The ankle, or talocrural, joint is
an articulation of three bones: the talus, the fibula, and the
tibia (1). Three ligaments provide lateral support to the ankle:
the anterior talofibular ligament, the calcaneofibular ligament,
and the posterior talofibular ligament (1). The deltoid ligament
(which consists of the anterior and posterior tibiotalar
ligaments, the tibiocalcaneal ligament, and the tibionavicular
ligaments) provides medial support to the ankle (1). Peroneus
longus, peroneus brevis, and peroneus tertius evert and provide
dynamic stability to the ankle (1).
Ankle Sprains
Approximately 30% of injuries suffered by collegiate and high
school athletes are ankle sprains (1). In the U.S., ankle
sprains occur with an estimated incidence of 2.15 sprains per
1,000 people per year (2). The anterior talofibular ligament and
the calcaneofibular ligament are the first and second most
commonly sprained ligaments, respectively (1). These ligaments
are often sprained simultaneously via a forced plantarflexion
and inversion mechanism (1). While less common than an inversion
mechanism of injury, a forced eversion mechanism of injury may
result in a deltoid ligament sprain (1).
Classification of Ankle Sprains
A sprain occurs when a ligament is stretched or torn (3).
Sprains are classified by grades I (least severe) to III (most
severe) (1).
Examination of Ankle Sprains
A physical therapy examination of a sprained ankle should
subjectively include questions regarding "the onset of symptoms, the
distribution of symptoms, aggravating and easing postures, mechanism
of injury, prior treatments, and prior history of ankle pain" (4).
Objectively, a clinician may choose to examine posture, single leg
balance, gait, range of motion, joint mobility, muscle strength, and
special tests when appropriate (i.e. figure-of-eight test, anterior
drawer, inversion stress test, talar tilt, eversion stress test,
external rotation stress test, squeeze test, Cotton test, fibular
translation test) (4,5).
Treatment of Ankle Sprains
The healing process consists of three phases: acute, subacute, and
maturation (1). Depending on the severity of the ankle sprain, the
acute phase will last 3-5 days (1). During the acute phase, the
patient should use cryotherapy (ice) to reduce pain and swelling
(2). Most studies recommend icing for 20 minutes every two hours;
however, some research shows that an intermittent protocol of 10
minutes icing, 10 minutes off, 10 minutes icing every two hours
results in greater short-term pain relief (2). Patients should start
bearing weight and exercise as soon as the pain allows (2).
During the subacute phase, which begins around three days after the
original injury and lasts up to six weeks, tissue repair begins and
collagen fibers start forming scar tissue on the injured ligament
(1). Gentle stress to the repairing tissue is necessary to ensure
that the collagen fibers are aligning and developing properly (1).
The maturation phase may start as early as one week post injury
(grade I sprains) or as late as three weeks post injury (grade III
sprains) (1). During the maturation phase, it is important to
continue stressing the repairing ligaments to ensure that the
collagen scar tissue fibers align and develop appropriately (1).
While the maturation phase may last up to a year, return to normal
activities may occur as early as one to two weeks post injury (grade
I sprains) or as late as 12-16 weeks post injury (grade III sprains)
(1).
Physical Therapy and Ankle Sprains - What the Evidence Shows
Earlier Cochrane reviews (2011 and 2005) have shown that therapeutic
ultrasound and hyperbaric oxygen are not effective treatments for
acute ankle sprains (2).
Evidence shows that initiating range of motion exercises and
mobilizing the ankle joint within one week post injury results in
better outcomes (return to work or sport)(2). Incorporating
strengthening and proprioceptive training into the rehabilitation
process has been shown to not only reduce subsequent ankle injuries,
but also reduce future hamstring, knee, and other lower extremity
injuries (2).
A systematic review of 8 studies published in 2014 demonstrated that
joint mobilization and manipulation techniques improve pain and
range of motion in patients suffering from acute ankle sprains and
improve function in patients suffering from subacute/chronic ankle
sprains (6).
A study published by Cleland et al. in 2013 compared outcomes
between a group receiving manual therapy in addition to an exercise
program to a group completing only a home exercise program (4).
Manual therapy techniques utilized included proximal tibiofibular
joint thrust manipulations, distal tibiofibular joint mobilizations,
talocrural manipulations, talocrural mobilizations, and subtalar
joint mobilizations (4). Both groups completed the same exercise
program, consisting of stretching, strengthening, balance, and
dynamic activities (4). Researchers concluded that in this study,
combining manual therapy with exercise resulted in greater
improvements in short-term and long-term pain and function than
exercise alone (4).
Having had a previous ankle sprain is the greatest risk factor for
having a future ankle sprain (2). Therefore, proper treatment and
rehabilitation is of utmost importance when treating an ankle sprain
to prevent a future reoccurrence.
Last Revised: March 24, 2014
By: Michelle Kornder, SPT
References
1) Brotzman, SB. Chapter 5: Foot and Ankle Injuries. In Brotzman,
SB, Manske RC. Clinical Orthopaedic Rehabilitation: An
Evidence-Based Approach. 3rd ed. Philadelphia, PA: Mosby, Inc.;2011.
2) Tiemstra JD. Update on Acute Ankle Sprains. American Family
Physician. 2012;85(12):1170- 1176. Available from: University of
Wisconsin Madison, Madison, WI. Accessed March 11, 2014.
3) Mayo Clinic. Diseases and Conditions: Sprains and strains.
Available at: http://www.mayoclinic.org/diseases-conditions/sprains-and-strains/basics/definition/con-
20020958. Accessibility verified March 11, 2014.
4) 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. Available from: University of
Wisconsin Madison, Madison, WI. Accessed March 11, 2014.
5) Hallisy, Thein-Nissenbaum. PT 677 -MS Dysfunction: Examination,
Diagnosis, & Management II. Madison, WI: Department of Physical
Therapy; 2013.
6) Loudon JK, Reiman MP, Sylvain J. The efficacy of manual joint
mobilisation/manipulation in treatment of lateral ankle sprains: a
systematic review. Br J Sports Med. 2014;48:365-370. Available from:
University of Wisconsin Madison, Madison, WI. Accessed March 11,
2014.
7) Kerkhoffs GM, van den Bekerom M, Elders LAM, et al. Diagnosis,
treatment and prevention of ankle sprains: an evidence-based
clinical guideline. Br J Sports Med. 2012;46:854-860. Available
from: University of Wisconsin Madison, Madison, WI. Accessed March
11, 2014. |
