ANKLE SPRAIN REHAB
Ankle sprains can happen any time of year. Summer hiking, winter slips and falls, and year-round sporting activities. Often people feel like an ankle sprain is no big deal, but it is an injury that can stick around longer than you anticipate and cause issues up the lower extremity due to altered gait and compensations. It is important to start rehab early and continue through to the end. When you aren’t walking effectively due to a sore ankle, the knee, hip and lower back can begin to have secondary problems.
The most common injury is an inversion sprain, where you roll onto the outside of your ankle. Commonly two major ligaments are affected – the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). While these are typically the main structures affected, ankle sprains can also involve a muscle strain or a joint dysfunction in one of the tarsal (ankle) joints.
Ligament sprains are graded 1 to 3, depending on the degree of injury. A grade 1 ligament sprain is mild with often a quick recovery. You may have some swelling and pain around the outer ankle, but you have good strength and range of motion. A grade 2 injury is more moderate and may take 4-8+ weeks to heal. The ligament may be partially torn but is still intact and there is moderate swelling, bruising and difficulty weight bearing and walking. A grade 3 is more severe with a rupture of one or more of the ligaments, moderate swelling, bruising, and weakness.
The Ottawa Ankle Rules (OAR) are guidelines, for adults > 19 years with acute ankle and mid foot injuries, to rule out fractures and reduce unnecessary imaging. Historically, imaging was ordered for most ankle sprains, even though only 15% showed clinical fractures. Ankle x-rays are recommended if there is pain along the “malleolar region” (the distal ends of the long bones in our ankle), pain at the base of the 5th metatarsal bone, and the inability to weight bear initially (unable to take 4 steps independently, despite limping). These guidelines exclude recommendations for those under 19 years of age, with multiple painful injuries, pregnant, cognitively impaired or those with sensory deficits in their extremities.
Doherty et al. (2016) found that 40% of individuals develop chronic ankle instability after a first-time lateral ankle sprain (LAS). This study stated that “an inability to complete jumping and landing tasks within 2 weeks of a first time LAS and poorer dynamic postural control and lower function 6 months after a first time LAS were predictive of eventual chronic ankle instability.”
There are three main goals when rehabilitating an acute ankle sprain: (1) minimize swelling (2) improve ankle function and (3) normalize walking.
The Oxford Health NHS Foundation recommends avoiding NSAIDS (non- steroidal anti-inflammatory drugs, such as Ibuprofen) for the first 3 days after an injury. Modified rest for 24-48 hours and icing 10-20 min 3-4x/day for the first 3 days will help reduce swelling and pain. Elevation and compression can also be used to help reduce swelling and pain.
Active range of motion exercises can be started as tolerated, such as ankle pumps (up and down) and ankle circles. Secondly, add in ankle strengthening. Move your ankle in 4 main directions, using an elastic band looped around your forefoot and push into plantar flexion (pushing down), dorsiflexion (pulling up), inversion (inwards) and eversion (outwards). Single leg balance (supported as needed) is the next step.
Try to balance on your injured foot, building up to 1 min 3x/day. Focusing on a proper walking pattern as soon as possible can help mitigate lower extremity compensations. A walking aid or brace can help your gait pattern and stability when used early on. Doherty et al. (2017) showed strong evidence for exercise therapy and bracing in preventing the recurrence of an ankle sprain. It is recommended to wear a lace up ankle stabilizing orthotic (ASO) for 6-12 months post injury.
Later stages of rehab may involve squatting, step ups, heel raises and plyometrics such as hopping in different directions. When you are ready to return to activities, we look at several aspects of your readiness: pain levels, range of motion, strength, power, dynamic postural control, balance and agility.
These programs and progressions need to be tailored to your individual needs, function and goals. The timelines may differ depending on the severity of the injury and other co-morbidities. Generally, as you start to slowly load your ankle post injury, if any specific exercise or walking significantly increase your symptoms, you may need to scale back on intensity, frequency or volume of movement. We would love to help determine the best plan of action for your post ankle sprain and get you effectively back to your activities with optimal strength, function and endurance.
Jennifer Gordon (BSc.PT, BA Kin, AFCI)
Physiotherapist – Bragg Creek Physiotherapy
www.braggcreekphysio.com
