Treatment Protocol for Sprained Ankles

By Thomas Michaud, DC

In the U.S. alone, 23,000 people sprain their ankle each day, resulting in 1.6 million doctor office visits annually.¹ The direct and indirect costs (e.g., lost days from work) associated with treating ankle sprains exceed $1.1 billion annually.² To make matters worse, these numbers do not take into account the long-term disability often associated with ankle sprains. In a 10-year follow-up of patients suffering ankle sprains, 72 percent showed signs of arthritis in the ankle joint.³

Given the serious long-term consequences associated with ankle sprains, it is important to identify which individuals are prone to injury. Although numerous factors have been proven to correlate with the development of ankle sprains (such as high arches, impaired balance, tight calves, and decreased cardiovascular fitness), by far, the best predictors of future ankle sprain are prior ankle sprain and being overweight. In fact, overweight athletes with a prior history of ankle sprain are 19 times more likely to suffer another ankle sprain.⁴Because force centered on the ankle can exceed seven times body weight, even a few extra pounds will greatly increase your potential for ankle sprain.

Conversely, previous ankle sprain can result in impaired coordination and calf tightness that can increase your potential for reinjury. In a three-dimensional study of motion in the foot and ankle while walking, individuals with a prior history of ankle sprain had reduced ground clearance during swing phase in the foot was tilted in excessively when it hit the ground.⁵

Despite the strong connection between prior sprain and future sprain, there is a counterintuitive inverse relationship between the severity of ligament damage and the potential for reinjury. In a two-year follow-up of 202 elite runners presenting with inversion ankle sprains, researchers determined that patients with the worst ligament tears rarely suffered reinjury (reinjury rates in this group were 0-5 percent), while individuals with less severe ankle sprains suffered significantly higher rates of re-sprain (18 percent of patients with moderate sprains were reinjured during this two-year period).⁶

This explains previous research confirming that patients with completely torn ankle ligaments treated with surgical reconstruction had worse short and long-term outcomes than individuals who refused surgical intervention,⁷ and emphasizes the importance of aggressively treating even the most minor ankle sprain. It also makes it clear that runners with severe ankle ligament injuries should avoid surgery.

Regardless of the degree of ligament damage, the goal of treating an ankle sprain is to restore strength, flexibility, proprioception, and endurance as quickly as possible during the first few days following injury. Adding an elastic bandage to a standard air cast has been proven to reduce the length of time to full recovery by 50 percent.⁸ The table below outlines a popular treatment protocol for managing ankle sprains, while the figure above illustrates an effective tubing exercise that can be performed once symptoms of the acute sprain are reduced.

Phase 1: Patient unable to bear weight

• Compressive wrap with U-shaped felt balance around fibula. Change every four hours
• Active abduction / adduction of toes for five seconds; repeat 10 times
• Write out alphabet with toes, five times per day
• Stationary bike, 15 minutes per day
• Ankle rock board, seated (off-weight-bearing), 30 circles, performed clockwise and counterclockwise two times per day. Perform on uninjured ankle while standing for three minutes. This has been shown to increase proprioception in the contralateral limb
• Mild grade 3 and grade 4 mobilization of the joints of the foot and ankle

Phase 2: Patient can walk with minimal discomfort; sprained ankle has 90 percent full range of motion

• Mobilize all stiff joints in the lower extremity and pelvis
• Band exercises in all planes; three sets of 25 in each direction
• Double-leg and then single-leg heel raises on the involved side, three sets of 10 reps, two times per day
• Standing closed-eye balance, 30 seconds, five times per day
• Standing single-leg ankle rock board, one minute, five time per day
• Closed kinetic-chain exercises

Phase 3: Patient can hop on involved ankle without pain

• Running at 80 percent full speed; avoid forefoot touch-down
• Mini-tramp; three sets of 30 jumps forward, backward and side to side. Begin on both legs; progress to single-limb
• Plyometrics on a 50 cm and 25 cm box, positioned 1 meter apart. Jump from one box to the ground, then to the other box, landing as softly as possible. Three sets of five reps.

Besides the standard exercise routines, it is also important that problems with balance be addressed. The simple addition of an inexpensive foam balance pad can significantly lessen the risk of injury. In one study, there was a 77 percent decrease in the rate of reinjury when overweight athletes with a prior history of ankle sprain performed balance training on a foam stability pad for five minutes on each leg for four weeks.⁹ Another study from the Netherlands¹⁰found that individuals treated with balance-board exercises reduced their subsequent reinjury rates by 47 percent.

Because foam pads and balance boards do not put your foot through a full range of motion, I recommend a rock board that forces your foot to tilt in more than it tilts out (which is how your ankle is designed to move). The board places your foot in the position of a future sprain and then forces you to use your muscles to pull yourself out of the risky position. At first, perform this exercise while seated; after a few days, it can be done while standing.

The improvements in proprioception associated with balance-board training can be enhanced by skin taping. As demonstrated by Matsusaka. et al.,¹¹ placing a single strip of adhesive tape along the lateral leg and heel while performing balance-board training produces more rapid improvements in postural sway (i.e., taped subjects returned to baseline values of postural sway with six weeks of training, compared to eight weeks with balance board training alone).

It is also interesting that balance-board training on one limb will produce significant improvements in balance on the contralateral, untrained limb.¹² The proprioceptive cross-training effect allows the injured individual to train the opposite, uninjured leg to enhance proprioception in the injured leg, even if the injured leg is cast-immobilized.

Perhaps the best way to restore proprioception is with manipulation of the calcaneocuboid and talocrural joints. The importance of incorporating manipulation into a protocol for managing ankle inversion sprain is supported with research by Lopez-Rodriguez, et al.,¹³ in which manipulation resulted in an improved progression of forces throughout the foot during stance phase. In performing a placebo-controlled study of 52 athletes presenting with grade 2 ankle sprains, these authors determined that ankle adjustments produced a clinically significant redistribution of load throughout the foot, as measured with stabilometric and baropodometric techniques.

In addition to decreased proprioception from ligament and nerve damage following sprain, altered proprioception may also be the result of a damaged retinaculum. In an interesting MRI study of ankle sprains, Stecco, et al.,¹⁴ determined that the ankle retinaculum is injured in more than 80 percent of ankle sprains, and that the damaged retinaculum may be responsible for lessened proprioception. The authors demonstrated that manual intervention in the form of fascial release resulted in long-term reductions in pain and improved balance, as measured on stabilometric platforms.

References

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2. Heiderscheit B, Chumanov E, Michalski M, et al. Effects of step rate manipulation on joint mechanics during running. Med Sci Sports Exerc, 2011;43:296-302.
3. Verhagen E, van Mechelen W, de Vente W. The  effect of preventive measures on the incidence of ankle sprains. Clin J Sport Med, 2000;10:291-296.
4. Tyler TF, McHugh MP, Mirabella MR, Mullaney MJ, Nicholas SJ. Risk factors for noncontact ankle sprains in high school football players: the role of previous ankle sprains and body mass index. Am J Sports Med, 2006;34:471-475.
5. Delahunt E, Monaghan K, Caulfield B. Altered neuromuscular control and ankle joint kinematics during walking in subjects with functional instability of the ankle joint. Am J Sports Med, 2006;34:1970-1976.
6. Malliaropoulos N, Ntessalen M, Papacostsa E, et al. Reinjury after acute lateral ankle sprains in elite track and field athletes. Am J Sports Med, 2009;37:1755.
7. Kaikkonen A, Kannus P, Jarvinen M. Surgery versus functional treatment in ankle ligament tears: a prospective study. Clin Orthop, 1996;326:194-202.
8. Beynnon B, Renstrom P, Haugh L, et al. A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. Am J Sports Med, 2006;34:1401.
9. McHugh M, Tyler T, Mirabella M, et al. The effectiveness of a balance training intervention in reducing the incidence of noncontact ankle sprains in high school football players. Am J Sports Med, 2007;35:1289.
10. Verhagen E, van der Beek A, Twisk J, et al. The effect of proprioceptive balance board training for the prevention of ankle sprains. Am J Sports Med, 2004;32:1385-1393.
11. Matsusaka N, Yokoyama S, Tsurusaki T, et al. Effect of ankle disk training combined with tactile stimulation to the leg and foot on functional instability of the ankle. Am J Sports Med, 2001;29:25.
12. Osborne M, Chou L, Laskowski E, et al. The effect of ankle disk training on reaction times in subjects with a history of ankle sprain. Am J Sports Med, 2001;29:627.
13. Lopez-Rodriguez S, Fernandez de-las-Penas C, Albuquerque-Sendin F, et al. Immediate effects of manipulation of the talocrural joint on stabilomitry and baropodometry in patients with ankle sprain. J Manip Phys Ther, 2007;30:186-192.
14. Stecco A, Stecco C, Macchi V, et al. RMI study and clinical correlations of ankle retinacula damage and outcomes of ankle sprain. Surg Radiol Anat. Published online: Feb. 9, 2011.