Relevant Anatomy

The ankle, or talocrural joint, is a junction of the tibia, fibula, and talus (Fig. 5-1). The anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL) provide static support to the joint laterally (Fig. 5-2A), whereas the deltoid ligament complex (DLC), made up of the anterior and posterior tibiotalar ligaments, the tibiocalcaneal ligament, and the tibionavicular ligament, provides medial support (Fig. 5-2B). The inferior anterior and posterior tibiofibular ligaments and the interosseous membrane provide additional support for the talocrural joint (Fig. 5-2C and D).

Figure 5-1 The ankle, which is a junction of the talus, the tibia, and the fibula.

Figure 5-2 Ankle anatomy. A, Static support for the lateral ankle includes the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). B, Static support for the medial ankle is provided by the deltoid ligament complex (DLC). C and D, An anterior (C, left) and posterior (D, right) view of the ankle showing the ATFL, CFL, PTFL, DLC and the anterior inferior tibiofibular ligament and posterior tibiofibular ligament, which provide additional support to the joint.

The ATFL is the most commonly injured ligament, followed by the CFL. The CFL is usually injured in combination with the ATFL. Sprains to both the ATFL and CFL are a result of a combined inversion and plantarflexion mechanism (Fig. 5-3A). A less likely mechanism of eversion may cause injury to the DLC (Fig. 5-3B). Injury to the anterior and posterior tibiofibular ligaments (syndesmosis) and the interosseous membrane are discussed later in this chapter.

Figure 5-3 Mechanisms of injury. A, Inversion with plantarflexion is the most common mechanism of injury for ankle sprains and will typically result in injury to the anterior talofibular ligament (ATFL) and possibly the calcaneofibular ligament (CFL). B, Although not as common as an inversion sprain, eversion is the mechanism of injury for sprains of the deltoid ligament complex (DLC). C, The peroneal tendons are lateral dynamic stabilizers of the ankle.

The muscles that attach to and act upon the foot provide dynamic control of the ankle. The peroneal muscle group, composed of the peroneus brevis, longus, and tertius muscles, is of significant importance because they are responsible for everting the ankle and, therefore, resisting inversion (Fig. 5-3C). Because there are no muscles that attach directly to the talus, motion of the talus is dictated by foot and ankle position. The most stable position of the ankle is in dorsiflexion. As the foot moves into dorsiflexion, the talus glides posteriorly and the widest portion of the talus becomes wedged into the ankle mortise. As the ankle moves into plantarflexion, the talus glides anteriorly and the ankle becomes less stable, which is why most ankle sprains involve some degree of plantarflexion as the mechanism.

Classification of Ankle Sprains

Regardless of whether the lateral or medial ligaments are injured, the severity of an ankle sprain is typically placed into one of three grades based on the amount of ligamentous damage. The degree of tissue damage, the amount of joint laxity, and the extent of dysfunction increase with each increase in grade.

Diagnosis

It is only through a thorough examination that the severity of an ankle sprain can be established (Table 5-1). Detailed information on conducting a thorough examination of the ankle is beyond the scope of this text; however, common signs and symptoms associated with each grade of lateral ankle sprain are listed in Table 5-2. The examiner must also be aware of additional injuries that can occur with ankle sprains. Such injuries include, but are not limited to, avulsion fractures, fractures, muscle and tendon strains, articular cartilage damage of the ankle mortise, and tarsal subluxations and dislocations. Although some of these injuries (such as muscle strains) can be adequately treated with the following standard treatment protocol, others (such as articular cartilage damage) may require revisions of the standard treatment protocol for ankle sprains.

Table 5-1 Examination of the Ankle After an Inversion Injury

Table 5-2 Clinical Signs and Symptoms Associated with Ankle Sprains

ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; FWB, full weightbearing; PTFL, posterior talofibular ligament.

The emphasis for the following standard treatment protocol is placed on treating ankle sprains in the absence of other significant injuries. It should be noted that the patient should be re-evaluated throughout the rehabilitation program for any limitations that need to be considered. For example, although it is common to include stretching of the heel cord in a rehabilitation protocol for ankle sprains, a specific patient may not have tightness of the heel cord and therefore may not need to perform the stretches. It is also important to look for signs of aggravation or reinjury (e.g., increased pain, increased tenderness, increased swelling, decreased range of motion, decreased strength). Occasionally, even the best-planned rehabilitation protocols can cause aggravation to an injury. It is important that the therapy provider know when it is time to slow down or change the protocol. Also, some patients may buy into the “no pain, no gain” philosophy and not report an increasingly painful and stiff ankle, believing it needs to be pushed harder to get better when the opposite may be true.

The Injury and Healing Process

The body’s healing process occurs in a natural sequence of events and can be divided into three stages: the inflammatory or acute stage; the subacute, repair, or proliferation stage; and the remodeling or maturation stage. It is important to have an understanding of what takes place during each of these stages in order to support the body’s natural healing process and limit the potential for additional injury. Although a full description of all of the events that occur during the stages of tissue healing is beyond the scope of this text, a summary of the clinically relevant events follows.

In the acute stage, the cardinal signs and symptoms of inflammation (pain, edema, erythema, warmth, decreased function) are evident. This stage begins immediately after the onset of injury and typically lasts 3 to 5 days.

The subacute stage, which begins at about 3 days after injury and can last up to 6 weeks, is marked by a decrease in the signs and symptoms of inflammation and the beginning of tissue repair. It is during this stage that weak collagen fibers begin to develop a scar at the injured site. Approximately 7 days after injury, there is a significant amount of collagen in the area. As the subacute stage progresses, it is important to provide some stress to the newly forming scar tissue to minimize adherence to surrounding tissues and to encourage proper scar tissue alignment and development; however, in the early stages the collagen fibers are weak and unorganized so it is more important to avoid too much stress, which can be detrimental to the healing tissues.

Activities associated with the maturation stage begin approximately 1 week after injury in grade I sprains and approximately 3 weeks after injury in grade III sprains. During the maturation stage, the collagen tissues become stronger and more organized. Although nowhere near normal, the scar’s tensile strength usually has increased considerably by the fifth or sixth week. It is important to stress the scar tissue adequately to decrease the potential of developing a dysfunctional scar. Appropriate levels of tissue stress will also continue to encourage proper alignment and development as the scar tissue matures. The maturation phase can last longer than a year, although patients typically return to their activity level much sooner than that.

Treatment and Rehabilitation Protocol for Acute Ankle Sprain

It is important to remember that the duration of each stage of tissue repair depends, in part, on the extent of injury. Because there is less tissue damage in a grade I sprain, there is a shorter duration of healing with a quicker transition from one phase of tissue healing to the next when compared to a grade II sprain. This is important to consider when establishing a treatment and rehabilitation protocol because patients with grade I sprains can be progressed quicker than patients with grade II sprains. The same can be said when comparing grade II and grade III sprains. Although many factors affect the length of time before a patient can return to normal physical activities, patients with grade I sprains can often return to their normal physical activity levels within 1 to 2 weeks, whereas patients with grade II sprains can expect to return in 4 to 8 weeks. There is a greater range of expected return estimates in patients with grade III injuries, which can take as long as 12 to 16 weeks to recover.

Without ignoring where the injury is in the healing process, the clinician should progressively manage the patient’s signs and symptoms, functional limitations, and impairments instead of solely focusing on the number of days since the injury. Table 5-3 lists the common signs and symptoms associated with each stage of tissue healing. Changes in the signs and symptoms, in addition to the number of days postinjury, can help the clinician determine when to progress the patient’s treatment and rehabilitation program.

Table 5-3 Clinical Signs and Symptoms Associated with the Stages of Tissue Healing

⇑, increased; TTP, tenderness to palpation; ROM, range of motion; ⇓, decreased; s/s, signs and symptoms.

* Presence and amount depend on severity of sprain.

The steps in treating and rehabilitating ankle sprains typically follow this progression:

While the rehabilitation program is progressing through these steps that focus on the injured ankle, it is important to maintain overall strength and conditioning for the rest of the body. Rehabilitation Protocol 5-1 provides an outline of the ankle sprain rehabilitation protocol described here.

Figure 5-53 Hopping from side to side emphasizes functional strength and power.

Acute Stage: Goals and Interventions After Ankle Sprain

During the acute phase the primary goals of the rehabilitation program are as follows:

• Protect the injured tissues from further injury.

• Encourage tissue healing.

• Limit the pain, swelling, and spasm associated with inflammation.

• Maintain function of the noninjured tissues.

• Maintain overall body conditioning.

Goal A: Protect the Injured Tissues from Further Injury

Although the patient should rest the injured tissues to limit additional stress and potential injury, it is important to remember that absolute rest is seldom a wise choice. Patients should be encouraged to participate in pain-free activities that do not stress the injured ligaments. The type of activities that can be safely tolerated vary with the severity of the ankle sprain. Typically with grade I ankle sprains, the patient can safely participate in light to moderate activities. Those with grade II and grade III sprains should have greater limits on their activities. Because most ankle sprains involve the lateral ligaments and are caused by plantarflexion and inversion, the patient should avoid activities that cause extremes of these motions for at least the first several days.

Protection with splinting, bracing, taping (Fig. 5-4 A–M), or wrapping the injured ankle may be necessary, especially in grade II or III sprains. A systematic review (Kerkhoffs et al. 2001) concluded that lace-up supports were most effective, that taping was associated with skin irritation and was no better than semi-rigid supports, and that elastic bandages were the least effective form of stabilization.

Figure 5-4 A, Have the patient sit with the knee extended and the ankle dorsiflexed to a 90-degree angle. Place heel and lace pads over the Achilles tendon and the instep of the ankle. Spray the foot, ankle, and distal aspect of the lower leg with tape adhesive. B, Apply underwrap around the ankle from the midfoot to the midcalf. The underwrap should go up to the base of the calf muscle or approximately 5 to 6 inches above the malleoli. Efforts should be made to apply as few layers of underwrap as possible. Although no longer a common practice, the adhesive tape can be applied directly to the patient’s skin without using underwrap. C, Apply two or three anchors to the distal aspect of the lower leg (1–3). Each strip should overlap the previous one by approximately one half of the width of the tape. Apply one anchor to the midfoot (4). D, Apply three stirrup strips (5–7), beginning at the medial aspect of the lower leg running inferiorly along the leg then laterally under the rearfoot and finishing on the lateral aspect of the lower leg. Each strip should overlap the previous one by approximately one half of the width of the tape. E, Apply three horseshoe strips (8–10) running from the medial aspect of the foot to the lateral aspect beginning and ending on the distal anchor (See #4 in Part C). Note: An alternative method, called a “closed basketweave,” alternates one stirrup strip with one horseshoe strip until three of each are applied. If this were to be done, strip 5 would be followed by strip 8, then strip 6 would be followed by strip 9, and strip 7 would be followed by strip 10. F–J, Apply two heel locks (11,12). The first heel lock (11) begins high on the anterior aspect of the lower leg, runs posteriorly behind the calcaneus, circles along the medial aspect of the calcaneus, then finishes along the anterior–medial aspect of the midfoot. The second heel lock (12) begins high on the anterior aspect of the lower leg, runs posteriorly behind the calcaneus, circles along the lateral aspect of the calcaneus, then finishes along the anterior–lateral aspect of the midfoot. K–L, Apply a figure-eight strip (13) beginning at the medial aspect of the calcaneus and running laterally to the plantar aspect of the calcaneus, then moving medially toward the instep before moving posteriorly around the lower leg and ending up where the strip began at the medial aspect of the calcaneus. M, Finish the tape job with closing strips. Begin the strips at the superior aspect of the lower leg and work inferiorly, overlapping the previous strip by approximately one half of the width of the tape. Finish with a closing strip over the midfoot.

Patients with grade II or III sprains also may need supportive devices such as crutches, a walking cane, or a walking boot to move about. Although there has long been debate as to whether or not to immobilize sprained ankles or omit immobilization and immediately begin a “functional treatment” plan, current practices are to use a functional treatment plan, especially when managing grades I and II sprains. A functional treatment plan limits immobilization and encourages pain-free activities that do not overstress the injured ligaments. Functional rehabilitation has been shown to be associated with more frequent return to sports and higher rates of patient satisfaction than immobilization (Kerkhoffs et al. 2001). If the patient’s ankle is to be immobilized, it should be noted that long periods of immobilization may lead to prolonged joint stiffness and contractures, weakening of noninjured ligaments, and muscle atrophy.

Goal B: Encourage Tissue Healing

In a healthy patient, the body will go through its normal healing process as long as there is no additional trauma to the tissues. Rest and protection of the injured tissues are important to allow the body to progress through its normal healing processes. Toward the end of the acute phase, pulsed ultrasound can be used to promote tissue healing while limiting undesirable thermal effects obtained with continuous ultrasound.

Goal C: Limit Pain, Swelling, and Spasm

It is important to remember that the inflammatory process is a protective mechanism and is necessary for the body to heal; however, the inflammation process needs to be controlled to minimize patient suffering and prevent chronic inflammation. The combination of rest, ice, compression, and elevation (RICE) is one of the more commonly used approaches to treat the acute inflammatory response. Ice and other forms of cryotherapy help prevent swelling, decrease pain, and limit spasm. Both elevation and compression with elastic wraps or compression stockinet assist with minimizing swelling. Electrical stimulation can also be used to minimize pain, swelling, and spasm. Therapeutic modalities that combine ice, compression, and elevation, such as an intermittent compression unit, also are beneficial.

Grade I joint mobilization techniques to the talus can also be used to minimize pain in the ankle joint. Performing a joint mobilization technique to the distal tibiofibular joint often provides pain relief when a “positional fault” is present. An anterior positional fault of the distal fibula is often seen in patients with a lateral ankle sprain. Applying a posterior mobilizing force to the distal fibula may help correct the anterior positional fault (Fig. 5-5).

Figure 5-5 Posterior mobilization of distal fibula to address anterior positional fault of the fibula following a lateral ankle sprain. The patient is supine on a table. The clinician places the palm of the hand on the lateral malleolus and provides a posterior force to the lateral malleolus.

Goal D: Maintain Function of Noninjured Tissues

Although rest may be needed for the injured ankle ligaments, muscles, tendons, and joint capsule, normal function of the noninjured tissues must be maintained with activity. The patient should be encouraged to engage in activities that do not stress the injured ligaments. Because most ankle sprains involve the lateral ligaments and are caused by plantarflexion and inversion, care must be taken to minimize extreme motions in those directions, especially in grade II and III sprains. With injuries that involve the deltoid ligament complex (DLC), care is taken to avoid extreme eversion. General mobility exercises are useful in preventing disuse of the noninjured tissues while minimizing stress to the injured ligaments:

• Ankle pumps

• Plantarflexion and dorsiflexion ROM progressing from passive range of motion (PROM) to active-assisted range of motion (AAROM) to active range of motion (AROM) as tolerated (Fig. 5-6)

• Heel-cord and posterior calf stretches (Fig. 5-7)

• ABCs or alphabets

• Towel curls and/or marble pick-ups (Fig. 5-8)

Figure 5-6 Active range of motion (AROM). A, Dorsiflexion. B, Plantarflexion. C, Inversion. D, Eversion.

Figure 5-7 Stretching the Achilles tendon, gastrocnemius, and soleus.

Figure 5-8 Towel curls (A) and picking up objects with the toes (B) to maintain mobility of the foot and ankle and to strengthen the intrinsic muscles of the foot.

It is especially important to perform these types of activities if the patient is placed in a cast, splint, or walking boot or if the patient is using crutches or a cane. Prolonged use of these assistive and protective devices can result in disuse of healthy tissues around the ankle. If the patient is immobilized, placed in a walking boot, or prevented from full weightbearing (FWB) ambulation for a period, the metatarsophalangeal (MTP) joints should also be treated with some form of mobilization activities (joint mobilizations, PROM, AAROM, AROM, stretches) (Fig. 5-9). At times, patients may be hesitant to attempt partial weightbearing (PWB) or FWB, general mobility exercises, or stretching activities, even though they have been cleared to do so. In this situation, the use of cryokinetics may be warranted. One way to include cryokinetics is to place the injured ankle in a cold whirlpool bath for 15 to 20 minutes or until it becomes “numb.” While the ankle is numb, the patient can begin to increase the weightbearing on the ankle, stretch, or perform general mobility exercises. This allows the patient to perform the appropriate activities in a pain-free state.

Figure 5-9 Mobilizing the first metatarsal phalangeal (MTP) joint to maintain mobility. When patients are not able to fully weight bear (FWB) in ambulation, the MTP joints may become hypomobile.

Goal E: Maintain Overall Body Conditioning

Although the injured ligaments may need to be rested, the rest of the body does not. Patients should be encouraged to engage in pain-free physical activities to maintain their overall body conditioning. Exercising on a stationary bike or upper body ergometer and nonweightbearing (NWB) running in a therapy pool can help maintain cardiovascular endurance and function without stressing the injured tissues. Strengthening exercises for the lower extremities, such as open kinetic chain knee flexion and extension and open kinetic chain hip flexion, extension, abduction, and adduction exercises, should also be performed. These exercises also help to prevent disuse issues of the noninjured body areas while minimizing stress on the injured tissues. Patients should also continue their normal strength training exercises for the trunk and upper extremities. It should be noted that many of these activities put the patient’s ankle in a gravity-dependent position, which is a precaution when treating or attempting to prevent swelling. The rehabilitation provider should weigh the risks of the gravity-dependent position to the benefits of maintaining the body’s overall condition. The use of a compression stockinet or elastic wrap while performing these exercises can help prevent the influx of edema to the area.

Subacute Stage: Goals and Interventions

During the subacute phase the primary goals are as follows:

• Prevent further injury.

• Minimize pain and inflammation.

• Promote tissue healing.

• Restore ROM and flexibility.

• Re-establish neuromuscular control and restore muscular strength and endurance.

• Re-establish proprioception, agility, and coordination.

• Maintain overall body conditioning.

Goal F: Prevent Further Injury

Although the initial inflammatory response has ended and the early scar tissue is beginning to develop, it is important to remember that the scar tissue is still very weak and improper activities can easily cause reinjury. In the early days of this phase, extremes of plantarflexion and inversion should still be minimized to prevent damage to the newly formed scar tissue. Although patients who used crutches or a cane during the acute phase should be weaned from these supports as FWB becomes tolerated, other protective devices (such as brace or tape) should still be used, especially with grade II or III sprains.

Goal G: Minimize Pain and Inflammation

Continued use of therapeutic modalities is warranted at this time. As the initial signs and symptoms of acute inflammation diminish, thermotherapy techniques such as warm whirlpools and hot packs should be introduced. Thermotherapy techniques help to reduce pain, spasm, and subacute inflammation. Therapeutic ultrasound may also be used at this time, progressing from pulsed to continuous duty cycles. Continuous ultrasound also assists with pain relief, tissue healing, and reduction of subacute edema. The continued use of electrical stimulation can assist with minimizing pain and inflammation. It is still wise to continue cryotherapy, especially after activity, to reduce pain and limit inflammation. Although the goal is to minimize pain and inflammation, it should be noted that an increase in pain or inflammation, especially after the acute stage, often is a sign that the injured structures are not ready for the activity being performed. If the patient experiences an increase in pain, inflammation, or both, he or she should be re-evaluated to ensure there is no worsening of the injury and the rehabilitation protocol should be slowed until the pain and inflammation are under control. Grades I and II joint mobilizations are also indicated at this time to assist with pain control (Fig. 5-10).

Figure 5-10 Posterior mobilization to the talus. Grade I and II joint mobilization techniques are effective in reducing pain.

Goal H: Promote Tissue Healing

Continuing to protect the injured ligaments from reinjury will allow the body to go through its normal healing process. The continued use of therapeutic modalities such as ultrasound and thermotherapy help promote tissue healing. The introduction of ROM and strengthening exercises will also promote proper alignment and improved strength of the scar tissue provided the activities do not produce too much stress. Therapeutic massage techniques can also be used beginning with “flushing-type” techniques such as pétrissage to promote blood flow and circulation and progressing to more aggressive techniques such as cross-friction massage to promote tissue alignment.

Goal I: Restore Range of Motion and Flexibility

The general mobility and ROM exercises that were begun in the acute stage are continued. As the subacute stage progresses, so should the sets and reps of the exercises, the degree of motion performed, and the intensity of the stretches. The patient should be encouraged to perform ROM exercises and stretches several times throughout the day. Initially, dorsiflexion and limited plantarflexion should be emphasized. Pedaling on a stationary bike can help with both plantarflexion and dorsiflexion. If not done in the acute stage, the use of PROM or AAROM should be replaced by AROM. Use of a BAPS or wobble board can be introduced, first in a NWB position before progressing to PWB then FWB position (Fig. 5-11). The patient should be instructed to perform the motions in a slow and controlled manner at all times. The patient should begin with dorsiflexion, plantarflexion, and eversion before incorporating inversion, then progress to circling the board while touching all sides of the board in both clockwise and counterclockwise directions. With all of the stretches and ROM activities, the patient is instructed to gradually increase the ROM, taking extra caution with plantarflexion and inversion or other motions that cause pain. Inversion with plantarflexion should be introduced and progressed as tolerated. Cryokinetics are still indicated in the early portion of the subacute phase and can be used until the patient has little to no discomfort with the activities. Progressing from grade II to grade III joint mobilizations can be used for decreased ROM caused by altered arthrokinematics and positional faults to the fibula and talus (Fig. 5-12). Caution must be taken, however, when performing an anterior mobilization technique of the talus in a patient with a grade II or III lateral ligament sprain because an anterior movement of the talus stresses the anterior talofibular ligament and mimics the movement of the talus that occurred with the plantarflexion and inversion mechanism of injury. Because the talus subluxes anteriorly in a sprain caused by plantarflexion and inversion, a posterior mobilization to the talus may be more appropriate (see Fig. 5-10). Massage, myofascial release, and other manual therapy techniques to treat soft tissue restrictions may also help restore ROM, flexibility, and tissue mobility.

Figure 5-11 Using a BAPS board to maintain range of motion. A, The patient should begin in a nonweightbearing (NWB) position and progress to a partial weightbearing position (PWB) (B), before moving to full weightbearing (FWB) (C). The patient can perform uniplanar motions in plantarflexion, dorsiflexion, inversion, and eversion or multiplanar motions by performing “circles,” which require the patient to touch all of the edges of the board in both a clockwise and counterclockwise direction.

Figure 5-12 Joint mobilization techniques to restore range of motion and arthrokinematics. A, Anterior mobilization to increase plantarflexion. B, Medial mobilization to increase eversion. C, Lateral mobilization to increase inversion. D, Distraction of the talocrural joint for pain control and general mobility.

Goal J: Re-Establish Neuromuscular Control and Restore Muscular Strength and Endurance

Towel curls and marble pick-ups were included with the general mobility exercises in the acute stage; however, they also can be used to strengthen the intrinsic muscles of the foot (see Fig. 5-8). Patients can begin isometric exercises in a neutral ankle position against plantarflexion, dorsiflexion, inversion, and eversion forces. Because strength gains related to isometric exercises only strengthen the muscle at that length, it is important to progress to performing isometrics in a variety of degrees within a ROM, but painful ROM should be avoided. Isometric exercises should begin with submaximal contractions and progress to maximal contractions. Isometric exercises should be progressed to isotonic exercises as tolerated. Resistance can be provided manually, with cuff weights or elastic bands or cords (Fig. 5-13). Isotonic exercises should begin with a limited ROM and progress to full ROM as tolerated and should progress from submaximal resistance to maximal efforts. As weightbearing becomes tolerated, heel and toe raises can be incorporated as can walking on the heels or toes (Fig. 5-14). As the patient’s pain-free ROM increases, proprioceptive neuromuscular facilitation (PNF) techniques can be used.

Figure 5-13 Isotonic exercises. A, Eversion against manual resistance. B, Eversion using a cuff weight for resistance. C, Using an elastic band to resist eversion. Strengthening exercises should be performed in dorsiflexion, plantarflexion, inversion, and eversion.

Figure 5-14 Closed kinetic chain exercises. Heel raises (A) and toe raises (B) should be incorporated once the patient is able to fully bear weight. The patient can also walk on the toes or heels as a more functional strength training exercise.

Goal K: Re-Establish Proprioception, Agility, and Coordination

In the early phase of proprioception training, the patient may need to perform unloaded exercises such as joint repositioning if PWB or FWB are contraindicated or poorly tolerated. The patient should progress to PWB and FWB exercises as tolerated. Early exercises to encourage loading of the ankle include “weight shifts” in various directions. With weight shifts, the patient stands with his or her weight shifted to the noninjured leg, then progressively shifts the weight onto the injured leg before returning to the NWB position. This process is repeated for a prescribed number of sets. The patient should progressively shift more of his or her weight to the injured leg until equal weight is distributed on both legs. This progresses to the patient shifting more weight on the injured leg until he or she can finally bear full weight on the injured leg. These shifts should begin in a stance with the feet about shoulder-width apart and progress to a staggered stance requiring the patient to shift forward, backward, and laterally. Another exercise has the patient stepping onto a step or box and stepping down on the uninjured ankle. Once that is tolerated, the patient can step down from the box onto the injured ankle. The patient may need an assistive device such as a chair or railing in the beginning of this progression, but use of the device should be discontinued as soon as tolerated. Again, the patient should perform these step-ups and step-downs in various directions (Fig. 5-15).

Figure 5-15 Proprioception exercises without perturbations. A, Stepping up and down on the injured leg develops proprioception. B, Lateral step-ups increase the difficulty of the exercise.

The patient next progresses to activities with patient-controlled perturbations. The patient stands first in a two-foot stance with the weight evenly distributed while performing upper extremity or trunk exercises such as pulling on elastic bands in various directions, moving a weighted medicine ball in various directions, or bending over to pick up an object. The patient may also perform motions with the noninjured leg instead of, or in addition to, the upper extremity motions (Fig. 5-16). The patient should begin with uniplanar motions and progress to multiplanar motions. The patient can also perform these activities in a tandem stance (heel to toe) or a single-legged stance.

Figure 5-16 Proprioception exercises with patient-initiated perturbations. A, Single-legged stance with movement. B, On an unstable surface. C, Single-legged stance with lower extremity motion. D, On an unstable platform. E, Dynamic squats on an unstable platform.

The patient then progresses to activities where he or she must react to perturbations provided by the clinician. These types of activities involve the patient standing in a two-foot stance, a tandem stance, or a single-legged stance and reacting to a perturbation caused by the clinician. These types of perturbations include pushing or pulling on the patient’s body, either by direct contact or with elastic tubing or a stick, and playing catch with the patient (Fig. 5-17).

Figure 5-17 Proprioception exercises with clinician-initiated perturbations. A, Single-legged stance while playing catch. B, “Stick fighting” drills.

As the patient’s proprioception improves, agility and coordination exercises should be introduced. Walking, walking backward, front lunges, back lunges, side lunges, step-ups, step-downs, and so on can be incorporated as tolerated. Patients can also perform lateral movement exercises on a slide board or Fitter machine (Fig. 5-18).

Figure 5-18 Dynamic proprioception exercises. A, Lunges on an unstable surface. B, Lateral movements on a slide board while playing catch.

These exercises should progress from a two-foot stance with the feet at shoulder width, to a stance with both feet together, to a tandem stance with the feet apart, to a tandem heel to toe stance, and finally to a one-legged stance. The exercises can be made more difficult by having the patient perform the activities with his or her eyes closed; while shaking his or her head; or while standing on an unstable surface such as a foam pad, balance disc, or trampoline.

Goal L: Maintain Overall Body Conditioning

The same upper body and trunk exercises that were used during the acute phase can still be used in the subacute phase. As the patient better tolerates weightbearing, closed kinetic chain (CKC) lower extremity strength training exercises such as lunges, squats, leg presses, and calf raises can be added to the program (Fig. 5-19). Cardiovascular exercises such as walking, light jogging, climbing stairs (i.e., Stairmaster), and swimming can also be added.

Figure 5-19 Closed kinetic chain exercises. A, Leg press. B, Single-leg press on an unstable platform.

Return to Activity Criteria After Acute Ankle Sprain

The goal of the rehabilitation program should be to return the patient to full activity. When making a decision regarding the patient’s status and ability to return to activity, the following goals should be met.

Prevention of Ankle Sprains

Because ankle sprains are one of the most common injuries in active individuals, it is prudent to attempt to prevent their occurrence and recurrence, especially in high-risk activities like basketball and soccer. A “prehab” program uses exercises commonly used in the rehabilitation protocol to prevent ankle sprains from occurring or recurring. Some of the more commonly used exercises include those described in the proprioception and strengthening phases in Rehabilitation Protocol 5-1. Hübscher et al. (2010) in a systematic review determined that balance training alone resulted in a significant reduction in the risk of ankle sprain, confirming the results of an earlier systematic review (McKeon and Hertel 2008) that found a substantially reduced risk of ankle sprains with prophylactic bracing, especially in those with a history of a previous sprain. Special emphasis should be placed on strengthening the muscles that evert the foot.

Another common practice is the use of prophylactic ankle braces or taping techniques. Many ankle braces are on the market, ranging from slide-on neoprene sleeves to lace-up braces to semi-rigid ankle orthosis. Whereas most braces offer some form of protection, the semi-rigid type braces offer the most support. The effectiveness of bracing in preventing ankle sprain is still unclear. One recent study of prophylactic ankle bracing on the incidence of ankle injuries in a group of high school volleyball players (Frey et al. 2010) found that overall the use of an ankle brace did not significantly alter the frequency of ankle sprains. In contrast, a systematic review (Dizon and Reyes 2010) concluded that ankle sprains were reduced by 69% with the use of ankle brace and by 71% with taping in previously injured athletes, and a study of collegiate female volleyball players (Pedowitz et al. 2008) found that a double-upright brace significantly reduced the rate of ankle sprain. When a brace is not available or is impractical (such as in dancers), ankle taping can be used. Figure 5-4 (A–M) demonstrates one ankle taping technique. Although the order of the specific strips can vary, the basic techniques are common with most taping protocols. One of the major drawbacks of taping is skin irritation and that the tape eventually loosens and loses its support.

Chronic Symptoms After a “Simple” Ankle Sprain

If chronic symptoms persist after an ankle sprain, further workup should be performed. A myriad of associated injuries may account for ongoing symptoms (Table 5-4). Of note, Gerber et al. (1998) found that the factor most predictive of residual symptoms after a lateral ankle sprain is presence of a syndesmosis sprain. Therefore, in patients with ongoing ankle pain after lateral sprain, make sure there is not concomitant missed syndesmotic injury.

Table 5-4 Possible Etiologies of Recalcitrant (Chronic) Ankle Pain

Diagnosis

Evaluation of a patient with chronic ankle instability begins with a careful patient history to assess the presenting complaint, mechanism of injury, level of activity, and severity of disability. Clinical examination may note only minimal ecchymosis and swelling along the joint line. Testing for ligament laxity is easier in patients with chronic instability than in patients with acute injuries because the limb is less painful. Plain radiographs and magnetic resonance imaging (MRI) are helpful to rule out other possible causes of ankle pain and instability, such as fracture, impingement, osteochondral lesions, or peroneal tendon injury.

The usefulness of stress radiographs is controversial, with most recent studies indicating that they are of questionable value. Because of the high variability of normal ankle laxity, comparison views of the uninjured side are usually needed. Although the figures used by clinicians vary, generally 3 to 5 degrees more laxity than the uninjured side or an absolute value of 10 degrees is considered a positive finding.

An important part of the evaluation of patients with chronic ankle instability is identification of associated pathology. Several studies have indicated that more than half of those with chronic ankle instability have associated extra-articular conditions or injuries, including articular cartilage damage, peroneal tendon injuries, impingement lesions, and associated tarsal conditions.

Treatment

Generally, conservative treatment is used first to treat proprioceptive deficits and any static disorders. Balance deficits have been identified in most patients with chronic ankle instability (Brown and Mynark 2007, Hale et al. 2007, Wikstrom et al. 2010). A systematic analysis (Webster and Gribble 2010) found that functional rehabilitation interventions were associated with improved ankle stability for both postural control and self-reported function in patients with chronic ankle instability, whereas a randomized controlled trial (McKeon et al. 2008) found that 4 weeks of balance training significantly improved self-reported function, static postural control, and dynamic postural control. In another group of patients with a history of ankle sprains, balance was improved after 4 weeks of elastic resistance exercise (Han et al. 2009). Patients with primarily functional instability are more likely to benefit from rehabilitation than patients with primarily mechanical instability (Ajis and Maffulli 2006).

Common Surgical Techniques for Management of Chronic Lateral Ankle Instability

Anatomic repair may involve the following:

• Imbrication of the lateral ankle ligaments (Broström procedure) (Fig. 5-22)

• Augmentation of the Broström repair with extensor retinaculum (Gould modification) (Fig. 5-23)

• Allograft Biotenodesis (Arthrex, Naples, FL) Broström-type procedure using allograft anterior tibial tendon or hamstring if poor local tissue (Fig. 5-24)

• Periosteal turndown flap off of fibula periosteum to augment the previous Broström ligament reconstruction above

Figure 5-22 Imbrication of the lateral ankle ligaments (Broström procedure).

Figure 5-23 Augmentation of the Broström repair with extensor retinaculum (Gould modification).

Figure 5-24 Allograft Biotenodesis Broström-type procedure using allograft anterior tibial tendon or hamstring.

In general, anatomic repair techniques have produced better results than tenodesis techniques (e.g., Watson-Jones or Chrisman Snook). One comparative study reported 80% good to excellent results with anatomic reconstruction and 33% good or excellent results with the Evans procedure (Krips et al. 2002). Arthroscopy can be used to identify and treat intra-articular conditions such as osteochondral talar lesions, impingement, loose bodies, painful ossicles, adhesions, and osteophytes, and arthroscopic techniques have been developed for tendon reconstruction (Lui 2007). Regardless of the surgical technique, functional rehabilitation has been shown to produce better results than 4 to 6 weeks of immobilization (de Vries et al. 2006).

Rehabilitation Protocol 5-2 shows a postoperative Broström ligament rehabilitation protocol.

REHABILITATION PROTOCOL 5-2 After Modified Broström Ankle Ligament Reconstruction

Modified Hamilton Protocol

Days 0–4

Place ankle in neutral dorsiflexion in removable walking boot and discharge patient as weightbearing as tolerated (WBAT) in boot with crutches.

Maximally elevate and cryotherapy.

Wean crutches at 7 to 10 days to walking boot only WBAT.

Days 4–7

Progress WBAT in removable walking boot and wean crutches at day 7 to 10.

Week 4

Remove walking boot at 4 to 6 weeks.

Apply air splint for protection, to be worn for 6 to 8 weeks after surgery.

Begin gentle range of motion (ROM) exercises of the ankle.

Begin isometric peroneal strengthening exercises.

Avoid adduction and inversion of ankle until 6 weeks postoperative.

Begin stationary cycling and light swimming.

Week 6

Begin proprioception/balancing activities.

Unilateral balancing for timed intervals.

Unilateral balancing with visual cues.

Balancing on one leg and catching #2 plyoball.

Slide board, increasing distance.

Fitter activity, catching ball.

Side-to-side bilateral hopping (progress to unilateral).

Front-to-back bilateral hopping (progress to unilateral).

Diagonal patterns, hopping.

Mini-tramp jogging.

Shuttle leg press and rebounding, bilateral and unilateral.

Positive deceleration, ankle everters, Kin-Com.

Complete rehabilitation of the peroneals is essential.

Dancers should perform peroneal exercises in full plantarflexion, the position of function in these athletes.

Early in rehabilitation, deweighted pool exercises may be beneficial.

Dancers should perform plantarflexion/eversion exercises with a weighted belt (2–20 pounds).

Weeks 8–12

Patient can return to dancing or sport if peroneal strength is normal and symmetric with uninvolved limb.