Middlebury

 

Ankle Sprains

Anatomy, Pathology, and Classification of Ankle Sprains

Ankle Anatomy
Grade Signs and symptoms
I
  • Stretched anterior talofibular(ATFL) and calcaneofibular ligaments (CFL)
  • Mild tenderness and swelling
  • Slight or no functional loss (i.e., able to bear weight and ambulate with minimal pain)
  • No mechanical instability
II
  • ATFL tears partially, and the CFL stretches with moderate functional impairment
  • Moderate pain and swelling
  • Mild to moderate ecchymosis
  • Tenderness over involved structures
  • Some loss of motion and function (i.e., pain with weight-bearing) Mild to moderate instabilit
III
  • Rupture of the ATFL and CFL, partial tearing of the PTFL
  • Severe swelling (more than 4 cm about the fibula)
  • Severe ecchymosis
  • Loss of function and motion (i.e., patient is unable to bear weight or ambulate)
  • Mechanical instability

Six Phases of Ankle Rehabilitation

Phase 1: P.P.R.I.C.E. (first 48-72 hours)

Protection

Aircast (after horseshoe wrap) – see below.

Avoid activities that cause pain.

Pain Control

(assuming no allergies, intolerances, or drug interactions)

Aleve: 2 pills every 12 hours with food for 5 to 7 days, then 1 pill every 12 hours with food as needed for pain, or

Ibuprofen: 200 mg tabs.  2-3 tabs 3x / Day with food x 5-7 days, then 2 tabs 3x / Day with food as needed for pain.

Acetaminophen: 500 – 650 mg every 6 hours as needed for pain.  Do not exceed 4000 mg/ 24 hours. (be sure that you are not taking other medications containing acetaminophen – too much can damage your liver and be fatal).

Rest

Modify your activities so you do not feel pain. Use crutches if it hurts when you walk.  The Health Center Staff will teach you how to use crutches.

Ice

Place ice bag (or a bag of frozen peas – reusable, but do not eat after use) over a paper towel or thin sheet and place over injured area for 20 minutes.  Repeat every 2 hours as much as possible. Stop if the skin turns white or blue while icing.

Compression
Remove any compression device if your foot becomes painful, numb, or tingles.

Horseshoe and Ace bandage.

Keep this on for the first 24 hours – even when icing.  It will prevent swelling from accumulating in the ankle joint, which will drastically improve the speed of your recovery.  At 24-48 hours, continue to wear this, but remove it for icing. After 48-72 hours, most patients can switch to an Aircast type protective splint.

Elevation

Try to keep your ankle above the level of your heart as much as possible to help reduce swelling.  At night, place a pillow or 8 inches of books under your mattress, elevating the entire foot above the level of the bed.

At this point, most patients benefit from referral to a physical therapist.  Ask your Doctor or Nurse Practitioner if you are interested in this option.

Phase 2: Range of Motion (ROM) / Heat

Heat is useful after the first 72 hours post-injury to: reduce pain, improve flexibility, speed up healing.  Begin applying a moist heating pad (available at the health center)  for 15 –20 minutes 2 times per day, 5 –7 days per week until all the swelling is gone (usually 1-2 weeks).

Ankle Brace

Switch from the Horseshoe Wrap to an aircast plastic splint.  If you do not have pain with walking, return the crutches and walk normally while in the splint.

After the first 48-72 hours, the pain should be improving. Begin ROM exercises slowly, and increase gradually until the ROM is equal in both ankles:

ROM Exercises
  1. Up Downs, (non-weight bearing).
    Gently move foot up and down in the neutral plane.
  2. Achilles tendon stretch, (non-weight bearing)
    Use a towel to pull foot toward face.
    Pain-free stretch for 15 to 30 seconds; perform five repetitions; repeat three to five times a day. Maintain extremity in a non-gravity position with compression.
  3. Alphabet exercises, (non-weight bearing)
    Move ankle in multiple planes of motion by drawing letters of alphabet (lower case and upper case). Repeat four to five times a day.
  4. Achilles tendon stretch, (weight bearing)
    Stand with heel on floor and bend at knees.
    Pain-free stretch for 15 to 30 seconds; perform five repetitions; repeat three to five times a day.

Phase 3: Strength

You can also do these exercises with your uninjured ankle, to keep it strong.

Isometric exercises

Resistance can be provided by immovable object (wall or floor) or opposite foot. For each exercise, hold 5 seconds; do 10 repetitions; repeat three times a day. Strengthening exercises should only be done in positions that do not cause pain.

Plantar flexion Push foot downward (away from head).
Dorsiflexion Pull foot upward (toward head).
Inversion Push foot inward (toward midline of body).
Eversion Push foot outward (away from midline of body).
Isotonic exercises

Resistance can be provided by opposite foot, rubber tubing or weights.  For each exercise, hold 1 second for flexion (concentric) component and perform relaxation (eccentric) component over 4 seconds; do three sets of 10 repetitions; repeat two times a day.  Emphasis is placed on the eccentric component; exercises should be performed slowly and under control.

Plantar flexion Push foot downward (away from head).
Dorsiflexion Pull foot upward (toward head).
Inversion Push foot inward (toward midline of body).
Eversion Push foot outward (away from midline of body).
Toe curls and marble pickups

Place foot on a towel; then curl toes, moving the towel toward body. Use toes to pick up marbles or other small object.  Two sets of 10 repetitions; repeat two times a day.Toe curls can be done throughout the day, at work or at home.

Toe raises, heel walks and toe walks

Lift body by rising up on toes. Walk forward and backward on toes and heels. Three sets of 10 repetitions; repeat two times a day; progress walking as tolerated.  Strengthening can occur from using the body as resistance in weight- bearing position.

Phase 4: Propioception

(a.k.a. balance re-training)

Ankle Balance

When a joint is injured, small sensors that help with balance, known as proprioceptors, are injured as well. After restoring ROM & strength, proproiceptors must be re-trained to help prevent another sprain, or make the next one less severe. This phase of rehab is often ignored – but with disastrous consequence. Do the following exercises for at least 3 weeks, if not longer:

Balance on one foot with the heel on the ground for as long as you can – at least 3 minutes 2-3 times per day.  After a few days, do this while brushing your teeth with your eyes closed, or while playing catch. Finally, once you are good with these, try doing them, in the order listed above , with your heel off the ground.  Some patients like to wear their aircast splint for these exercises initially.

Phase 5: Functional rehabilitation

When all of the earlier phases have been completed, you may begin a gradual return-to-running program that starts with walking and jogging, then progressing to running, sprinting, circles, figure eights, cutting, pivoting, and jumping. When all of these activities can be done without pain or limitation, you may return to practice and, eventually, full participation. Protection with taping or bracing during daily activity is recommended until strength returns to normal. When are ready to start the functional progression, protective devices are recommended only during exercise and sports participation. Exercises are listed below.

Sprints

Once you can jog and run at a moderate pace, perform 40 yard sprints at ½ speed. Gradually increase speed by 25% over the next two weeks as tolerated.

Figure Eights

Run in a figure eight pattern. Start with big, ten yard, circles, and over several days decrease to smaller circles.

Shuffles

Shuffle sideways, using small steps initially, and gradually increase the length of each shuffle.

Zigzags

Run zigzags, changing direction every 5 yards, in a progression similar to sprinting listed above.

Phase 6: Prevention of Repeat Injury

Static support (eg, taping, braces, or high-top shoes) and proprioception exercises increase neuromuscular response to inversion. No preventive strategy effectively eliminates all sprains. However, preventive measures and proper rehabilitation of injuries may reduce the frequency and severity of ankle injuries.

  • Wear flat shoes instead of high heels.
  • When playing sports, wear a lace-up ankle support (brace) for added protection for at least six months after your injury. The benefit of the brace seems to persist up to one year after injury. Preseason conditioning may optimize performance and prevent ankle injury.
  • Don't stop doing the ankle exercises after your ankle feels better. Keep doing the exercises several times a week to keep your ankles strong.

Warning Signs / When to Seek Help

  1. Inability to bear weight,
  2. Numbness in your foot or ankle,
  3. Increasing swelling,
  4. Re-injury during rehab.,
  5. A sensation that your ankle is giving way when walking,
  6. Persistent or worsening pain.
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