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Ankle sprain recovery. What works?

Posted May 2, 2017

By Carrie Baker, PhD, ATC

Lateral ankle sprains are the most common musculoskeletal disorder in active populations. As an Athletic Trainer (AT) you probably see this condition all of the time. The question is why do lateral ankle sprains happen in the first place, why do they happen again, what are the long-term effects of repeated injury and what can we do to help?

There is research available about lateral ankle sprain focusing on the ongoing factors of long-term effects such as post-traumatic osteoarthritis, financial impact of lateral ankle sprains and people with chronic ankle instability.1 ATs aim to provide the best patient centered care that we can by addressing patient goals, assessing outcomes and providing an exercise and care program that is specific to our athlete

The first step in this approach is to educate the athlete after the first ankle sprain. It is important to inform athletes that an ankle sprain can cause significant pain, dysfunction and disability. Early management and treatment can greatly improve healing and returning to activity.1 I mentioned establishing goals, for most athletes these will be similar, with the ultimate goal of returning to play as quickly as possible. For those not within the athletic population, goals might consist of: to play with my kids, participate in recreational tennis or participate in my life without pain and dysfunction.

Outcome measures have been a major focus for athletic training education, and previously highlighted on this blog (PRO Blog). Adapting them into practice is essential to track patient progress and make informed decisions regarding progression and care of the patient. Outcome measures come in many different forms.

Objective measures, such as range of motion measured by goniometry, strength in the form of maximal voluntary isometric contracts, electromyography (EMG) to determine muscle activities are all useful tools. Patient reported outcomes (PROs) are also helpful to assess patient quality of life, daily function, and symptoms or disabilities specific to an injury. PROs specific to the ankle, such as the Foot and Ankle Ability Measure (FAAM), 2 have been used widely throughout the literature.

The FAAM is very useful in that it has subscales. There are the FAAM activities of daily living (ADL) subscale, as well as a sport subscale that might be more helpful depending on your athlete. Another measure not specific to the ankle but to function is the Lower Extremity Functional Scale (LEFS),3 which is a self-reported measure of lower extremity function. A more holistic approach to PROs is a Global Rating of Change Scale.4 This can be used in a number of ways, such as to assess pain, function or ability. Regardless of the outcome measure you choose, an objective measure that documents patient progression is necessary to give best care.

Now that we have established patient goals and outcome measures, what type of rehabilitation program will give the athlete the best outcomes in the shortest amount of time?

It depends on several factors, such as age, activity level, comorbidities, access to a healthcare and compliance of the patient. In general, however, evidence based treatments and rehabilitation programs have demonstrated success for athletes with lateral ankle sprains. Key approaches to ankle rehabilitation are multimodal, 5 target bilateral deficits 6 and contextually encourage the appropriate use of hip-based and/or ankle-based static and dynamic movement strategies. Below I will highlight rehab techniques and progressions using a multimodal approach. These guidelines have been adapted from Basset and Prapavessis7 and Cleland et al.8

Lateral ankle sprains are the most common musculoskeletal disorder in active populations. As an Athletic Trainer (AT) you probably see this condition all of the time. The question is why do lateral ankle sprains happen in the first place, why do they happen again, what are the long-term effects of repeated injury and what can we do to help? There is research available about lateral ankle sprain focusing on the ongoing factors of long-term effects such as post-traumatic osteoarthritis, financial impact of lateral ankle sprains and people with chronic ankle instability.1 ATs aim to provide the best patient centered care that we can by addressing patient goals, assessing outcomes and providing an exercise and care program that is specific to our athlete

The first step in this approach is to educate the athlete after the first ankle sprain. It is important to inform athletes that an ankle sprain can cause significant pain, dysfunction and disability. Early management and treatment can greatly improve healing and returning to activity.1 I mentioned establishing goals, for most athletes these will be similar, with the ultimate goal of returning to play as quickly as possible. For those not within the athletic population, goals might consist of: to play with my kids, participate in recreational tennis or participate in my life without pain and dysfunction.

Outcome measures have been a major focus for athletic training education, and previously highlighted on this blog (PRO Blog). Adapting them into practice is essential to track patient progress and make informed decisions regarding progression and care of the patient. Outcome measures come in many different forms.

Objective measures, such as range of motion measured by goniometry, strength in the form of maximal voluntary isometric contracts, electromyography (EMG) to determine muscle activities are all useful tools. Patient reported outcomes (PROs) are also helpful to assess patient quality of life, daily function, and symptoms or disabilities specific to an injury. PROs specific to the ankle, such as the Foot and Ankle Ability Measure (FAAM), 2 have been used widely throughout the literature.

The FAAM is very useful in that it has subscales. There are the FAAM activities of daily living (ADL) subscale, as well as a sport subscale that might be more helpful depending on your athlete. Another measure not specific to the ankle but to function is the Lower Extremity Functional Scale (LEFS),3 which is a self-reported measure of lower extremity function. A more holistic approach to PROs is a Global Rating of Change Scale.4 This can be used in a number of ways, such as to assess pain, function or ability. Regardless of the outcome measure you choose, an objective measure that documents patient progression is necessary to give best care.

Now that we have established patient goals and outcome measures, what type of rehabilitation program will give the athlete the best outcomes in the shortest amount of time?

It depends on several factors, such as age, activity level, comorbidities, access to a healthcare and compliance of the patient. In general, however, evidence based treatments and rehabilitation programs have demonstrated success for athletes with lateral ankle sprains. Key approaches to ankle rehabilitation are multimodal, 5 target bilateral deficits 6 and contextually encourage the appropriate use of hip-based and/or ankle-based static and dynamic movement strategies. Below I will highlight rehab techniques and progressions using a multimodal approach. These guidelines have been adapted from Basset and Prapavessis7 and Cleland et al.8

1. Protect the injured structure; PRICE

Progress as swelling and bruising decrease

2. Mobility: pain-free active ROM and mobilization exercises

Progress to greater ROM adding holds at end-ranges

3. Strengthening: multiplanar ankle isometrics, and targeted foot intrinsic exercises

Progress to isotonic using bands for resistance; increase ROM, duration of hold and level of band over time

4. Stretching: calf, heel cord and hamstrings

Progress from sitting to standing stretches

5. Balance: static and dynamic balance as tolerated

Progress from eyes open to closed, 2 to 1 limb, 1 limb eyes closed when able to stand without losing balance (3x30sec); decrease standing base, increase level of perturbation

6. Functional activities: walking, running, and hopping according to patient activities

Progress when ROM and balance exercises have been fully progressed. Functional activities should be patient specific and target the lower extremity and core (hip/trunk)

Mobilizations (Maitland III-IV):

Promote dorsiflexion according to restriction

Rearfoot distraction with passive dorsiflexion and pronation

Anterior-to-posterior (A/P) glides of talocrural joint

Weight-bearing A/P glides

Promote eversion

Talocrural lateral glides

Subtalar lateral glides

Promote tibiofibular restriction

A/P proximal tibiofibular glides

A/P distal tibiofibular glide

Ultimately our goal as an AT is to prevent injuries. We know that the likelihood of sustaining another ankle sprain is higher after an initial sprain. There are a couple of key indicators that predict if an individual might go on to have chronic dysfunction.

  • After a first-time ankle injury, at 2 weeks post-injury can the patient:
    • Land on affected leg from a height of a step?
    • Land on both limbs from a jump

Research has found that at 2 weeks, if either criteria is not met, the patient is likely to develop more dysfunction and further injury than patients that can complete this task.6 A thorough multimodal approach to therapy, using outcomes to assess progress along the way to achieve patient-centered goals is the best evidence in the treatment of ankle sprains.

Resources

1. Gribble PA, Bleakley CM, Caulfield BM, et al. 2016 consensus statement of the International Ankle Consortium: prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine. 2016;50:1493-1495.

2. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. Nov 2005;26(11):968-983.

3. Binkley JM, Stratford PW, Lott SA, Riddle DL. The lower extrenity functional scale (LEFS): Scale development, measurement properties, and clinical application. Physical Therapy. 1999;79(4):371-383.

4. Kamper SJ, Maher CG, Mackay G. Global Rating of Change Scales: A Review of Strengths and Weaknesses and Considerations for Design. Journal of Manual & Manipulative Therapy. 2009;17(3):163-170.

5. Gribble PA, Bleakley CM, Caulfield BM, et al. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine. 2016;50:1496-1505.

6. Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Recovery From a First-Time Lateral Ankle Sprain and the Predictors of Chronic Ankle Instability. The American Journal of Sports Medicine. 2016;44(4):995-1003.

7. Bassett SF, Prapavessis H. Home-based physical therapy intervention with adherence-enhancing strategies versus clinic-based management for patients with ankle sprains. Physical Therapy. 2007;87:1132-1143.

8. Cleland JA, Mintken P, McDevitt A, et al. Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial. Journal of Orthopaedic and Sports Physical Therapy. 2013;43(7):443-455.

About the Author

Baker fam

Carrie Baker, PhD, ATC is the Program Director for the Professional Graduate Athletic Training Program at the University of Tennessee at Chattanooga. She received degrees from Castleton State College in 2000, Old Dominion University 2002 and the University of Kentucky 2012. She has spent most of her career as a faculty member teaching athletic training courses, working in Division I athletics, as well as volunteering outreach services to high schools in a variety of locations. Baker has research interests in self-efficacy, balance and injury prevention. In her spare time, she loves spending time with her daughter and husband.