. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003;103:417-421.

8. Whitman JM, Cleland JA, Mintken PE, et al. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther. 2009;39:188-200

9. Truyols-Dominguez, S. et al. Efficacy of Thrust and Nonthrust Manipulation and Exercise With or Without the Addition of Myofascial Therapy for the Management of Acute Inversion Ankle Sprain: A Randomized Clinical Trial. J Orthop Sports Phys Ther 2013;43(5):300-309.

10. Cleland et al. Manual physical therapy and exercise versus supervised exercise program in the management of patients status post inversion ankle sprain. A multi centered trial. JOSPT. 2013.

12. Loudon JK, Reiman MP, Sylvain J. The efficacy of manual joint mobilisation/ manipulation in treatment of lateral ankle sprains: a systematic review. Br J Sports Med 2014;48: 365–370.

13. Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly KD, Struijs PA, van Dijk CN. Immobilisation for acute ankle sprain. A systematic review. Arch Orthop Trauma Surg. 2001;121:462-471.

14. Webster KA, Gribble PA. Functional rehabilitation interventions for chronic ankle instability: a systematic review. J Sport Rehabil. 2010;19:98-114.

15. Martin, R. et al. Ankle Stability and Movement Coordination Impairments: Ankle Ligament Sprains. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy AssociationJ Orthop Sports Phys Ther. 2013;43(9):A1-A40.