An ankle sprain is an injury to the ligaments supporting the ankle joint. It is one of the most common injuries linked to sporting activities, but can also result from as something as simple as incorrect foot placement when walking. Lateral ankle sprains account for 85% of all ankle sprains. Research has shown that 30 % of first time lateral ankle sprain (LAS) sufferers develop chronic ankle instability (CAI). CAI is described as recurrent episodes of lateral instability resulting in multiple ankle sprains. CAI is thought to be the result of neural (proprioception, reflexes, muscular reaction time), muscular (strength, power, and endurance), and mechanical mechanisms (ligamentous laxity).
Why is it so important to complete a rehabilitation program after injuring your ankle?
- The body is a chain reaction – Everyone requires their foot and ankle to have the sufficient mobility and strength to walk every day. If the foot or ankle has an issue it will affect the structures further up the kinetic chain as the body compensates to allow movement through gait. Far too often poorly managed ankle injuries lead to other biomechanical injuries to the knees, hips, spines and shoulders.
- Ankle injuries can linger and lead to CAI.
- CAI can lead to long term degeneration of your foot and ankle. A link has been established between CAI and post-traumatic ankle osteoarthritis (OA), with 68–78 % of CAI patients later developing ankle OA.
Ankle sprains are graded ranging from 1 to 3; with grading dependent on the amount of damage to the ligament and the severity of resultant symptoms.
- Grade 1 – stretching of the ligamentous fibres, with no macroscopic damage present and minimal swelling and tenderness. No functional impairment is present nor joint instability.
- Grade 2 – excessive stretching of the ligamentous fibres with resultant macroscopic damage. There is moderate pain, tenderness and swelling, with some joint instability and reduction in joint motion.
- Grade 3 – complete rupture of the ligament. This commonly results in severe swelling, pain, tenderness and a loss of function with difficulty weight bearing. Joint motion and instability are markedly impacted.
Rehabilitation of ankle injuries should be structured and individualised. In the acute phase, the focus should be on controlling inflammation, re-establishing full range of motion, and maintaining strength. Once pain-free range of motion and weight bearing have been established, balance-training exercises should be incorporated to normalise neuromuscular control. Advanced-phase rehabilitation activities should focus on regaining normal function. This includes exercises specific to those that will be performed during sport. While having a basic template to follow for the rehabilitation of ankle injuries is important, we must remember that individuals respond differently to exercises. Therefore, each program needs to be modified to fit the individual’s needs and to be specific to the functions they need to be able to complete post recovery.
The main areas to focus upon initially are:
- Controlling inflammation
- Adapting nutrition to assist with recovering from injury
- Begin gentle non weight bearing mobility exercises
- Weight bear as soon as pain allows
Once we are able to address the above we shift our focus to:
- Begin strengthening exercises
- Begin proprioceptive exercises
- Progress non weight bearing mobility exercises to weight bearing mobility in all three planes
- Nutritional advice for decreased ability to exercise
And finally, we make sure we have:
- Full mobility of the injured foot and ankle in all three planes of motion
- Progress strengthening exercises
- Progress proprioceptive exercises
- Sports specific exercises
- Building to return to sport
Proprioceptive work should then be continued post return to sport as new studies have shown the importance of proprioceptive work in relation to injury prevention. One study of a professional European basketball team on a progressive proprioception program over 6 years showed an incidence decrease of 81% for ankle sprains, 78% for low back pain and 64.5% for knee sprains.
Proprioception is the body’s ability to recognise its own position in space. Even with our eyes closed, we are aware of the vague position of our limbs in relation to the ground, gravity and the rest of our body.
Proprioception Video 1. Initial Phase
This video demonstrates an exercise to help improve proprioception, we utilise the head as the driver to challenge the system more. Towards the end of the video a simple regression of this exercise is shown, this can be used if you find the original exercise too hard.
Proprioception video 2. Progression
This video shows some progressions of the exercises in the first video, the aim is to challenge your proprioception further by using some arm drivers to accentuate the movement occurring. Then we introduce a medicine ball to place more load through the body which again challenges the system in a different way.
Despite ankle sprains being a common occurrence, the potential for these acute injuries to become chronic and result in long term deterioration to the ankle joint means they require a comprehensive, structured and individualised treatment approach. Such treatment aims to address both the immediate and long term mobility and strength of the lower limbs while decreasing the risk of future injury to the ankle and other body parts in the kinetic chain.
If you are struggling with an ankle injury, or wish to make sure your training and prehab can help prevent them from occurring in the first place, come in and see us at Absolute, where industry leading Allied Health practitioners and Performance Coaches are under the one roof.
Written by Osteopath Ashley Gudgeon. Osteopathy Melbourne CBD
