Ankle sprain? A bit of understanding and rehab strategies.

Did you just sprain your ankle? I did recently. It hurts! Ankle sprains occur so often that sometimes it can be easy to overlook helpful treatment strategies to accelerate the healing because, well, they will heal on their own, right?

Ankle sprains are the most common lower extremity injury in sport. The most common is an inversion sprain where the foot rolls under the inside portion of the ankle. There are eversion sprains and diastasis (aka "high ankle") sprains, but these are less common. ​

To x-ray or not to x-ray? That is the question.
The first question is always, "Do I need an x-ray?" Typically an x-ray is needed if a patient meets certain x-ray decision making criteria. For instance, the Ottawa Ankle Rules and other questions may help to determine whether an x-ray is necessary. Things like:

• Is the patient older (55 years old or greater)?
• Is the patient unable to take 4 steps (it's okay if there is a limp)?
• Is there bony tenderness? Specifically along the big bumps on the side of the ankle called the malleoli, the navicular, the cuboid, and the base of the 5th metatarsal.
• Is there rapid swelling or bruising within 60 minutes post-injury?
• Is there a lack of an arterial pulse or sensation?

If these questions are met with a no, then proceeding without x-rays is often safe. 

Severity or "grades" of ankle sprains.
Patients usually like to know the severity of an ankle sprain. This is understandable as it will help gauge the prognosis. The severity for most sprains ranges from mild, to moderate, to severe.

1. Mild ankle sprain - With a mild ankle sprain there usually is no bruising and swelling, but if there is, it is typically localized over the injury site and will peak around 5-7 days. The tenderness is also localized to the injury site. Any limp will be usually limited to 1-2 days with pain most often just near end range of the ankle motion that caused the injury in the first place. These typically recover in 1-2 weeks and often times patients won't seek treatment because symptoms are mild.
2. Moderate ankle sprain - A moderate ankle sprain will typically present with bruising and swelling that is mainly localized to one side of the foot but may last for several days to weeks. The swelling can be enough to make the edges of the Achilles disappear. Tenderness can be more spread out over the ankle and any limp will be obvious lasting between 2-14 days. There may be laxity in the joint when a doctor applies firm end range of motion. The recovery time will be longer between 1-2 months but it is not uncommon to see recoveries lasting 6 to 12 months due to the timeframes of healing associated with the four stages of healing (Inflammation, Consolidation, Regeneration "repair", and Remodeling).
3. Severe ankle sprain - A severe ankle sprain refers to a full or complete rupturing of a ligament. There will be extensive and diffuse swelling with bruising on both sides of the ankle usually. Both edges of the Achilles tendon edges will be very difficult to visualize. The patient will be unable to weight bear and there will be nearly complete loss of range of motion. There is significant laxity in the joint because of the ligament failure. Due to the amount of injury and after a fracture is ruled out, there is a need to assess tendon straining or rupture. Depending on the amount of damage and considering the type of treatment implemented, recovery can last anywhere between 8 weeks to longer than 4 years.

What treatment strategies can be used to accelerate the healing?
During an acute phase of injury, an old and still popular acronym for an ankle sprain, and nearly any injury, has been to R.I.C.E. This stands for Rest, Ice, Compression, and Elevation. Over the years, most injury and exercise specialists have moved away from this to recommend new acronyms like P.O.L.I.C.E. (Protection, Optimal Loading, Ice, Compression, and Elevation) or M.I.C.E. (Movement, Inflammation exonerated, Compression, and Elevation). While I do like to still compress and elevate an injury when swelling is persistent and severe, I'm not incredibly fond of using ice as this can delay healing. The acronym I use in my practice is M.O.V.E.

• Movement: Movement will gently restore active range of motion and will gradually  stimulate tissue healing. Movement also improves blood flow which will bring oxygen into the cell and drive out metabolic waste.
• Optimal loading: When we mechanically load tissues, even injured ones, there is neurological signaling called mechanotransduction that will cause a release of chemical growth factor hormones from the cells. This will enhance protein and fiber synthesis and repair.
• Vital Nutrients: We need food to live. Poor nourishment of our body can literally be like a slow poisoning ultimately leading to disease. Even before an injury, having the right nutrition of vital nutrients in our body will help our body heal faster. After an injury, nutrition and proper supplementation will certainly enhance tissue repair, allow inflammation to work for us not against us, and facilitate optimal healing.
• Emotional Encouragement: It is so important to condition the brain to be confident and positive. This will improve recovery. Staying optimistic despite the current pain and limitations, will help a patient remain focused as they slowly return to activity. Conditioning the brain also includes getting proper sleep. Without adequate sleep our body will not release the appropriate amount of tissue repair hormones.

What about rehab? Rehab must start the same day of the injury. Even if small.
Ankle sprain rehab exercises:
1. Mobility exercises

• Draw the alphabet, A through Z, every hour. This will slowly begin to restore normal range of ankle mobility.
• Passive movement. Using a resistance band or your other hand slowly apply a gentle force from all directions to move throughout plantar flexion, dorsiflexion, inversion, and eversion.
• Passive loading. With the foot on a chair or bench, slowly lean bodyweight slightly into the injured ankle causing dorsiflexion (ankle bending toward you) and then move slowly side to side to cause a bit of inversion and eversion movement in the ankle joint.

2. Stability exercises

• Single leg stance. Once a patient can place weight on the ankle and foot with minimal or no pain, improving balance is necessary. Begin with eyes open then progress to eyes closed and eventually to an unstable surface like a cushion or pillow. Be certain to have a chair or table nearby to catch yourself if loosing balance too quickly. It is important to hold as long as possible, and as long as the other ankle is "healthy", a patient can use the healthy ankle as a standard to aim for.
• Star Excursion Balance Test: After single leg stance is improving, it is important to challenge multiple planes of motions on the ankle. After finding the short foot position of the stance leg, try toe tapping with the opposite foot in every position on the diagram. The further out a patient touches, the more challenging it will be on the stance foot.

3. Strength exercises

• ​Isometrics using resistance band. The goal is to apply enough resistance without causing pain. Complete 5 repetitions of holding stationary resistance for 10-15 seconds every 4 to 6 hours. Apply the force from all directions to challenge plantar flexion, dorsiflexion, inversion, and eversion.
• Calf Raises. It is best to slowly progress from isometrics to the actual coming up onto the toes of the injured foot over time. To do an isometric version of calf raises, come up on to the toes of the GOOD foot first then slowly transfer bodyweight onto the ball of the injured foot. As strength improves with isometrics, a patient can begin to slowly drop the heel down to the ground while bodyweight is being applied to the injured foot. Once a patient tolerates the lowering of the heel down, then they can begin the actual coming back up onto the toes of the injured foot.
• Plyometrics and agility drills. Once a patient has near full mobility, stability and strength as detailed above, it is good to start reintroducing challenging movements like hopping, jumping, and running movements.

Bottom Line
Ankle sprains are common. It is important to seek treatment from a medical professional especially in moderate to severe cases or if symptoms are not improving. Ankle sprains do have a good prognosis as they often heal with the most commonly reported residual problem being ankle stiffness. A patient's overall health, including physical and mental, along with proper nutrition and supplementation will significantly impact recovery. It is important to regain mobility, stability, and strength in a rehab process early on. This will speed the healing along. Also, by incorporating a long-term strategy to strengthening the ankles, a patient can reduce the occurrence of ankle injuries and how long it takes to heal if an injury were to occur again.

References:
Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO. Return-to-Play in Sport: A Decision-based Model.  J. Sports Med. 2010;20:379-385.
Delahunt E, Bleakley CM, Bossard DS, et al. Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. Br J Sports Med. 2018;52(20):1304–1310.
Khan K, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. J. Sports. Med. 2009;43:247-251. (Request with CPSBC or view UBC) DOI: 10.1136/bjsm.2008.054239
Mirkin G. Why Ice Delays Recovery. Dr. Gabe Mirkin on Health, Fitness and Nutrition blog. Updated October 13, 2016.
Recek C. Calf Pump Activity Influencing Venous Hemodynamics in the Lower Extremity.  J. Angiol. 2013;22:023-030.

Disclaimer
The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

TAGS: ankle sprain injury, ankle sprain rehab, lateral ankle sprains, lateral ankle injury, lateral ankle sprain rehab, inversion sprain