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Ankle sprains are one of the most common injuries in athletes and physically active people. When working with patients who have an ankle sprain, it is important that clinicians work hard to get these individuals back on their feet and functioning normally as soon as possible. Unfortunately, common treatment methods based on outdated research increase the rehab time and prevent patients from getting back to their normal lives quickly. This post will discuss some of those misconceptions as well as break down the steps to take when working with patients who have an ankle sprain.

Step 1:

Clinical assessment: 

As the first touch in the healthcare system, your job is to rule out more serious injuries, namely fractures.  Many clinicians jump to x-rays, but this is typically an unnecessary step as only 15% of ankle sprains have an associated fracture. By utilizing the Ottawa Ankle Rules, a series of easy-to-perform clinical tests, you will be able to determine if there is a possible fracture that requires radiographs.  If these tests are negative, you can save your patient the unnecessary expense and radiation of an x-ray.

Step 2:

Do NOT immobilize:

Do NOT immobilize the affected ankle if the patient does not have a fracture. Traditionally, sprained ankles have been put in a boot or brace, but immobilization can have detrimental effects that delay healing and return to activity. Not only does immobilization increase stiffness in the joints and soft tissues, but it also contributes to atrophy of the muscles that support the foot and ankle and alters the normal gait pattern.  An excellent clinical example of how poorly immobilization promotes healing and recovery is with the transition in ACL tear recovery. In the not too distant past, post-op ACL patients were immobilized for weeks or months in a cast, but in recent decades, we have transitioned to early mobilization, which has dramatically improved outcomes. Like with ACL recovery, immobilizing ankles results in longer return times and more functional deficits after initial injury.

Step 3:

Early PT Referral:

The most important step is to refer your patient to a physical therapist – the musculoskeletal primary care provider – as soon as possible. Studies have shown that with early physical therapy, patients with acute ankle sprains had significant improvement in early and long term ankle pain and function compared to those without. Ankle mobility and strengthening can decrease rehab time and improve healing. Physical therapists are able to assess and prescribe exactly what your ankle needs to get back to normal function. 

Physical Therapy Outlook:

As stated above, immobilization can hinder ankle sprain recovery. Therefore, your physical therapy sessions will include movement in many different fashions specific to the severity of the ankle sprain. Early physical therapy will include:

    • Soft tissue massage – decrease swelling and increase mobility in the surrounding tissue

    • Dry needling – increase blood flow for healing and increase tissue mobility

    • K-tape – decrease swelling and help eliminate bruising

    • Joint mobilizations – increase movement of the ankle joint and surrounding foot joints

    • Movement exercises – increase surrounding tissue and joint movement, increase blood flow for healing, and decrease swelling

    • Strengthening exercises – increase strength of ankle, knee, and hip to allow for ligament healing

    • Neuromuscular exercises – increase stability of ankle, knee, and hip to allow for healing and prevent future injury

Early Return to Sport/Activity:

Research has shown that patients have been able to return to sport or activity quicker when they start with early mobilization and physical therapy, than if they were to immobilize for 2 weeks. The reason being is that continuous passive motion (even though the patient may have pain) can help in providing a load or movement that is necessary to spark the production of proteins necessary to heal. This in turn, decreases the breakdown of cells post-injury that are caused from swelling and inflammation. By utilizing physical therapy to improve mobility and strength of the ankle patients are able to return to their sport/activity more quickly.

References:

  1. Petersen W, Rembitzki IV, Koppenburg AG, et al. Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg. 2013;133(8):1129–1141. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718986/
  2. Kannus P. et al. . (2003) Basic science and clinical studies coincide: active treatment approach is needed after a sports injuryScand. J. Med. Sci. Sports 13, 150–154. https://www.researchgate.net/profile/Tero_Jaervinen/publication/13624542_Effects_of_immobilization_and_subsequent_low-_to_high-intensity_exercise_on_morphology_of_rat_calf_muscles/links/59e399faaca2724cbfe3adab/Effects-of-immobilization-and-subsequent-low-to-high-intensity-exercise-on-morphology-of-rat-calf-muscles.pdf
  3. Kristin Hultman, Anne Fältström & Ulrika Öberg (2010) The effect of early physiotherapy after an acute ankle sprain, Advances in Physiotherapy, 12:2, 65-73. https://www.tandfonline.com/doi/abs/10.3109/14038190903174262
  4. Chinn L, Hertel J. Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med. 2010;29(1):157–167. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2786815/
  5. Salom-Moreno J, Ayuso-Casado B, Tamaral-Costa B, Sánchez-Milá Z, Fernández-de-Las-Peñas C, Alburquerque-Sendín F. Trigger Point Dry Needling and Proprioceptive Exercises for the Management of Chronic Ankle Instability: A Randomized Clinical Trial. Evid Based Complement Alternat Med. 2015;2015:790209. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430654/

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