Education Resource Center

by John Hyland, DC

Sprains of the ankle are common injuries, since this joint is required to perform complex movements under high forces during normal walking. This can be particularly important for patients who participate in recreational activities and sports that require running and jumping. Proper evaluation and management in the early stages of an ankle sprain are very important in preventing chronic instabilities. With appropriate treatment, significant improvements in function and stability can be achieved, even in patients with long-standing ankle problems.

Acute Care

Initial treatment of ankle sprains follows the standard RICE protocol, which has recently been adapted to PRICE. This major change in the treatment of acute injuries affects most all soft-tissue traumas. Even with severe ankle sprains, using these procedures has been shown to speed recovery and return to sports.

The change from RICE to PRICE consists of adding some form of biomechanically appropriate protection to the injured joint (see Table 1). This then allows the R to be updated from rest to restricted activity. With the injured joint protected, patients can be encouraged to continue their activities (rather than using the now-discredited bedrest), with some restrictions. In the case of ankle sprains, this entails the use of a lightweight but laterally rigid brace, which protects against inversion and eversion. If a patient has been placed in a walking cast rather than a mobilizing brace, frequent prolonged stretching of the Achilles tendon must be performed in order to prevent shortening.

TABLE 1

Treatment of Acute Injuries

P

protection of the injured joint (brace or support)

R

restricted activity (contralateral exercising)

I

ice (cryotherapy)

C

compression (elastic)

E

elevation (above heart level)

A study by Konradsen, et al. found that even in severe, Grade III lateral ankle sprains (with joint instability), encouraging early activation and walking in an Aircast® functional brace produced a more rapid return to full work and sports activities than use of a cast.1 The long-term results were equally good, with a minimum of chronic instability. This is consistent with the reports from studies of injuries to other joints, which demonstrate generally better results by encouraging early activity of injured joints while providing restrictions and protection from further damage.

Exercises

During the initial acute stage, exercises for the damaged ankle are not appropriate. However, general full body conditioning should be continued, using methods that do not place undue stress on the healing ankle (a stationary cycle with pedal straps is recommended).2 Additionally, vigorous exercise of the contralateral joint’s muscles has been shown to provide a healing stimulus and a more rapid return to activities.3 This is called cross-over or cross education and is based on the neurological interconnections between extremities. In the case of lateral ankle (inversion) sprains, the peroneus muscles should be targeted. The patient can begin the rehabilitation process by frequently exercising the peroneus muscles of the uninjured ankle, using elastic tubing (such as a Thera-Ciser™) to perform eversion exercises. Since a recent study of cross education of the quadriceps found better results when the lengthening (eccentric) muscle action was emphasized, I want patients to focus more attention and spend more time on the returning part of the exercise.4

In the early sub-acute phase, as healing progresses, patients should begin to perform non-resistive active exercises, concentrating on mobility of the injured ankle. This usually takes the form of writing the alphabet with the foot while seated. The entire alphabet should be performed several times a day. This may be accompanied by isometric exercises for the peroneus muscles. The seated patient pushes the foot outwards (laterally) against an unmovable object, holding each contraction for five seconds or longer.

Once the joint can be passively moved through a normal range, isotonic resistance exercising of the peroneal muscles using elastic tubing should be started.5 Initially, these exercises should be performed from a sitting position, with the heel resting on the floor, to reduce the forces on the ankle joint while still maintaining the functional alignment.

As strength builds, the patient should progress to standing during the exercises, in order to re-train the ankle support muscles in a closed-chain position. Further sport-specific exercises should be introduced to ensure that an athlete has all the strength and mobility to participate in sports. Examples include rope jumping, which progresses to side-to-side jumps, carioca steps, figure eight runs, and even backwards running. Plyometric procedures should be introduced only when all other capabilities have returned to pre-injury capacity.

Proprioception

One reason that some ankle injuries become chronic or recur appears to be the loss of the normal coordination of the muscles about the ankle, rather than simply their strength.6 An easy test for this type of problem is to have the patient stand on each leg with the eyes open, and then closed. Check to see if there is less capability of the injured leg. Practice of the one-legged stance and use of “wobble” boards might be required to regain normal proprioceptive coordination. Subotnick recommends that an athlete should be able to demonstrate a “stork stand” for a least one minute on the injured leg before being allowed to return to full competition.7

Orthotics

In many patients, a custom-made functional orthotic can also be helpful in preventing future (and often more disabling) damage to the injured ankle. A careful evaluation of the biomechanics of the foot and ankle will find some patients who have underlying anatomical or functional problems. Particularly in the case of athletes, use of a stabilizing, custom-made orthotic with good torsional rigidity should be considered. Orthotic support and control of inversion/eversion is necessary and highly recommended whenever there is a deficit in biomechanical function.8

Summary

Recent studies demonstrate that even in severe ankle injuries, a well-informed conservative and active treatment approach will result in good outcomes. Using active rehabilitation concepts, including the use of contralateral exercising, isotonic exercises with elastic tubing, and proprioceptive training techniques, most doctors of Chiropractic can manage acute ankle sprain injuries very well. In some patients, custom orthotics will be needed to help prevent future problems and joint degeneration.

About the Author
A 1980 graduate of Logan College of Chiropractic, Dr. John Hyland has practiced for more than 20 years in Colorado. In addition to his specialty board certifications in Chiropractic orthopedics (DABCO) and radiology (DACBR), Dr. Hyland is nationally certified as a strength and conditioning specialist (CSCS) and a health education specialist (CHES). He now consults Chiropractors in the concepts and procedures of spinal rehabilitation and wellness exercise.


1 Konradsen L, Holmer P, Sondergaard L. Early mobilizing treatment for grade III ankle ligament injuries. Foot & Ankle 1991; 12:69-73.

2 Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management and Rehabilitation. Englewood Cliffs: Prentice-Hall, 1983:394.

3 Stromberg BV. Contralateral therapy in upper extremity rehabilitation. Am J Phys Med 1988; 65:135-143.

4 Hortobagyi T, Lambert NJ, Hill JP. Greater cross education following training with muscle lengthening than shortening. Med Sci Sports Exerc 1997; 29:107-112.

5 Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management and Rehabilitation. Englewood Cliffs: Prentice-Hall, 1983:397.

6 Lentell GL, Katzman LL, Walters MR. The relationship between muscle function and ankle stability. J Orth Sports Phy Ther 1990; 11:605-611.

7 Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989: 284.

8 Heiser JR. Rehabilitation of lower extremity athletic injuries. Contemp Podiat Phys 1992; Aug:20-27.

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