Did you know:
1/3 of patients with inversion ankle sprains continue to have symptoms for 1 year. (1)
25% of patients report pain, instability, crepitus, weakness, stiffness, or swelling for the next 3 years.
75% of active patients re-injure the same ankle. (2)
These numbers are staggering. Fortunately, evidence-based chiropractors are on the front line to manage these patients to full recovery and limit re-exacerbation with three proven stages to rehabilitation. Successful management of ankle sprains and prevention of re-injury depends on a couple of fundamental principles—each is equally important.
STEP 1: Recognize Who is Susceptible to Chronic Ankle Pain
Specific patient populations are predisposed to chronic pain. Disability questionnaires, like the Fear-Avoidance Beliefs Questionnaire, can identify patients that may require extra help due to their fear of movement therapy. This form will monitor your progress with ankle rehabilitation before and after treatment. (3)
STEP 2: Learn How to Move
The literature supports an early return to activity after acute inversion sprains. Exercises and treatments that promote joint motion and early recovery to weight-bearing are more effective than immobilization. Grade III sprains (ligament rupture) often require immobilization. However, grade I and II ankle sprains should forego complete immobilization and focus on regaining full range of motion. Early rehab and return to weight-bearing will increase ankle range of motion, decrease pain, and reduce swelling sooner than immobilization.
In a study by Linde et al., 150 patients with inversion ankle sprains were treated with early motion and weight-bearing. After one month, 90% of the patients treated with early motion and weight-bearing demonstrated pain-free gait, and 97% had increased workability. (4) Early mobility exercises would typically include:
Ankle Alphabet
Standing Gastroc Stretch
Standing Soleus Stretch
Single Leg Stance
These four exercises promote balance and increased ankle dorsiflexion—a pivotal contributor to an ankle injury. Patients who have lost an average of 11 degrees of dorsiflexion are five times more likely to suffer lateral ankle sprains. (5)
In-office care should also include mobilization and manipulation for restoring function. Joint mobilization decreases pain, increases dorsiflexion, and improves ankle function. (6) Instrument-assisted soft tissue manipulation or transverse friction massage to the affected ligament may help mobilize scar tissue and increase flexibility. Myofascial release may help release tightness or adhesions in the gastroc and soleus.
Knowing when to treat and when to refer is critical. Whitman’s clinical prediction rule identifies four variables to predict the success of manipulation and exercise for treating inversion ankle sprains. (7) The presence of three out of four of the following variables predict greater than a 95% success rate for manual therapy and exercise:
- Symptoms worse when standing
- Symptoms worse in the evening
- Navicular drop greater than 5 mm
- Distal tibiofibular joint hypomobility
STEP 3: Prevent Re-Injury
The most crucial variable in the successful prevention of future ankle sprains is improving BALANCE. Balance training reduces the incidence of ankle sprains and increases dynamic neuromuscular control, postural sway, and joint position sense in athletes. A study by de Vasconcelos et al. (2018) found that balance training reduced the incidence of ankle sprains by 38% compared with the control group. (9)
Two of the most common exercises used for balance and proprioception include the single-leg stance exercise and Veles.
Finally, it's important to start walking “normal” as soon as possible. As evidence-based chiropractors, we need to return patients to their normal gait as soon as tolerable. Patients with foot and ankle pain will often favor a supinated gait to unload the soft tissues of the foot and arch in favor of their bony architecture on the lateral foot. The lateral column of the foot affords stability but at the expense of a very inefficient gait. Over an extended period, these patients may develop a Tailor’s bunion, i.e., 5th metatarsal head bursitis. However, in the case of ankle sprains, a rapid increase in activity may overload the metatarsal fast enough to cause a Jones Fracture. Return to normal gait will minimize these compensations.
Article written by ChiroUp
References
- van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med.
- McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basket¬ball: injury rate and risk factors. Br J Sports Med. 2001;35:103-108
- Suttmiller AM, McCann RS. Injury-Related Fear in Individuals With and Without Chronic Ankle Instability: A Systematic Review. Journal of Sport Rehabilitation. 2021 Sep 20;1:1-0. Link
- Linde F, Hvass I, Juergensen U, Madsen F. Early mobilizing treatment of ankle sprains: A clinical trial comparing three types of treatment. Scan J Sports Sci.1971;8:71-7
- de Noronha M, Refshauge KM, Herbert RD, Kilbreath SL, Hertel J. Do voluntary strength, proprioception, range of motion, or postural sway predict occurrence of lateral ankle sprain? Br J Sports Med. 2006;40:824-828
- Janice K Loudon, Michael P Reiman, and Jonathan Sylvain The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review Br J Sports Med doi:10.1136/bjsports-2013-092763
- Whitman, Julie M., et al. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther 2009,39(3): 188-200.
- John C, Stotz A, Gmachowski J, Rahlf AL, Hamacher D, Hollander K, Zech A. Is an Elastic Ankle Support Effective in Improving Jump Landing Performance, Static and Dynamic Balance in Young Adults With and Without Chronic Ankle Instability?. Journal of Sport Rehabilitation. 2019 Jan 1;1(aop):1-21. Link
- de Vasconcelos GS et al. Effects of proprioceptive training on the incidence of ankle sprain in athletes: systematic review and meta-analysis. Clin Rehabil. 2018