The Physician and Sportsmedicine: Rehabilitating Ankle Sprains

The Physician and Sportsmedicine

Rehabilitating Ankle Sprains

Richard Sandor, MD
Scott Brone, PT, CSCS


William O. Roberts, MD
Department Editor


THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 8 - AUGUST 2002


Ankle sprains are very common, accounting for 20% to 40% of all sports-related injuries. [1,2] These injuries are known to recur often and create prolonged disability. [2,3] Ankle sprains are classified into grades 1, 2, 3, which generally correspond to mild, moderate, or severe. They are also classified into three anatomic types: lateral, medial, and syndesmosis. This protocol focuses on lateral sprains of all grades.

The treatment of choice for lateral ankle sprains has evolved from cast immobilization and possible surgery to early and active ankle mobilization. [4] Once a qualified healthcare professional has made the correct diagnosis, early-mobilization protocols can help the patient return to activity significantly sooner than with immobilization. [5] Mobilization and rehabilitation of grades 1 and 2 sprains have generally been divided into three phases. Phase 1 rehabilitation is rest, ice, compression, and elevation (RICE) and protected weight bearing as needed. Phase 2 consists of restoring ankle motion, strength, and proprioception and can begin when the patient can place some weight on the ankle (see the exercises below). Phase 3 includes activity-specific drills before return to full activity.


Rehabilitation Exercises

Specific exercises (figures 1 through 10) are done in phase-2 rehabilitation and are designed for easy home use. (The "alphabets" can be started in phase 1 rehabilitation.) The exercises are intended both for recreational athletes and nonathletes, who have neither the time nor the inclination for more intensive supervised rehabilitation. Competitive athletes would probably be better served by a formal physical therapy evaluation and treatment plan incorporating more intensive strengthening and proprioceptive exercises with equipment that is usually unavailable for home use. Exercise bands are available from supply houses (eg, North Coast Medical, 1-800-821-9319).

The exercise protocol.   Patients begin with the first 2 exercises in group 1, and add exercises until they can do all in group 1 with little pain. Then they add 2 exercises in group 2 but continue to do the windshield wiper (figure 1) and exercise band eversion and inversion (figure 5). Once patients can do group 2 exercises, they can progress to group 3 but should continue to do exercise band eversion and inversion (figure 5) and the full-weight-bearing single-leg stand (figure 8).

The movements should be done slowly and controlled to reap the full benefits. Patients are encouraged to discontinue using crutches or canes as soon as pain will allow. Walking is permitted to the limits of pain. Once group 3 exercises can be completed comfortably, patients may progress to a light jog on a treadmill or level ground for 10 to 20 minutes. The next phase of rehabilitation is agility drills and sport-specific drills that should be guided by a healthcare professional.

The exercises.   For each exercise patients do two sets of 10 to 15 repetitions two to three times a day.

Gauging recovery.   Recovery following an ankle sprain is highly variable. Some patients can progress from injury to completion of group 3 exercises in as little as a week, while others take 6 weeks or longer. If any of the exercises increase pain or swelling, patients should discontinue that exercise. If patients have no improvement after 1 week, they should return to their physicians for further evaluation or perhaps structured physical therapy.

GROUP 1 EXERCISES
EXERCISE 1. The 'alphabets.' While seated with the edge of the heel on the floor, patients draw the entire alphabet one letter at a time by moving the injured ankle and using the great toe as the 'pen.'
FIGURE 1. Windshield wiper. Sit with the foot flat on the floor and facing straight ahead. Rotate the affected foot to mimic a windshield wiper blade: Pivot the foot outward and touch the inside edge of the foot to the floor (A), then rotate it inward and touch the outside of the foot to the floor (B). FIGURE 2. Seated calf raise. Sit with the injured foot flat on the floor. Lift the heel as far as possible while keeping the toes on the floor, then return the heel to the floor. FIGURE 3. Single-leg stand (partial weight-bearing). Stand while placing one hand on a table. Shift some of the weight to the injured foot for 15 seconds. Increase the time spent on the injured foot by 15 seconds until you can stand for 45 seconds. Then gradually increase the amount of weight supported by the injured foot until full body weight is used.


FIGURE 4. Eversion and inversion isometrics. Eversion (A): Stand and place the outside of the injured foot against a table leg or door jamb. Push outward with the foot for 2 to 3 seconds. Inversion (B): Stand with the inside of the foot against the table leg or door jamb and push inward for 2 to 3 seconds. FIGURE 5. Exercise band eversion and inversion. Eversion: Sit with the involved leg straight. Tie a loop in an elastic exercise band and attach the other end to a heavy object such as a table leg. Place the loop around the ball of the foot (A). Rotate (evert) the foot away from the table leg and return it to the starting position (1 repetition). Do not rotate the leg to do the exercise. Inversion (B): Reverse the position of the exercise band and rotate (invert) the foot inward, away from the table leg. Once patients can do group 1 exercises, they can progress to group 2.


GROUP 2 EXERCISES
FIGURE 6. Gastrocnemius stretch. Place the injured foot behind the uninjured foot and keep the back knee straight, with the heel firmly planted on the floor. Lean forward against a wall so that you feel a stretch in the calf farthest from the wall. Hold for 30 seconds. FIGURE 7. Soleus stretch. Stand with the injured foot in front of the other foot. Bend the knee of the back foot and lower your body toward the floor without letting the back heel rise off the floor. You should feel the stretch in the lower calf of the back leg.


FIGURE 8. Full­weight-bearing single-leg stand and standing calf raise. Stand with the injured foot on the floor and the other leg bent at the knee and off the floor (as shown for the standing calf raise). Maintain full weight on injured leg for 30 seconds. Standing calf raise. Raise up on the ball of the injured foot then return the heel to the floor. Weight is supported only on the injured side. FIGURE 9. Single-leg stand with a towel. Roll a towel into a strip 4 inches wide, 1 to 2 inches high, and 12 to 18 inches long. Stand with the injured ankle on the towel as for the single-leg stand (figure 3). Hold for 30 seconds.


GROUP 3 EXERCISES
FIGURE 10. Lateral step and lateral bound. Step: Place a rolled towel on the ground and stand with both feet to one side of the towel (A). Step over the towel with the injured ankle (B), and remain on one foot (C). Reverse the process and step over the towel in the opposite direction. Increase speed as pain will allow. Bound: The starting position is the same as for the step. With both feet on one side of the towel, hop over the towel and land on the right foot. Then, hop back over the towel and land on the left foot. Gradually increase speed and height of bound as comfort allows.



References

  1. Coughlin MJ, Mann RA, (eds): Surgery of the Foot and Ankle. St Louis, Mosby, 1999, p 1114

  2. Gerber JP, Williams GN, Scoville CR, et al: Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 1998;19(10):653-660

  3. Dettori JR, Basmania CJ: Early ankle mobilization, part 2: a one-year follow-up of acute, lateral ankle sprains (a randomized clinical trial). Mil Med 1994;159(1):20-24

  4. Kannus P, Renstrom P: Treatment for acute tears of the lateral ligament of the ankle: operation, cast, or early controlled mobilization. J Bone Joint Surg Am 1991;73(2):305-312

  5. Eiff MP, Smith AT, Smith GE: Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med 1994;22(1):83-88


Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

Dr Sandor is a medical orthopedist with the Camino Medical Group in Sunnyvale, California. Mr Brone is a physical therapist with P.O.W.E.R. Physical Therapy, Inc in Mountain View, California.

Disclosure information: Dr Sandor and Mr Brone disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


Copyright (C) 2002. The McGraw-Hill Companies. All Rights Reserved


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