Summary of high ankle sprain (Syndesmotic injury)
A high ankle sprain is an injury to the joint created by the distal tibia and fibula and the anterior tibiofibular ligament, the transverse ligamnet, the posterior inferior tibiofibular ligament and the interosseous ligament. The mechanism of injury is forceful dorsiflexion, external rotation, or in less frequent cases it can be injured in a plantarflexion inversion action. In the case of a high ankle sprain conservative treatment may not be an option. If the syndesmosis is torn, since it accounts for a large portion of ankle instability, surgery may be indicated. Another important note is the fact that it has been documented that an injury involving the syndesmosis takes twice as long to rehabilitate as a grade III ankle sprain1,7,9.
Guide to Physical Therapy Practice
Practice pattern 4D: Impaired joint mobility, motor function, muscle performance and range of motion associated with connective tissue dysfunction. http://guidetoptpractice.apta.org/content/current
From the guide some of the effective rehabilitative exercises are:
1. Strength, power and endurance
2. Flexibility exercises
3. Gait and locomotion training
4. Balance, coordination and agility training
Some important goals for this condition the guide points out are:
1. Joint swelling, inflammation, or restriction is reduced
2. Pain is decreased
3. Gait, locomotion and balance are improved
4. Joint integrity and mobility are improved
5. Muscle performance (strength, power, endurance) are improved
6. ROM is improved
7. Weight-bearing status improves
8. Impact on health, wellness and fitness
It is important to note that each patient with a high ankle sprain are not all the same and the treatment of a high ankle sprain should be patient specific.
Rehabilitation of a high ankle sprain
While few randomized control trials exist on the rehabilitative process of a syndesmotic injury, some protocols have been developed via case studies and expert opinion13. Multiple phases exist for the rehabilitation of a high ankle sprain, with the most accepted number of phases being three.13,14.
Phase 1 of rehabilitation
the goals of therapy should focus on reducing inflammation, restoring active and passive ROM, and maintaining strength and cardiovascular endurance.
At home the patient should4,14:
1. PRICE for pain relief and inflammation reduction
2. Ankle active ROM exercises
3. Restricted weight bearing
If a brace was prescribed for the patient then it should be worn at all times except when doing PRICE or ankle ROM exercises.
During a typical physical therapy session the therapist can perform the following4,14:
1. ankle mobilizations
2. passive stretching techniques
3. Soft tissue massage
4. restriced ankle ROM
5. stationary bike or upper extremity pedaling if the stationary bike cannot be tolerated.
Progression to the next phase will take place when swelling and pain are under control and the patient walks with a minimal limp13.
Phase 2 of rehabilitation
In the second phase of rehabilitation the main focus is increasing strength, proprioception and encouraging normal gait and performance of basic skills such as hopping, light jogging and maneuvering around obstacles13. Strengthening exercises should begin with lower weight higher repetition sets and progress to higher weight lower repetition sets13.
Some good exercises are13,14:
1. resisted ankle ROM with theraband
2. resisted heel and toe rasies
3. lunges
4. squats
Early on in the second phase the patient can just do a single leg stance on the foam pad or mini trampoline until they become proficient at that. Proprioception exercises will be very important to decrease the probability of recurrent high ankle sprains. A useful training tool for proprioception in a population with ankle instability is vibration training6. Other options for proprioception are13,14,15:
1. BAPS board
2. Foam pads of different give to allow for progression
2. mini trampoline
At home the patient can use a pillow for the proprioceptive exercises in their home exercise program. Strengthening exercises should be progressed in the home exercise program in this phase as well.
As the single leg stance becomes easy the therapist should start to add in a ball toss, squats or lunges onto the the foam pad or mini trampoline.
Progression of the strength and proprioception exercises are patient specific. Progressing too quickly can be detrimental to the patient and overall rehabilitation time. Close observation of each individual patient and dialogue will be important for the therapist to determine when it is time to progress the patient.
Phase 3 of rehabilitation
In order to progress to the third and final stage of rehabilitation the patient has to be able to jog and hop repetitively without any problems13. The third phase of rehabilitation is focused on getting the patient back to their prior level of function. Whether it be athletics, recreational running or just being independent and pain free with everyday activities. More aggressive strengthening, sport specific drills, jumping rope, leaping, side and backward shuffling should be the focus; also, plyometrics are added late in phase three to enhance power13.
Sport specific drills may include:
1. simulating passing routes for football players
2. dribbling a soccer ball in straight lines and around obstacles for soccer players
3. running lay-up drills for basketball players
Running on different types of surfaces would be beneficial for recreational runners. For the patient just wanting to get their independence back stair exercises and increasing the intensity of their strengthening exercises will be beneficial for them.
Patient observation to ensure proper progression through the rehabilitation phases is vital as every patient is different, some patients will progress quicker than others.
Use of modalities and pain relief
The most commonly used and effective modalities are ice and TENS. Ice can be used to help decrease inflammation and pain and is effective throughout rehabilitation. TENS and IFC have been shown to be effective early on in rehabilitation for pain relief, but when pain is no longer an issue TENS and IFC become unnecessary13,14. If a fracture exists the use of TENS and IFC are contraindicated, so before using make sure the patient does not have a fracture. NSAID's can be taken along with therapy and modalities to aid in pain relief and inflammation reduction. Conservative treatment is helpful in grade I and II high ankle sprains but in sprains involving syndesmosis tears surgery may be necessary.
Special Instructions
Early on in rehabilitation of a high ankle sprain it is important to keep weight off of the involved ankle, as stressing it can lead to heterotrophic ossification in the interosseous membrane and delay rehabilitation even more4,7. If the syndesmosis is torn, since it accounts for a large portion of ankle instability, surgery may be indicated. Another important note is the fact that it has been documented that an injury involving the syndesmosis takes twice as long to rehabilitate as a grade III ankle sprain1,7,9.
References
1. Scheyerer MJ, Helfet DL, Wirth S, Werner C. Diagnostics in suspicion of ankle syndesmotic injury. Am J Orthop. 2011;40(4):192-197.
2. Mohammed R, Syed S, Metikala S, Ali SA. Evaluation of the syndesmptic-only fixation for Weber-C ankle fractures with syndesmotic injury. Indi J Orthop. 2011;45(5):454-458.
3. Hermans JJ, Beumer A, de Jong TAW, Kleinrensink G-J. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat. 2010;217:633-645.
4. Dubin JC, Comeau D, McClelland RI, Dubin RA, Ferrel E. Lateral and syndesmotic ankle injuries: a narrative literature review. J Chiro Med. 2011;10:204-219.
5. Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007;15:330-339.
6. Cloak R, Nevill AM, Clarke F, Day S, Wyon MA. Vibration training improves balance in unstable ankles. Int J Sports Med. 2010;31:894-900.
7. Mei-Dan O, Kots E, Barchilon V, Massarwe S, Nyska M, Mann G. A dynamic unltrasound examination for the diagnosis of ankle syndesmotic injury in profefssional athletes. Am J Sports Med. 2009;37(5):1009-1016.
8. Hsu YT, Wu CC, Lee WC, Fan KF, Tseng IC, Lee PC. Surgical treatment of syndesmotic diastasis: emphasis on effect of syndesmotic screw on ankle function. Int Orthop. 2010;35:359-364.
9. Egol KA, Pahk B, Walsh M, Tejwani NC, Davidovitch RI, Koval KJ. Outcome after unstable ankle fracture: effect of syndesmotic stabilization. J Orthop Trauma. 2010;24:7-11.
10. Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med. 2004;32(8):1941-1945.
11. Taylor DC, Tenuta JJ, Uhorchak JM, Arciero RA. Aggressive surgical treatment and early return to sports in athletes with grade III syndesmosis sprains. Am J Sports Med. 2007;35(11):1833-1838.
12. Beumer A, Van Hemert WL, Niesing R, et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res. 2004;432:227-234.
13. Williams GN, Jones MH, Amendola A. Syndesmotic ankle sprains in athletes. Am J Sports Med. 2007;35(7):1197-1207.
14. Pajaczkowski JA. Rehabilitation of distal tibiofibular syndesmosis sprains: a case report. J Can Chiropr Assoc 2007;51(1):42-49.
15. Mulligan EP. Evaluation and management of ankle syndesmosis injuries. Physical Therapy in Sport. 2011;12:57-69.
