Have you rolled your ankle recently?

Up to 70% of us have ‘rolled’ our ankle at some point causing a lateral ankle sprain.
The most common symptoms are pain and swelling on the outside of the ankle. Pain is made worse by turning the foot in, running, uneven surfaces or suddenly changing direction.

Ligaments involved in lateral ankle sprains (green)

Lateral ankle sprains commonly involve the anterior talofibular and calcaneofibular ligaments ➡️and can be graded into:
☝️Grade 1 = Mild pain and swelling with no bruising. No ligament laxity and able to weight bear. Mostly stretched ligament with no or minimal tearing.
🤙Grade 2 = Moderate pain, swelling and mild bruising. Mild loss of range of motion and function, pain weight bearing and walking. Some ligament laxity with end-point tension. Mild to moderate ligament tear.
🤟Grade 3 = Severe pain, swelling and bruising. Inability to weight bear or walk. Marked instability with gross ligament laxity and no end-point tension. Severe ligament tear.

However, a lateral ankle sprain can be further complicated by a fracture and/or tendon injury. Ruling out a fracture via the Ottawa ankle rules is important and a fundamental step in accurately diagnosing ankle sprains. If there is pain at either malleolus (ankle bones) coupled with an inability to walk four steps unassisted an x-ray should be taken to assess for fracture.

Depending on the grade and complexity of the sprain you may need professional treatment. Most lateral ankle sprains are thought to be harmless and so treatment is often not sought. However, you are up to 9x more likely to ‘roll’ your ankle again within 6 months and 40% of people develop chronic ankle instability following a lateral ankle sprain when not managed correctly (i.e. return to activity to fast and inadequate rehab)(Tassignon, 2019) .

Initial management is focused on reducing pain/swelling and restoring range of motion before progressing to muscle strengthening, balance and coordination and a return to activity program.

 

Exercises for Ankle Sprains

So what can you do when you sprain your ankle?

LEVEL 1
• PEACE – Protect by limiting full ankle movement for 24-72hours. Elevate to minimise swelling. Avoid anti-inflammatory medications if you can deal with the pain. Compress with a bandage to reduce swelling. Educate.
• LOVE – Load the injured tissue and resume weight bearing and walking as soon as pain allows. Be Optimistic, a positive mindset enhances the likelihood of optimal recovery. Vascularisation of injured tissues is promoted with movement and building tolerance to load. Patient performs Exercises in pain free range initially progressing to more advanced rehab exercises.
• Alphabet mobilisation – A low load exercise to begin restorating full ankle joint range of motion, reduce inflammation and promote blood flow.

LEVEL 2
• Banded eversion and inversion – A good starting point in building muscular strength. Resistance and repetitions shoulder be increased as pain reduces.
• Double leg to single leg calf raise – Slowly incorporate load into the ankle and calf complex to build tissue tolerance and minimise risk of chronic instability by building a strong base for support.
• Double leg to single leg calf raise on step – Increased dorsiflexion range of motion with eccentric load increases muscle and tendon load to improve ankle strength.

Lateral ankle sprain exercisesLEVEL 1 |• PEACE – Protect by limiting full ankle movement for 24-72hours. Elevate to minimise swelling. Avoid anti-inflammatory medications if you can deal with the pain. Compress with a bandage to reduce swelling. Educate.• LOVE – Load the injured tissue and resume weight bearing and walking as soon as pain allows. Be Optimistic, a positive mindset enhances the likelihood of optimal recovery. Vascularisation of injured tissues is promoted with movement and building tolerance to load. Patient performs Exercises in pain free range initially progressing to more advanced rehab exercises.• Alphabet mobilisation – A low load exercise to begin restorating full ankle joint range of motion, reduce inflammation and promote blood flow.LEVEL 2 |• Banded eversion and inversion – A good starting point in building muscular strength. Resistance and repetitions shoulder be increased as pain reduces.• Double leg to single leg calf raise – Slowly incorporate load into the ankle and calf complex to build tissue tolerance and minimise risk of chronic instability by building a strong base for support.• Double leg to single leg calf raise on step – Increased dorsiflexion range of motion with eccentric load increases muscle and tendon load to improve ankle strength.LEVEL 3 |The advanced rehab stage should be incorporated into a return to activity program involving plyometrics, cutting, accelerating, decelerating etc. It is important to increase your ability to adequately react and adapt to unexpected stimuli.• Single leg banded Palloff press – Incorporate an increased level of instability whilst weight bearing. Offset objects such as banded encourage proprioceptors within the joint, muscle and surrounding tissue to control foot/ankle position whilst in a weight-bearing position.• Multiplanar weighted balance – Use a mobile load to create changing demand for the tissues to further increase control with increased load.• Unstable surface multiplanar weighted balance – Add an unstable surface to further challenge tissues and build tolerance.• Lateral hopping – introducing plyometric loading strategies to assist a return to activity protocol.

Posted by Trident Health on Wednesday, July 3, 2019

LEVEL 3
The advanced rehab stage should be incorporated into a return to activity program involving plyometrics, cutting, accelerating, decelerating etc. It is important to increase your ability to adequately react and adapt to unexpected stimuli.
• Single leg banded Palloff press – Incorporate an increased level of instability whilst weight bearing. Offset objects such as banded encourage proprioceptors within the joint, muscle and surrounding tissue to control foot/ankle position whilst in a weight-bearing position.
• Multiplanar weighted balance – Use a mobile load to create changing demand for the tissues to further increase control with increased load.
• Unstable surface multiplanar weighted balance – Add an unstable surface to further challenge tissues and build tolerance.
• Lateral hopping – introducing plyometric loading strategies to assist a return to activity protocol.

 

Bio-mechanical Considerations with ankle Sprains

1. Joint Mobility-
Hypo-mobility | Post-lateral ankle sprain the ankle and foot complex can initially become rigid due to protective muscle spasm and intra-articular inflammation. It is important to restore full ankle range of motion as quickly as tissue damage, pain and inflammation allow.
– Hyper-mobility | Conversely, the ankle joint can also be too lax post-lateral ankle sprain and thus there needs to be a high suspicion of a higher grade ankle sprain, involvement of the peroneal muscle group or a strong recurrent history of ankle sprains needs to be evaluated.

2. Balance
– Lower limb proprioception (awareness of joint in space) and neuromuscular control are often negatively affected post-lateral ankle sprain. Balance tests (i.e. Y-balance and star-balance) can be used to assess whether you are able to accurately control your foot and ankle position under load. It is important when rehabilitating ankle balance that you try replicate positions of vulnerability through external stimuli (bands, torso pushes) and unstable surfaces (balance mat) to reduce the risk of re-injury or chronic ankle instability.

Bio-mechanical considerations for lateral ankle sprains.1. Joint Mobility- Hypo-mobility | Post-lateral ankle sprain the ankle and foot complex can initially become rigid due to protective muscle spasm and intra-articular inflammation. It is important to restore full ankle range of motion as quickly as tissue damage, pain and inflammation allow.- Hyper-mobility | Conversely, the ankle joint can also be too lax post-lateral ankle sprain and thus there needs to be a high suspicion of a higher grade ankle sprain, involvement of the peroneal muscle group or a strong recurrent history of ankle sprains needs to be evaluated.2. Balance- Lower limb proprioception (awareness of joint in space) and neuromuscular control are often negatively affected post-lateral ankle sprain. Balance tests (i.e. Y-balance and star-balance) can be used to assess whether you are able to accurately control your foot and ankle position under load. It is important when rehabilitating ankle balance that you try replicate positions of vulnerability through external stimuli (bands, torso pushes) and unstable surfaces (balance mat) to reduce the risk of re-injury or chronic ankle instability.3. Other- Extrinsic factors such as shoes, playing surface (road, grass or trail), type of activity/sport, and position within the team are all factors to consider and discuss before returning to activity.- Intrinsic factors, other than those already mentioned, may include wider assessment of technique and capabilities.

Posted by Trident Health on Wednesday, July 3, 2019

3. Other
– Extrinsic factors such as shoes, playing surface (road, grass or trail), type of activity/sport, and position within the team are all factors to consider and discuss before returning to activity.
– Intrinsic factors, other than those already mentioned, may include wider assessment of technique and capabilities.