NONOPERATIVE MANAGEMENT OF SPRAINED ANKLE



 Ankle sprain is one of the most common musculoskeletal injuries with physically active individuals who are at higher risk than the general population.First- , second- ,and third - degree (grades) are usually managed conservatively. 

The most common type of ankle sprain is caused by inversion stress and can result in a partial or complete tear of anterior talofibular (ATF) ligament and often the calcaneofibular (CF) ligament. 

The posterior talofibular (PTF)  ligament, the strongest of lateral ligaments, is rarely torn in isolation; significant inversion stress is required to tear the PTF ligament. 

History of a previous ankle sprain is a risk factor for future sprain. 

Using an external support (lace - up ankle brace or athletic ankle bracing) has been shown to decrease the incidence of ankle sprain. 

PHASES OF MANAGEMENT 

PROTECTION PHASE

- Use compression, elevation, and repeated intermittent applications of ice to minimize swelling. 

- Provide external support (brace, semi-rigid ankle orthotic, or walking boot) in conjunction with progressive, functional weight bearing. 

- Use gentle joint mobilization techniques to maintain mobility and inhibit pain. 

- Perform gentle sagittal plane active ROM in a pain-free range. 

- Educate the patient about the importance of RICE (rest, ice, compression, and elevation), and instruct the patient to apply ice every 2 waking hours during the first 24-48 hours and about partial weight bearing with crutches and instruct in progressive weight bearing. Also, muscle setting (isometric) exercises and active toe curls to help maintain muscle integrity and assist with circulation. 

CONTROLLED MOTION PHASE

- As the acute symptoms subside, continue to provide protection for the involved ligament with an orthosis during weight bearing. Commercial orthosis, such as an air splint, provide medial-lateral stability while allowing dorsiflexion and plantarflexion. 

- Provide gait training to normalize walking over level ground and on stairs. 

- Apply cross-fiction massage to the ligaments as tolerated. 

-Use grade 2 mobilization techniques to maintain mobility of the joint, particularly posterior glide of the talus. 

-Advance therapeutic exercise resistance or intensity. Avoid end-range inversion. Exercises should be completed throughout the day. 

-Nonweight- bearing active ROM into dorsiflexion, plantarflexion, inversion and eversion, toe-curls, and ankle alphabet. 

- Sitting with the heel on the floor and performing foot intrinsic exercises, towel gathering or picking up objects with the toes. 

-Stretch the gastrocnemius-soleus muscle group to restore full ankle dorsiflexion. Begin with towel stretch in long sitting, then progress to weight bearing stretches.
 
- As swelling decreases and weight bearing tolerance increases, progress to progressive resistive exercise ( strength  and endurance) and neuromuscular re-education (balance and proprioception). 
Include isometric and isotonic exercise, bicycle ergometry, and partial to full weight- bearing balance board exercises. 
Initially, have the patient wear a range- limiting brace or orthosis to prevent excessive stress on the healing ligament. 

RETURN TO FUNCTION PHASE

-Progress strengthening exercises by adding elastic resistance to foot movements in long-sitting ( open-chain ) and sitting with the heel on the floor for partial weight bearing. 

- Progress neuromuscular reeducation training to improve balance, coordination, stability, and neuromuscular response in full weight bearing. Progressively challenge dynamic lower extremity stabilizers by introducing varying degrees of surface instability and external perturbation. 

-Incoroprate movement patterns, such as forward/backward walking and cross-over side stepping with elastic resistance secured around the unaffected lower extremity. 

-Utilize an unstable surface, such as BOSU, BAPS board, or mini-trampoline, or an ankle destabilization shoe or boot. 

-Depending on the final goals of rehabilitation, train the ankle with weight- bearing activities, such as walking on uneven ground, jogging, running, jumping, hopping, and sprinting. Incorporate agility activities such as controlled twisting, turning, and lateral weight shifting. 
Provide distracting activities such as a ball toss to increase automaticity of postural control. 

-When the patient is involved in sports activities, the ankle should be splinted or taped and appropriate shoes should be worn to protect the ligament from re-injury.