Ankle Sprain Rehabilitation

by Nazish Waliany

As ultimate players, we generally don't take very good care of our bodies. Running in 100+ degree heat, playing four or five grueling games in one day, laying out at all angles, and continuing to play on injured joints and strained muscles, we are gluttons for punishment. One of the most common injuries we see on the field is an ankle sprain. Not only are they popular in ultimate, ankle sprains are the most common sports-related injury to the foot and ankle. Because of their prevalence, the rehabilitation process should be taken seriously to prevent recurrent injuries or any loss of function in the future.

A sprain is the stretching or tearing of one or more ligaments surrounding a joint. Ligaments are made up mostly of elastic collagen, and their purpose is to hold one bone to another in a joint. When a ligament is damaged, the stability of the joint is compromised. Additionally, ligaments also contain receptors that determine the positioning of the joint. This sense, called proprioception, is crucial to one's balance and stability in the most basic movements. Ligamentous damage can jeopardize the proprioceptive abilities of the joint and cause instability and possibly further injury.

The most common mechanism of injury of an ankle sprain is inversion combined with plantarflexion, or when the sole of your foot turns inward and down. The ligaments that are affected with this type of sprain are usually the anterior talofibular ligament, the calcaneal fibular ligament, and the posterior talofibular ligament. Following the initial injury, most people will experience swelling, bruising, and a specific site of pain and tenderness.

Sprains are classified by their severity as follows:

• Grade I: minor tearing or stretching of the ligament, no functional loss of ankle stability
• Grade II: partial tearing of the ligament, moderate instability
• Grade III: complete rupture of the ligament, significant instability

The three phases of healing of any joint sprain consists of inflammation, repair and remodeling. Inflammation is our body's immediate reaction to trauma, which includes a surge of red and white blood cells to the site of injury. The inflammation process brings blood to the area, which causes the area to be red, warm, and swollen. After the first few days following an acute injury, collagen is introduced to begin to repair the ligament. Within the first three weeks following the injury, mobilization of the ligament should be limited and controlled to make sure the collagen fibers are oriented efficiently. Six to eight weeks after the initial injury, collagen fibers are strengthened and oriented longitudinally for optimal function.

In order for proper healing to occur, the treatments in each phase should be appropriate and controlled. If the activities are too extreme, the inflammation phase will be prolonged, and healing will be interrupted. The following treatment ideas are appropriate for the indicated length of time following the injury. These are suggested time frames; each treatment protocol should be individualized as every ankle may respond differently.

Rehab Days 1-7
The rehabilitation process for grades I and II sprains begins similarly. For the first 3-4 days, one should practice “RICE,” or rest, ice, compression, and elevation:

• Rest: Try to stay off of your ankle as much as possible in these first few days. If you must be on your feet a lot throughout the day, a semi-rigid ankle brace is recommended, such as an Aircast brace or a lace-up brace.
• Ice: Icing should be done in 15 minutes on/15 minutes off intervals. You should repeat the intervals 2-3 times if possible, and repeat this 2-3 times per day. Ice reduces inflammation as well as pain.
• Compression: Wrapping the ankle in a elastic wrap or Ace bandage also can help control pain and offer some support and stability. If the ankle cannot be elevated throughout the day, the compression wrap is extremely important to limit increased swelling.
• Elevation: To reduce swelling, it is recommended that the injured ankle is elevated higher than the heart. This is also a great position in which to ice.

It is also a good idea to start some gentle ankle range of motion. You can lie on your back with your foot above your heart and either move your ankle up and down or slowly write the alphabet with your ankle. Just be sure not to push too far, or you risk further stretching the injured ligament.

Rehab Weeks 2-3
These next few weeks are very important in terms of tissue healing and rebuilding. The key to this phase is to increase strength and proprioception in your ankle to prevent further or repeated injury. Re-injury in this phase is common as individuals feel as though their ankle has healed, and they stress the ankle too much.

Exercises in this phase can progress based on a decrease in pain and swelling and an increase in weight-bearing tolerance. Some suggested progressive exercises are:

• 4-way ankle exercises: moving ankle up, down, inward and outward, add theraband to increase resistance in pain-free range
• Toe curls with towel: put towel on floor and gather towel with toes. Add a weight on towel to progress.
• Weight shifting: Step forward with your uninvolved leg, keeping your involved leg on the ground. Then step uninvolved leg back again, still keeping involved leg on the ground.
• Standing on one foot to increase balance and proprioception. This can be progressed by closing your eyes or standing on a pillow.
• Stand on involved leg and shift weight in slow, circular pattern around perimeter of foot in both clockwise and counterclockwise directions. Start this exercise standing on both legs, then progress to just involved leg.
• Calf and achilles tendon stretching to prevent loss of flexibility

Rehab Weeks 4-6
In this time period, individuals should focus on increasing strength not only in the muscles surrounding the ankle, but also the muscles surrounding the knee and hip as well. Exercises at this time should also work on balance and proprioception, but can be more challenging than the previous stage. Running can also be introduced at this time.

• Calf raises on a step. Start with both legs together, then progress to one leg at a time. Repeat calf raises with toes pointing forward, toes pointing inward, and toes pointing outward.
• Toe raises
• Double-leg squats, progress to single-leg squats
• Clock step: Stand on involved leg in center of circle with markers on floor at each hour of a clock. Tap toe of uninvolved leg to each marker while performing single-leg squat on involved leg. Do this in both clockwise and counterclockwise directions.
• Running: as your ankle begins to feel stronger and more stable, you can initiate running at slow speeds in straight lines. Start with jog-walk-jog intervals, then sprint-jog-sprint intervals on smooth surfaces. Progress to running in figure-eight patterns, and gradually increase your speed and make the patterns smaller.
• Agility: zig-zag cutting, back pedaling, side-stepping and carioca

Once these activities can be performed without increased pain, swelling, or instability, sport-specific activities can begin, including cutting, jumping, and sprinting, and plyometrics. Wearing a brace is recommended for 6-8 weeks after the injury.

Grade III sprains can sometimes be treated conservatively with the above treatment plan, but surgical repair is sometimes indicated. With conservative treatment, it is very important that the individual is diligent in his or her rehabilitation to prevent significant loss of range of motion, flexibility, and strength.

Chronic ankle sprains are usually related to a lack of proprioceptive recovery, decreased mobility in the ankle due to scar tissue or increased mobility in the ankle due to improper healing of the ligaments. These individuals should continue to work on strengthening and proprioceptive training to limit any functional deficits.

Consulting a physical therapist to establish a treatment protocol and to ensure that this protocol is progressed at an appropriate rate is also recommended. Rehabilitation of an ankle sprain is extremely important, and individuals should be diligent in their recovery in order to regain the loss of mobility, proprioception, strength and function after such an injury.

Nazish Waliany, PT, MS
nazishw (at) gmail (dot) com

Naz is gearing up for the co-ed series and continues to throw her full field flick hucks to her teammates.