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Sprained Ankle Rehabilitation

Sprained Ankle Rehabilitation focuses on the complete comeback of the ankle joint to the functional position and is divided in to different phases as detailed under.

A sprained ankle is an injury that occurs when you roll, twist or turn your ankle in an awkward way. This may cause stretch or tear of the ankle ligaments (tough bands of tissue) that help hold your ankle bones together. An ankle sprain can range from mild to severe, depending on how badly the ligament is damaged and how many ligaments are injured. With a mild sprain, the ankle may be tender, swollen, and stiff. But it usually feels stable, and you can walk with little pain. A more serious sprain might include bruising and tenderness around the ankle, and walking is painful. In a severe ankle sprain, the ankle is unstable and may feel "wobbly." You can't walk, because the ankle gives out and may be very painful.

Ankle sprain ligaments
Ankle sprain ligaments

Relevant Anatomy
The stability of any joint depends on the inherent constraints provided by the bony configuration and the active and passive soft tissue restraints. The ankle joint is quite stable in its neutral position however in plantar flexion of it is in a much looser fit, with a particular tendency toward inversion. Active soft tissue restraint depends on the muscle-tendon units involved in movement and support of the joint. Passive support of the ankle is provided by the medial, lateral, and posterior ligaments and the syndesmosis.

The lateral ankle ligament complex is the structure most commonly involved in ankle sprains.

The three main components of the lateral ligament complex are the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL)

The most common ankle injury involves an isolated tear of the ATFL, followed by a combined tear of the ATFL and the CFL. The mechanism of injury is usually inversion of the plantar flexed foot.

Grades of Ankle Sprains

Ankle sprains are classified into grade 1, 2, and 3. Depending on the amount of damage or the number of ligaments that are damaged, each sprain is classified from mild to severe.

  • A grade 1 sprain is defined as mild damage to a ligament or ligaments without instability of the affected joint.
  • A grade 2 sprain is considered a partial tear to the ligament, in which it is stretched to the point that it becomes loose.
  • A grade 3 sprain is a complete tear of a ligament, causing instability in the affected joint. Bruising may occur around the ankle.

Symptoms

Signs and symptoms of a sprained ankle include:

  • Pain
  • Swelling
  • Bruising
  • Tenderness to touch
  • Restricted range of motion
  • Instability of the ankle—this may occur when there has been complete tearing of the ligament or a complete dislocation of the ankle joint.

If there is severe tearing of the ligaments, you might also hear or feel a "pop" when the sprain occurs.

Treatment of ankle sprain

Functional rehabilitation is the preferred method of treatment for ankle sprains, as it allows an earlier return to work and physical activity without a higher rate of late symptoms (ankle instability, pain, stiffness, or muscle weakness). The type and duration of treatment depends on the grade of the ankle sprain.


For immediate at-home treatment of ankle sprains (in acute phase), the PRICE method is recommended. 


This includes:

  • Protection – Immediately protect your ankle do not allow for any further movements around the joint.
  • Rest — avoid putting weight on your ankle. Try to move as little as possible for the first few days. Use crutches or a cane if you have to walk or move.
  • Ice — Begin by putting a bag of ice on your ankle for at least 20 minutes at a time. Do this three to five times a day for three days after the injury. This helps reduce swelling and numb pain. Give yourself about 90 minutes between icing sessions.
  • Compression — Wrap your injured ankle with an elastic bandage, like an CREPE bandage. Do not wrap it so tightly that your ankle becomes numb or that your toes turn blue.
  • Elevation — whenever possible, keep your ankle raised above heart level on a stack of pillows or other type of support structure.

In the subacute phase, goals include continued reduction of swelling, inflammation, and pain, while some motion, strengthening, and appropriate controlled weight-bearing are started. This is the period of collagen fiber proliferation, and too much stress on the ligaments at this point could result in weaker tissue.

Sprained Ankle Rehabilitation Protocol
The rehabilitative phase focuses on improving strength, endurance, balance, and weight-bearing proprioception. During this maturation phase of the healing ligament, about 3 weeks after the injury, controlled stretching of the muscles and movement of the joint promote a more normal orientation of the collagen fibers parallel with the stress lines. Repeated exercise during this phase has been shown to increase the mechanical and structural strength of the ligaments.

The rehabilitation of ankle sprains is to be done with the help of physical therapists. Brief details of Sprained Ankle Rehabilitation Protocol are given as under

Phase 1: Acute Phase


Timing


  • Grade 1 sprain: 1-3 days.
  • Grade 2 sprain: 2-4 days.
  • Grade 3 sprain: 3- 7 days.


Goals

  • Decrease swelling.
  • Decrease pain.
  • Protect from reinjury.
  • Maintain appropriate weight-bearing status.


Protection Options

  • Taping.
  • Functional bracing.
  • Removable cast boot (some grade 2 and most grade 3 sprains),
  •  Rest (crutches to promote ambulation without gait  deviation).


Ice
• Cryocuff ice machine /  Ice bags etc

Light Compression

  • Elastic (Ace) wrap.
  • TED hose.
  • Vasopneumatic pump

Elevation
• Above the heart (combined with ankle pumps)

Phase 2: Subacute Phase 

Timing 
  • Grade 1 sprain: 2-4 days. 
  • Grade 2 sprain: 3-5 days.
  • Grade 3 sprain: 4-8 days. 

Goals 
  • Decrease swelling. 
  • Decrease pain. 
  • Increase pain-free ROM. 
  • Begin strengthening. 
  • Begin non-weight-bearing proprioceptive training. 
  • Provide protective support as needed. 


Modalities to Decrease Pain and Swelling
  • Ice or contrast baths. 
  • Electrical stimulation (high-voltage galvanic or interferential) .  
  • Ultrasound.Cross-friction massage (gently). 


Therapeutic Exercises 

Active ROM exercises 
  • Dorsiflexion 
  • Inversion 
  • Foot circles 
  • Plantar flexion 
  • Eversion 

Strength exercises
  • Isometric in pain-free range 
  • Toe curls with towel (place weight on towel to increase resistance).
  • Pick up objects with toes (tissue, marbles). 
  • Proprioceptive training: - Seated Bio-mechanical Ankle Platform System (BAPS board or Wobble board. 

Stretching
  • StretchingPassive ROM-only dorsiflexion and plantar flexion in pain-free range, nor eversion or inversion. intensity. 
  • Achilles stretch (gentle).  

Phase 3: Rehabilitative Phase


Timing

  • Grade 1 sprain: 1 wk..
  • Grade 2 sprain: 2 wk.
  • Grade 3 sprain: 3 wk.

Goals
  • Increase pain-free ROM.
  • Progress strengthening. 
  • Progress proprioceptive training. 
  • Increase pain-free activities of daily living.
  • Pain-free full weight-bearing and uncompensated gait

Therapeutic Exercises

Stretching
  • Gastrocnemius and soleus with increased intensity
  • Joint mobilization (grades I, 2, and 3 for dorsi-flexion, plantar flexion, and eversion; hold inversion).
Strengthening
  • Weight-bearing exercises
  • Heel raises
  • Toe raises
  •  Stair steps
  • Quarter squats.
Eccentric/concentric and isotonics (Theraband andcuff weights)
  • Inversion 
  • Eversion 
  • Plantar flexion 
  • Dorsiflexion 
  • Peroneal strengthening.
Proprioceptive training (progress from non-weightbearing/controlled weight-bearing stage to full weightbearing
  • Standing BAPS board.
  • Standing wobble board.
  • KAT system.
  • Single-leg balance activities (stable to unstable surfaces, without to with distractions)