Physiotherapy for Ankle Sprain

Introduction:

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An ankle sprain is an injury to the tough bands of tissue (ligaments) that surround and connect the bones of the leg to the foot. The injury typically happens when you accidentally twist or turn your ankle in an awkward way. This can stretch or tear the ligaments that hold your ankle bones and joints together.

All ligaments have a specific range of motion and boundaries that allow them to keep the joints stabilized. When ligaments surrounding the ankle are pushed past these boundaries, it causes a sprain. Sprained ankles most commonly involve injuries to the ligaments on the outside of the ankle.

Causes:  A sprain occurs when your ankle is forced to move out of its normal position, which can cause one or more of the ankle's ligaments to stretch, partially tear or tear completely.

Causes of a sprained ankle might include:

·       A fall that causes your ankle to twist

·       Landing awkwardly on your foot after jumping or pivoting

·       Walking or exercising on an uneven surface

·       Another person stepping or landing on your foot during a sports activity

Symptoms: The inflammation that comes along with a sprained ankle can cause symptoms including:

• Swelling and bruising. It may be so swollen that you can press on the area with your finger and leave an indent.
• Pain. Your nerves are more sensitive after a sprain. The joint hurts and may throb. It’s often worse when you press on it, move your foot in certain ways, walk, or stand.
• Redness and warmth. A sprain causes more blood to flow to the area.
• Instability. The joint can feel weak when the ligament is totally torn.
• Trouble walking. A sprain may limit how much you can move your ankle

Risk factors:  Factors that increase your risk of a sprained ankle include:

·       Sports participation. Ankle sprains are a common sports injury, particularly in sports that require jumping, cutting action, or rolling or twisting of the foot such as basketball, tennis, football, soccer and trail running.

·       Uneven surfaces. Walking or running on uneven surfaces or poor field conditions may increase the risk of an ankle sprain.

·       Prior ankle injury. Once you've sprained your ankle or had another type of ankle injury, you're more likely to sprain it again.

·       Poor physical condition. Poor strength or flexibility in the ankles may increase the risk of a sprain when participating in sports.

·       Improper shoes. Shoes that don't fit properly or aren't appropriate for an activity, as well as high-heeled shoes in general, make ankles more vulnerable to injury.

Diagnosis: During a physical, your doctor will examine your ankle, foot and lower leg. The doctor will touch the skin around the injury to check for points of tenderness and move your foot to check the range of motion and to understand what positions cause discomfort or pain.

If the injury is severe, your doctor may recommend one or more of the following imaging scans to rule out a broken bone or to evaluate in more detail the extent of ligament damage:

·       X-ray. During an X-ray, a small amount of radiation passes through your body to produce images of the bones of the ankle. This test is good for ruling out bone fractures.

·       Magnetic resonance imaging (MRI). MRIs use radio waves and a strong magnetic field to produce detailed cross-sectional or 3-D images of soft internal structures of the ankle, including ligaments.

·       CT scan. CT scans can reveal more detail about the bones of the joint. CT scans take X-rays from many different angles and combine them to make cross-sectional or 3-D images.

·       Ultrasound. An ultrasound uses sound waves to produce real-time images. These images may help your doctor judge the condition of a ligament or tendon when the foot is in different positions.

Treatment:

Medical management: Anti-inflammatory pain medications reduce pain and fight swelling. Over-the-counter drugs such as ibuprofen and naproxen work for most people.

Surgical management: Surgery for sprained ankles is rare. It may be performed when the damage to the ligaments is severe and there is evidence of instability, or when the injury doesn’t improve with nonsurgical treatment. Surgical options include:

Arthroscopy: During an arthroscopy, a surgeon looks inside the joint to see if there are any loose fragments of bone or cartilage.

Reconstruction: For reconstruction surgery, a surgeon will repair the torn ligament with stitches. They may also use other ligaments or tendons around the foot or ankle to repair the damaged ligaments.

Physical therapy:

Physiotherapy is required with functional therapy of the ankle shown to be more efficient than immobilization. Functional therapy treatment can be divided in 4 stages, moving onto to the next stage as tissue healing allows 

1.    Inflammatory phase,

2.    Proliferative phase, 

3.    Early Remodeling,

4.    Late Maturation and Remodeling. 

Ø  Inflammatory phase (0 to 3): The goal is to reduce pain and swelling and improve circulation and partial foot support.

The most common approach to manage ankle sprain is the price protocol. Protection, Rest, Ice, Compression, Elevation

Ø  Proliferative phase (4 to 10 days): The goal is to recover the function of ankle and foot and improve load carrying capacity.

·       Patient education

·       Practice foot and ankle functions

·       Apply tape as soon as swelling has decreased.

Ø  Early remodeling (11 to 21 days): The goal is to improve muscle strength, active (functional) stability, mobility. Practice balance, muscle strength.

Ø  Late remodeling and maturation:  The goal is to improve regional load-carrying capacity, walking skills, improve the skills needed during activities of daily living as well as work and sports.

References:

·       Kolby and Kisner Therapeutic exercises edition 7

·       The comprehensive manual of therapeutic exercises by Elizabeth Bryan,2018

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