Physical Therapy Guidelines for Lateral Ankle Sprain
Background: This rehabilitation program is designed to return the individual to their activities as quickly and safely as possible. It is designed for rehabilitation following lateral ankle sprains. Modifications to this guideline may be necessary depending on physician specific instruction, specific tissue healing timeline, chronicity of injury, and other contributing impairments that need to be addressed. Time frames will vary depending on severity of tissue damage, individual patient progress, the presence of concomitant injuries/complications and the patient’s goals. This guideline is designed to progress the individual through rehabilitation to full sport/activity participation. This guideline is intended to provide the treating clinician a frame of reference for rehabilitation. It is not intended to substitute clinical judgment. If the clinician should have questions regarding progressions, they should contact the referring physician. For the purpose of this protocol, we are assuming that the patient has been properly evaluated and diagnosed. We will forgo a review of the clinical examination, foot and ankle assessment and indications for referral. Ankle injuries account for 10-30% of all sports injuries1. It has been reported that 20% of ankle sprains will develop chronic ankle instability2. Goals for Physical Therapy: Return the athlete to full participation as quickly as possible, while allowing injured tissue to heal without compromising it by further injury. Long Term Goals:
ROM to pre-injury levels
Strength to pre-injury levels
Power to pre-injury levels
Endurance to pre-injury levels
Acute Stage: 0-7 days
Protect Damaged Tissue
Reduce Swelling
Reduce Pain
Maintain ROM
Weight Bear as tolerated
Early mobilization is recommended to prevent detrimental side effects such as synovial adhesions, greater position of disorganized collagen fibrils and decreased collagen synthesis. If there is significant swelling and pain, immobilization for a maximum of 10 days has been shown to be beneficial3. Overall, functional treatment appears to be more favorable than immobilization 4. Early mobilization leads to the formation of more connective tissue which results in a more resilient ligament compared to its immobilized counterpart5.
Educate the patient on the importance of sustaining from activities that may cause further tissue damage and/or pain. Practice relative rest.
Use crutches if gait is painful or unsteady to offload the injured ankle and add stability, but encourage weight bearing as tolerated through affected extremity.
Use of ankle brace (semi-rigid or lace up) results in better clinical outcomes. Brace should be worn for 4-6 weeks for weight bearing activities6. (immobilization for severe cases)
Ice alone does not provide benefit. There are no indications that the isolated use of ice can increase function, as well as decrease swelling and pain for patients who lateral ankle sprains3.
Elevating the affected leg above the level of the heart in a supine position for 30 minutes at a time up to a total for 2-3 hours per day. There is limited evidence regarding effects of elevation.
Compression or pneumatic devices may decrease edema temporarily7.
The use of electrical stimulation to decrease pain and swelling may also be effective8.
Initiate gentle active ROM exercises such as Alphabets in supine, leg elevated position within a pain free range.
NSAIDs may be used during the acute, however care should be taken as there is potential for NSAIDs to delay the natural healing process3.
Sub-Acute Stage: 1 – 6weeks
Continue to decrease pain
Continue to decrease swelling
Progress weight bearing and gait patterning as tolerated
Initiate strengthening and proprioceptive activities
Joint Mobilization to restore dorsiflexion if necessary
During this stage, continue to work towards decreasing pain and swelling. Practice caution when prescribing and dosing exercises as there should not be an increase in pain and/or swelling during or following exercise. Exercise programs that are established early after ankle sprains and include neuromuscular and proprioceptive exercises have efficacy and can reduce prevalence of recurrent injuries3.
Following joint assessment, manual therapy can be performed at the talocrural joint with anterior to posterior mobilization applied to talus for improved dorsiflexion ROM and to decrease pain9.
Continue with pain and swelling treatments from acute stage if necessary
Consider mobilization/manipulation to the proximal and distal tibiofibular joints and calcaneocuboid joint if necessary
Practice caution with subtalar mobilizations as this stage.
Begin pain free AROM into PF and DF.
Gastrocnemius/Soleus Stretching
Cross Friction Massage on injured ligament
Continue gait training and weaning from brace if necessary
RROM toe flexion and extension
Stationary bike for circulation and tissue perfusion
Proprioceptive Exercises: Progress from sitting to standing on both and then single leg, eyes open to eyes closed, and reaching with dynamic challenge on level and progressing to uneven surfaces 10
Wobble Board, BAPS, Foam pad, Pillow, Star Excursion Balance Activities
Functional Rehab Stage: 6 Weeks
Advanced strengthening
Sport Specific drills
Agility
Endurance
Plyometrics
Observation of kinetic chain in landing and cutting maneuvers
At this stage of the rehabilitation process, swelling and pain should be resolved. Range of motion and isolated strength should be nearly or completely normalized to begin this stage. Patient will begin working on sport specific drills with goal of returning to full function in his/her respective sport or recreational activity.
Observation and assessment of kinetic chain with attention of lateral and posterior hip strength11,12.
Advanced strengthening to ensure adequate kinetic chain strength
o Squats o Lunges o Dead Lifts o Planks o Step Ups o Lateral Walks
Coordination and Agility training that is specific to patient’s sport/recreational activity. Begin:
o Speed Ladder
o Cutting
o Hopping (beginning bilaterally and progressing to affected limb only) Also consider beginning on total gym in partially un-weighted environment
o Jump Rope
o Running (begin as jog in place on mini-tramp and progress to flat, even surfaces to uneven terrain)
o Sport Specific: Golf Swing, Kick Soccer Ball, foot hold for rock climber, etc
Prevention of Chronic Ankle Instability
When discussing prevention of reoccurring ankle sprains, it’s important to consider the relationship between mechanical and functional stability. Mechanically, we expect to see alterations in accessory motion at the talocrural, tibiofibular, calcaneocuboid and subtalar joints involving either hypermobility or hypomobility secondary to ligament disruption, swelling, immobilization and compensation. This joint dysfunction can lead to changes in sensory input via mechanoreceptors and cause poor proprioception and functional stability13,14. A thorough assessment of joint mobility is critical to determine what intervention is necessary. In simple terms, if the joint is stiff then mobilization is suggested. If the joint is hypermobile, then consider bracing, taping or orthotics to limit excessive motion and postural sway, especially during sport or recreational activities15,16.
Discharge Planning and Assessing Return to Sport:
Independent with home exercise program
Independent functional mobility
TCJ and Subtalar Joint Mobility and ROM
Agility T-Test
Adequate Kinetic Chain Function
Single Leg Hop Tests
Single Limb Balance
Star Excursion Test17,18
Outcome Measures: LEFS, FAAM, FADI
It’s also important to remember psychological readiness. Athletes can be adversely affected by fear, anxiety and loss of confidence following an injury19. Scoring systems such as Trait Sport Confidence Inventory, State Sport Confidence Inventory, and the Injury-Psychological Readiness to Return to Sport Scale should be used to assess return to sport readiness.
Author: Garrett Foland PT, DPT 2022
References:
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5. Ligament Injury and Healing: An Overview of Current Clinical Concepts. Journal of Prolotherapy. Published March 29, 2012. Accessed July 1, 2020. http://journalofprolotherapy.com/ligament-injury-and-healing-an-overview-of-current-clinical-concepts/
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