Proper management of ankle injuries can help prevent chronic instability and recurrence
Ankle sprains are common injuries, because this joint is required to perform complex movements under high forces during normal walking. Those who participate in recreational activities and sports that require running and jumping place even more stress on their ankles, and eventually, many experience a sprain. Most active athletes have suffered at least one lateral ankle sprain, especially in fast-reacting sports such as basketball.1 The recurrence rate for ankle injuries is reported to be as high as 80%.2 Proper management in the early stages of an ankle sprain, especially sufficient rehabilitation, is 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.
Case the Ankle Joint
The proper function of the ankle joint, as well as smooth gait and good balance, are dependent on appropriate neurological coordination. Neurological instability is thought to develop when the mechanoreceptors in the ankle ligaments are damaged along with the collagen fibers. This alters afferent input to the central nervous system (CNS), adversely affecting proprioception and coordination of fine, reactive movements.3 Because the CNS cannot accurately assess where the ankle joint is in space, adequate efferent responses cannot be sent to the muscles crossing the ankle complex to provide protective, dynamic restraint to potentially injurious positions. This is why restoration of proprioception and neuromuscular control are as important as muscle strengthening in ankle rehabilitation programs.4
RICE (rest, ice, compression, elevation) is the standard initial treatment of ankle injuries which has been adapted to PRICE—protection, rest, ice, compression, elevation. This major change acute injury treatment affects most soft tissue traumas. Even with severe ankle sprains, using these procedures can 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. With the injured joint protected, patients can continue safe activities (rather than using the now discredited bedrest), with some restrictions. In the case of ankle sprains, this may entail 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 to prevent shortening.
A 1991 study5 found that even in severe Grade III lateral ankle sprains (with joint instability), encouraging early activation and walking in a functional brace produced a rapid return to full work and sports activities than did the use of a cast. The long-term results were equally good, with a minimum of chronic instability.
Figure 1. Anterior stationary lunge.
The Pot of Goals
The primary goals of ankle rehabilitation are proper flexibility and movement, balanced strength, and good coordination. Weak muscles will need strengthening, beginning with isotonic exercises and progressing to more complex, plyometric activities. Neurological coordination can be improved or retrained with the use of balancing and rocker board exercises.
Flexibility. Foot stability depends on normal movement patterns and coordinated contractions of the support muscles. Connective tissues, such as ligaments, joint capsules, and the plantar fascia, in particular, are also important for good biomechanical performance.6 Athletes must receive corrective treatment whenever problem areas are found. If muscles or connective tissues are tight and shortened, regular sustained stretching while warm will be necessary to improve athletic performance and prevent injury.7
When joints are not moving sufficiently, specific extremity adjustments must be performed. A commonly found subluxation after an ankle sprain is an anterior talus, which will limit passive dorsiflexion until adjusted. The cuboid is also frequently affected by an inversion sprain, and may need specific adjusting.
Figure 2. Single leg balance with eyes closed.
Strength. Once the ankle joint can be passively moved through a normal range, start isotonic resistance exercise of the peroneal muscles using elastic tubing.8 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 retrain the ankle support muscles in a closed-chain position. Further sport-specific exercises can be introduced to ensure that athletes have all the strength and mobility. Examples include rope jumping, side-to-side jumps, carioca steps, figure-eight runs, and backwards running. Plyometric procedures should be introduced only when all other capabilities have returned to pre-injury capacity.9
Figure 3. Standing calf stretch.
Coordination. One reason that some ankle injuries become chronic or recur is the loss of the normal coordination of the muscles about the ankle, rather than simply their strength.10 An easy test for this problem is to have the patient stand on each leg with the eyes open and then closed. Check to see whether there is less capability of the injured leg. Practicing the one-leg stance and using a rocker board may be required to regain normal proprioceptive coordination. Initially, the ankle balance board should be used while seated, focusing on range of motion in all directions. As balance and strength return, the patient progresses to standing on the board with both legs, and then rotating in both directions. Next, perform single-leg stork stands, learning to maintain balance on the board, first with eyes open and then with eyes closed.11 This helps regain proprioceptive coordination when standing on one foot on the ground.
One researcher recommends that an athlete should be able to demonstrate a stork stand for a least 1 minute on the injured leg before being allowed to return to full competition after an inversion sprain.12 Eventually, the difficulty can progress to rotations in both directions and single leg squats for the more advanced athletes.13 CP
Kim D. Christensen, DC, CCSP, DACRB, CSCS, founded the SportsMedicine & Rehab Clinics of Washington. He is currently a postgraduate faculty member of numerous chiropractic colleges, president of the American Chiropractic Association (ACA) Rehab Council, and prolific lecturer and author. Christensen can be reached at Chiropractic Rehabilitation Consulting, 18604 NW 64th Ave, Ridgefield, WA 98642, or via email: kimd christensen@hotmail.com.
References
1. Smith RW, Reischl SF. Treatment of ankle sprains in young athletes. Am J Sports Med. 1986; 14:465–471.
2. Yeung MS, Chan K, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med. 1994;28:112–116.
3. Leanderson J, Eriksson E, Nilsson C. Proprioception in classical ballet dancers: a prospective study of the influence of an ankle sprain on proprioception in the ankle joint. Am J Sports Med. 1996;24:370–374.
4. Lephart SM, Pincivero DM, Giroldo JL, Fu F. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997;25:130–137.
5. Konradsen L, Holmer P, Sondergaard L. Early mobilizing treatment for grade III ankle ligament injuries. Foot & Ankle. 1991;12:69–73.
6. Huang CK. Biomechanical evaluation of longitudinal arch stability. Foot & Ankle. 1993;14:353–357.
7. Pope RP. A randomized trial of preexercise stretching for prevention of lower limb injury. Med Sci Sports Exerc. 2000;32:271–277.
8. Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation. Englewood Cliffs, NJ: Prentice-Hall; 1983:397.
9. Allerheiligan WB, Rogers R. Plyometric program design. Strength Conditioning. 1995;17:26–31.
10. Lentell GL, Katzman LL, Walters MR. The relationship between muscle function and ankle stability. J Orthop Sports Phys Ther. 1990;11:605–611.
11. Losito JM, O’Neill J. Rehabilitation of foot and ankle injuries. Sports Med Rehab. 1997;14:533–557.
12. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone; 1989:284.
13. Miller AS, Narson TM. Protocols for proprioceptive active retraining boards. Chiropractic Sports Medicine. 1995;9:51–55.
Resources
