Physiotherapy for an Ankle Sprain

Posted by Helen Potter on 20 March 2017 | Filed under Blog, In Touch Physiotherapy, Physiotherapy

 

What is an Ankle Sprain?

A twisting force to the lower leg or foot can cause an ankle sprain – the ligaments on the outside of the ankle are stretched and torn.

Risk factors for an Ankle Sprain

  • Weak toe flexor muscles and long posterior tendon may lead to poor foot mechanics such as overpronation
  • Tight calf muscles restrict flexibility in the dorsiflexion range of motion
  • Congenital or biomechanical misalignment of the ankle/talus joint may limit or lead to excess movement of the rear foot
  • Warming-up and stretching before activity possibly helps minimise risk of injury
  • Inadequate joint proprioception and slow neuromuscular response to off-balance position increase risk of a slow response
  • Running on uneven surfaces adds too much variability or excess arrange of motion
  • Shoes with weak heel support contribute to inadequate movement of the whole foot
  • Wearing high-heeled shoes – >15cm significantly increases the potential for ankle sprains
  • Ligaments are strong, fibrous tissues that connect leg bones to foot bones and stabilise the ankle joint.

Symptoms

  • Pain, bruising and swelling is common signs of a sprained ankle.
  • Tenderness to touch, inability to weight-bear, instability if severe
  • You may hear or feel a “pop” when the sprain occurs.

When to seek Physiotherapy assessment?

  • If you can walk immediately and swelling and pain disappears within a few days, you probably do not need treatment.
  • More gross swelling and bruising indicates more damage while being unable to weight bear on that foot may require and x-ray to look for a fracture.

Physical Examination post Ankle Sprain

Your physiotherapist will diagnose your ankle sprain by a careful examination of your foot and ankle.

Palpation tells us which ligaments are injured while testing of the range of motion, and the amount of swelling, pain, and bruising help us to grade severity.

Imaging Tests.  

  • X-rays are useful if you are unable to stand and I suspect a fracture, whereas stress x-rays help to show whether the ankle is moving abnormally because of injured ligaments.
  • Ultrasound imaging allows your doctor to observe the ligament directly while he or she moves your ankle.
  • An MRI may further help diagnose the stability the ligament provides.

Grade 1 Ankle Sprain (Mild)

  • Slight stretching and microscopic tearing of the ligament fibres
  • Mild tenderness and swelling around the ankle
  • ->* Fast recovery and return to sport

Grade 2 Ankle Sprain (Moderate)

  • Partial tearing of the ligament
  • Moderate tenderness and swelling above and below the ankle joint are common
  • An abnormal looseness of the ankle joint
  • Only some of the ligament fibres tear
  • * Intermediate recovery and return to sport

Grade 3 Ankle Sprain (Severe)

  • Complete tear of the ligament
  • Significant tenderness and swelling around the ankle
  • Substantial instability when pushing the ankle joint in certain movements
  • Slow recovery and delayed return to sport
  • Once you are pain-free, add resistance exercises to your therapy program.

Ankle Anatomy

Physiotherapy after Ankle Sprain – Aims

  • Reduce pain and swelling
  • Restore normal biomechanics to the ankle
  • Improve joint stability by assisting quality healing
  • Rehabilitation back to normal activities, function and sport
  • Decrease risk for a recurrent sprain.

Physiotherapy follows a three-phase program guide

  1. Phase 1 = Rest, protect the ankle and reduce the swelling
  2. Phase 2 = Restore range of motion, strength and flexibility
  3. Phase 3 = Advanced exercises for proprioception and gradual return to activities that do not turn or twist the ankle. Add activities that require sharp, sudden turns – such as tennis, basketball, or football as pain settles and stability improves.

Almost all ankle sprains can be treated without surgery, even a complete ligament tear (if it is immobilised appropriately). Recovery may take two weeks for minor sprains, or up to 6 to 12 weeks for more severe injuries.

Home Treatments for Ankle Sprain

Follow the RICER protocol as soon as possible after your injury:

  • Rest your ankle by not walking on it.
  • Immediate ice application to keep the swelling down. 20 to 30 minutes, x 3-4 daily.
  • Compress with crepe or elastic bandage to immobilise and support injury
  • Elevate your ankle above the heart as often as possible during the first 48 hours.
  • Partial weight-bearing during walking helps healing ligaments and promotes removal of swelling. You may use crutches or a stick, in the opposite hand to your injury.
  • Rehabilitation exercises are used to prevent stiffness, increase ankle strength, and prevent chronic ankle problems.

Medication

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) may help control pain and swelling.
  • Grade 2 sprain, a cast-boot or air stirrup-type brace can provide support.
  • Grade 3 sprains, a short leg cast for 2 to 3 weeks may help.

Physiotherapy.

Rehabilitation exercises prevent stiffness, increase ankle strength, and reduce risk of chronic ankle problems.

  • Early motion Exercises. To prevent stiffness, your doctor or physical therapist will provide you with exercises that involve range-of-motion or controlled movements of your ankle without resistance.
  • Strengthening Exercises. Once you can bear weight without increased pain or swelling, exercises to strengthen the muscles and tendons in the front and back of your leg and foot will be added to your treatment plan. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Exercises with resistance are added as tolerated.
  • Proprioception (Balance) Training. Poor balance often leads to repeat sprains and ankle instability. A good example of a balance exercise is standing on the affected foot with the opposite foot raised and eyes closed. Balance boards are often used in this stage of rehabilitation.
  • Endurance and Agility Exercises. Once you are pain-free, other exercises may be added, such as agility drills. Running in progressively smaller figures-of-8 is excellent for agility and calf and ankle strength. The goal is to increase strength and range of motion as balance improves over time.

Range of Movement Exercises in all directions

  1. These exercises are best if done short of pain initially, then gently moving further into range each day, as pain recedes.
  2. For the first three days (or as long as swelling and movement restriction are present) do 10-20 repetitions of each direction at least three times a day.
  3. Start with your foot in elevation (above your heart) then progress to standing two legs then one leg as pain allows.

                                                                              

Fig 3 – Foot/Ankle Up & Down                                                               Fig 4 – Foot and Ankle In & Out

                                                                                   

                                                                                                                                   

Fig 5 – Lunge Stretch (front leg)                                                          Fig 6 – Calf Stretch (back leg)

Gently coax your front knee of injured leg                            Gently lunge forwards until you feel a stretch in the calf or stiffness in ankle                                                                    

 

 

Lean forward over your toes, Keep heel down                              Back heel down, knee straight, Feet point forwards

                                                                                    

                                                                                   

 Fig 7 Advanced Kneeling Stretch 

Gently take your weight back onto your ankles

To stretch at the front of your ankles and shins.

Hold 15 seconds. Repeat x 4

Ankle Resistance Band Exercises

Resistance exercises can be done once a day, provided you do them well. The aim is to make your muscles work gradually harder (strength) and longer (endurance). Avoid pain but work to fatigue.

Eversion – Place a band around the foot (with foot and ankle turned inwards – fig 8). Slowly turn foot outwards with your little toe moving up. x 5-10 – Progress to 20 reps.

Ankle Inversion – Start with your foot turned up and out. Slowly move your foot and ankle up and inwards (fig 9) against the band.

                                   

Fig 8 – Ankle Eversion vs. band                       Fig 9 – Ankle inversion vs. band

Advanced Strength and Balance Exercises –

 Heel Raises

Standing on both feet, rise onto your toes – 10 Reps x 3 Sets (fig 10) (Keep your feet and knees shoulder width apart and facing forwards).

 

         Heel Raising Exercises                                                    Fig 10 – Heel raises                          Fig 11 – Heel raises over edge of a step                                     Fig 12 – Single leg heel

Heel Raises Progression

On one foot stand with the back half of your foot off the edge of a telephone book. Raise up onto your toes the lower into a stretch x 10 Reps x 3 Sets (fig 11). (Progress to one leg heel raises as pain and strength allow (fig 12)).

Balance Exercises – Proprioception

Proprioception is your ability to correct your body position when you accidently take a step off a kerb, land incorrectly from a jump or roll your ankle during sport. Small nerve fibres in your muscles, joints, fascia, tendons, ligaments, blood vessels and nerves register then tell your brain the position of your foot and ankle even if you have your eyes shut.

If your proprioceptive sense is poor, or if you have injured your proprioceptive nerve endings during an ankle sprain re-injury is likely to occur. By the time the brain gets the information and then coordinates it into a response, it’s too late. Overstretch or compression occurs.

Quality proprioception retraining attempts to prevent injury and re-injury. You can retrain proprioception by learning balance activities with your eyes closed. Exercises start in an easy position e.g.: eyes open feet equal on floor and progress to more challenging positions. Finally, we can even retrain in your near-injury position.

Single Leg Balance Standing on one leg, hold for 1 minute (Fig 13). Progress to eyes closed, then balance with distraction e.g.:  Pass a ball (Fig 14) or bounce it on the wall or floor (Fig 15).

                     Balance Exercise Wobble                                    Balance Exercise Intermediate                                  Balance Exercise Advanced       

Figure 13 – Single leg                         Figure 14 – Ball around back                               Figure 15 – Ball throws

Balance Exercises – Advanced

Balance on both feet on an unstable surface. Progress with eyes closed. Repeat one leg (Fig 16). If there is no pain and you feel safe, try Leg Hop in different directions from one point of the square to the next. Progress by increasing distance, “S” shape path, or by closing your eyes (Fig 17).

                         Proprioceptive Training                                                          

Figure 16 – Disc balance exercise                                          Figure 17 – Single leg hop

Balance Progression

Stand with slight weight on your front foot and lean forward to balance near the position of your injury. Add Functional sports activities such as throwing, catching, and ball dribbling.

 

 

  • Use additional support until your ankle is stronger than before 
  • Bracing help to increase support around the ankle joint and helps walking confidence
  • Physiotherapy ankle taping tries to prevent the ankle moving to end range of motion
  • Gradually wean off support as your pain improves, and swelling reduces
  • Not wearing a firm support bandage, tape or brace during healing of a severe injury may allow for stretching of repairing structures with resulting instability

Ankle Sprain Prevention

The best way to prevent ankle sprains is to maintain good muscle strength, balance, and flexibility. The following precautions will help reduce the risk of sprains:

  • Warm up thoroughly before exercise and physical activity
  • Pay careful attention when walking, running, or working on an uneven surface
  • Wear shoes that made for your activity
  • Slow down or stop activities when you feel pain or fatigue
  • Balance training to improve neuromuscular control, muscle coordination and proprioception
  • All foot and ankle movements need strenthening through a full range of motion
  • incorporating eccentric loading add further protection
  • Strengthening the toe flexor muscles provide greater support and stability to the arch of the foot during weight bearing
  • Training the evertors adds thickening to the lateral (most commonly sprained Ligament)
  • See a Podiatrist for assessment and recommendation for orthotics if needed
  • Keep active every day with incidental physical activity
  • Walk or cycle short distances
  • Park your car further away from entrances to shops and work
  • Get off the bus, tram or train two or three stops earlier and walk the rest
  • Use the stairs
  • Take advantage of any chance to be active
  • Ensure you take a 10-20min walk at lunchtime 
  • Replace your coffee breaks with exercise break

Surgical Treatment of a Sprained Ankle

Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for patients who experience persistent ankle instability after months of rehabilitation and nonsurgical treatment

  • Arthroscopy. Your doctor uses a small camera, an arthroscope, to look inside your ankle joint. He removes any loose fragments of bone or cartilage or parts of the ligament that may be caught in the joint.
  • Reconstruction. Your doctor may be able to repair the torn ligament with stitches or sutures or reconstruct the damaged ligament by replacing it with a tissue graft obtained from other ligaments and tendons found in the foot and around the ankle.

Immobilisation  

Your doctor may apply a cast or protective boot to protect the repaired or reconstructed the ligament. If you remove it too soon, a simple misstep can re-tear the repaired ligament.

Successful outcomes are dependent upon your commitment to rehabilitation exercises. Incomplete retraining is the most common cause of chronic ankle instability and re-injury, after a sprain.

Chronic Ankle Sprains

You may continue to sprain your ankle if the ligaments do not have time to heal completely and you have not improved your proprioception, strength and agility. You may feel a sense of the ankle giving way, and chronic pain.

Last review March 2017

 

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