Let’s Get Technical: Ankle Sprains

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At some point in your life you may have rolled and sprained your ankle. It’s the most common athletic injury in the U.S. with an estimated 30,000 sprains occurring each year. Whether your sprain is due to tripping in a pothole (my specialty), cutting and pivoting to hit a tennis ball, running, or falling in high heels, it’s essential to completely rehabilitate your ankle to avoid a progression to chronic ankle instability (CAI).

Predisposing factors that can lead to an increased risk of sustaining a lateral ankle sprain include:

• A past history of ankle sprain
• Poor running technique
• Inappropriate footwear
• Tight, weak calves
• Poor hip stability
• Poor ankle balance

Recent studies suggest that a simple ankle sprain is not as benign as previously thought.  Ankle sprains can have a substantial effect on how well and how far we move later in life. Study subjects were shown to have moved less, less well, and with a significant impact on their balance.

In addition to chronic instability, many patients will develop proprioceptive deficits in which they lose some of their ability to sense the position of the joint in space and fire the appropriate muscles. These muscles normally protect and prevent the ankle from rolling over will fire inefficiently, which increases the likelihood of a re-sprain.

It’s estimated that 30% of people who sustain lateral ankle sprains will advance into CAI, involving persistent ankle re-sprains and multiple episodes of the ankle giving way. CAI is believed to be the result of deficits in muscular strength, power and endurance, impaired , and ligamentous laxity.  A large number of these patients can develop post- traumatic ankle arthritis.

Ankle ligaments surround the ankle joints to provide passive stability, fluid motion and balance. They run bone to bone, are highly innervated, and provide feedback to our brains automatically letting us know where our foot and ankle are in space. The most commonly injured ligaments are the anterior talofibular and the calcaneal fibular. Less likely to be injured is the posterior talofibular ligament.

ankle sprainHealth care practitioners use functional and anatomic classifications depending on the severity of the ligament injury that provide a timeline for recovery.

Grade 1: Stretch the lateral ankle ligaments, but the patient is able to walk and can fully weight bear and usually takes 1-2 weeks to recover.

Grade 2: There’s a partial tear of one or several ankle ligaments, functionally one can walk but with a limp and takes 6-8 weeks to recover.

Grade 3: There’s a complete rupture of ligaments, and the patient is unable to walk. Rehab is going to take several months to completely recover, usually 8- 12 weeks.

It’s important to reduce the swelling early on to decrease further overstretch of the ankle ligaments. The RICE protocol (Rest, Ice, Compression, and Elevation) is used in the post-injury phase. A compression ice wrap should be applied 2x per day and the ankle should be protected with either an ankle brace or CAM walker to expedite healing, protect weight bearing, and guard the vulnerable ankle. Thereafter, progressive weight bearing is guided by symptom tolerance.

Physical therapists are mindful of developing appropriate treatment programs to prevent an ankle sprain from becoming the gateway to a continuum of disability. Researchers currently believe that CAI may be due to injury of the nerve receptors around the ankle and weakening of the lateral ankle ligaments following a sprain. If you have sprained your ankle in the past, it’s a good idea to have your balance tested by a physical therapist. Evaluating balance is one method of assessing sensory deficits after injury.

Acute rehab should focus on protection of the ankle ligament immediately after spraining, regaining ROM and initiating strengthening. In the intermediate stage of rehab it’s crucial to restore the sensory motor function of the ankle. A series of progressive balance or proprioceptive exercises should be incorporated. The last stage of ankle rehabilitation focuses on sport specific exercises and progresses strengthening and power to pre-injury levels.

A physical therapist will utilize modalities such as cold laser, electrical stimulation and ice, to control inflammation, manual therapy such as therapeutic massage and joint mobilization, and will structure an individualized exercise program to strengthen and restore balance and agility.

If you twist and injure your ankle consult a doctor or physical therapist about diagnosis, treatment and rehab. Rehabbing with a physical therapist will assure that you are literally back on your feet and more active than ever.

Note: ankle illustration courtesy of praisaeng at freedigitalphotos.net

Tamar Amitay Physical therapist NYCTamar Amitay, PT, MS, Founder and Principal of Thrive Integrated Physical Therapy, is a highly regarded physical therapist recognized within the New York City medical community as a remarkable clinician, diagnostician and healer. Graduating in 1986 with academic honors from New York University she has over 28 years of clinical experience in rehabilitation and outpatient private practice and working at NYU Rusk Institute, JFK Medical Center. (read more)