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Inside Ankle Sprain/Strains
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Ankle Injuries

Conservative Treatment

Acute Injury

Some 85% of acute ankle injuries are sprains, and some 85% of these involve the lateral ligaments only. Uncomplicated lateral ligament sprains can be expected to respond well to the type of treatment and rehabilitation program presented below.

While the vast majority of acute ankle injuries can thus be managed nonoperatively, certain acute injuries and structurally significant fractures may very well require operative treatment for best results. A logical approach to acute ankle injury in the athlete must therefore provide for an accurate evaluation and diagnosis of those injuries that generally merit orthopedic evaluation and treatment from those that do not & should respond well to conservative management.

Initial Treatment

Immediate treatment is required if there is any nerve, blood vessel, or skin impairment. This may entail correction of gross misalignment, which can usually be accomplished by gentle manipulation with gentle in-line traction on the ankle. It may be necessary to attempt this if orthopedic consultation is not readily available. It is important to assess and record the nerve and blood vessel status after any such attempt.

Splint immobilization is indicated for ankle fractures and peroneal or Achilles tendon dislocation. It is rarely indicated for other ankle injuries. If the athlete can be relied upon not to abuse his injury, immobilization and compression can be readily achieved with a compression splint.

 The RICE mnemonic, indicating rest, ice, compression, and elevation, applies in all cases. In the case of ankle injury, rest initially implies no weight bearing. When immobilization is not required, non-weight-bearing crutch ambulation is advanced to partial weight-bearing ambulation with heel-to-toe gait as tolerated. Ice implies application of, or immersion in, crushed ice for 20 minutes at least once every 4 waking hours and is continued until the swelling stabilizes (Heat applied at this time can actually increase healing time by 200-300%).  When immobilization is not required, compression can be achieved with an elasticized stockinette (Tubigrip) over a felt ‘horseshoe’ pad around the affected malleoli (ankle bone). As escaping blood accumulates, a pattern of a bluish ecchymosis may appear proximal to either or both malleoli. This finding is not cause for concern, but rather is an indication that the compression dressing has been properly applied. Elevation implies keeping the injured ankle at or above waist level at all times when the athlete is not actively using it. Both compression and elevation are continued until all swelling is resolved. At first, elevation may be intuitive, as the athlete soon realizes his ankle hurts more when it is used. Later, however, he may have to be reminded to keep it elevated.

Rehabilitation

Rehabilitation begins with the initial treatment of the acute injury and continues until the athlete is fully recovered. Specific measures are used to achieve the following specific objectives: prevention of swelling, reduction of swelling, restoration of normal motion, maintenance and restoration of strength, restoration of proprioception, and mainte­nance of fitness. At the same time, there is progression of functional use of the ankle, during which time it must be appropriately protected from further injury. Decisions relating the initiation and discontinuation of specific measures and to the progression of functional use of the ankle are rather straightforward:

Prevention of Swelling. Measures to prevent swelling are discussed under Initial Treatment, above.

Reduction of Swelling. Measures to reduce swelling include relative rest, elevation, compression, electrogalvanic stimulation (‘muscle-stim’), and contrast baths with active range of mo­tion exercises. Unless immobilization precludes their use, those measures not already begun can be started as soon as the swelling has stabilized. Otherwise they can be started as soon as immobilization is discontinued. It is important to emphasize that range-of-motion exercises be done during the warm phase of the contrast baths, if possible. These measures are continued until the swelling has resolved.

Restoration of Normal Motion. Measures to restore normal motion are begun as soon as the swelling has stabilized or immobilization is discontinued. These measures are active range-of-motion exercises, which includes alphabet writing, and specific chiropractic manipulation for any misaligned bones/joints of the affected extremity to assure proper biomechanical function and an optimum healing environment. The Journal of Orthopedic Trauma in 1993 found “Ankle stability is related to articular congruity with increased load-bearing emphasizing the importance of anatomical restoration of the ankle mortise in the injury state”.  What this means is that your ankle works better and heals faster when all of the bones in it are properly aligned.

Motion exercises are continued until full range of motion has been achieved. If full range of motion, particularly in dorsiflexion (flexing the foot upwards), has not been restored with alphabet writing alone, then other specific stretching exercises are prescribed. Specific chiropractic manipulation is performed as indicated to restore and maintain normal motion of the ankle joint.

Maintenance and Restoration of Strength. Measures to maintain and restore strength are also begun as soon as swelling has stabilized or as soon as immobilization is dis­continued. Initially, manual resistance isometric exercises (push against a towel) are used. Subsequently, Theraband exercises are started and advanced as tolerated. When the athlete is easily able to handle three sets of 20 repetitions of the strongest Theraband, isokinetic exercises (weight machine) can be started. Specific strengthening exercises are continued until full strength has been restored.

Ambulation. Partial weight-bearing (crutch) ambulation is permitted as soon as a normal heel-to-toe gait is possible. The crutches may be discontinued as soon as painless weight bearing is possible. However, the ankle must then be protected as ambulation is progressed. We prefer Aircast, Ace bandage, or athletic taping for this purpose. Ambulation is progressed sequentially as indicated in the table above, with the criterion for advance­ment being the absence of pain and swelling with the attempted activity. A reasonable predictor of ability to start running is the ability to stand on the toes and to hop up and down on the injured side. It will usually be apparent to the athlete that if he is unable to do this he is not yet ready to run.

Restoration of Proprioception. The importance of restoring proprio-ception (balance and position sense) has been consistently emphasized in the medical and chiropractic literature. We begin tilt-board or mini-trampoline exercises as soon as 75% motion and strength have been achieved, and advance these exercises as tolerated. On the mini-tramp, we start by playing ‘catch’ with the athlete standing on both feet, leading up to standing on one foot, followed by being crouched on the affected foot.  We let the athlete start running 20-yard figure-eights and doing 45-degree cuts when full motion has been achieved and advance to 10-yard figure-eights and 90-degree cuts as full strength is achieved.

Maintenance of Fitness. Measures to maintain fitness while the athlete’s injury precludes his usual training regimen are begun as soon as tolerated. Strength of the uninvolved limbs can be maintained with appropriate weight training. Endurance fitness can be maintained or even improved with swimming or stationary bicycling, which, as a rule, can be started well before the athlete is able to run.

Return To Sports Participation

Ideally, return to sports participation is simply the final step in the sequence of rehabilitation. For the athlete whose sport makes lesser demands of the ankle, return to the sport will occur prior to completion of the full rehabilitation program just dis­cussed. However, for the athlete whose sport places great demands on the ankle, e.g., football, basketball, tennis, completion of all steps of the rehabilitation program is highly recommended.

This recommendation notwithstanding, the physician or trainer is often asked to consider letting the athlete return to his sport before full rehabilitation has been achieved. The physician must then weigh the risks and consequences of re-injury against the athlete’s desire to return to play.

In the case of ankle sprains, whatever the risk of re-injury, the consequences are not much more than having to start all over with a fresh injury. The athlete is not at a significantly increased risk for incurring another acute injury because he will be playing with a taped ankle. Accordingly, if the athlete, and his parents as the case may be, are accepting of some increased risk of re-injury, and if he is functionally able to play, then he should probably be allowed to do so.