Best Practices in PT Management
Summary of the Condition
According to Brigham and Women’s Hospital Department of Rehabilitation Services, a typical problem list that a physical therapist may develop when initially working with an individual who had sustained a lateral ankle sprain would be:1
• Impaired ROM
• Impaired strength
• Impaired gait
• Impaired joint play
• Impaired balance/proprioception
• Impaired knowledge
• Impaired functional mobility
Guide to Physical Therapy Practice
Image taken from http://guidetoptpractice.apta.org/local/img/home_cover.gif
Practice Pattern 4D: Impaired joint mobility, motor function, muscle performance and range of motion associated with connective tissue dysfunction
Practice Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation http://guidetoptpractice.apta.org/content/current
One has to keep in mind that there are many medical conditions and physical therapy diagnoses that can fit into these Practice Patterns. The conditions vary from a muscle strain to trigeminal neuralgia. Therefore, when using The Guide to assist in the plan of care for the patient, one has to remember that everything that is suggested in The Guide will not be applicable to the patient the PT is working with.
The Guide states, “Over the course of 2 to 4 months, patient/client will demonstrate optimal joint mobility, motor function, muscle performance, and range of motion and the highest level of functioning in home, work (job/school/play), community, and leisure environments.” The number of sessions a patient may need is in the range of 6 to 24 visits.2
According to The Guide, therapeutic exercise interventions may include but are not limited to:2
• Aerobic capacity/endurance conditioning or reconditioning
• Flexibility exercises
• Balance, coordination, and agility training
• Gait and locomotion training
• Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles
Anticipated goals and expected outcomes may include but are not limited to:
• Joint swelling, inflammation, or restriction is reduced
• Pain is decreased
• Soft tissue swelling, inflammation, or restriction is reduced
• Gait, locomotion, and balance are improved
• Joint integrity and mobility are improved
• Muscle performance (strength, power, and endurance) is increased
• Range of motion is improved
• Weight-bearing status improves
• Impact on functional limitations
• Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved
• Safety is improved
• Impact on health, wellness, and fitness
Manual therapy interventions such as massage, mobilization/manipulation, and passive range of motion are interventions that are suggested by The Guide with the same anticipated goals and expected outcomes mentioned for the therapeutic exercise interventions. Some additional anticipated goals and expected outcomes are edema, lymphedema, or effusion reduction, decrease in neural compression, and an increased in sensory awareness.
For physical agents, The Guide recommends cryotherapy, ultrasound, taping and continuous passive motion (CPM). The anticipated goals and expected outcomes mentioned above for therapeutic exercise interventions and manual therapy interventions are similar to the goals and outcomes for physical agents.2
Management of Lateral Ankle Sprain
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The acute phase usually lasts around 24 to 72 hours upon injury. The initial goals of treating an acute ankle sprain are to decrease pain, limit inflammation, maintain range of motion, and protect the ankle from further injury.1,3,4 Literature has shown that protection, rest, ice, compression and elevation (PRICE) is the first effective phase of treatment for this injury.4-8 To manage pain and swelling during the acute phase, cryotherapy is usually the modality of choice and there is not any strong evidence that suggest otherwise.4,9,10 The standard method of cryotherapy is to ice the limb for 20 continuous minutes. Another method is to ice the limb for 10 minutes, take the ice off for 10 minutes, and put the ice back on for another 10 minutes. The intermittent cryotherapy treatment may significantly increase vasoconstriction compared to the standard cryotherapy. In result, the intermittent cryotherapy can significantly reduce the level of pain one week after injury. However, there seems to be no significant differences between function and swelling between the two methods of cryotherapy.7,10,11
Ultrasound has been suggested to decrease pain and swelling and assist with the healing process of the injury. The evidence on ultrasound either is not consistent, or simply does not demonstrate a significant difference that is superior to a placebo.1,4,5,9,12-14 Neuromuscular electrical stimulation (NMES) has also been suggested for the management of swelling in the early period after an ankle sprain. Man et al. concluded in their study that NMES was not effective in decreasing swelling but explained in the study limitations for the reasons of not having a significant difference in the study and warned the reader to consider all of the variables before making a strong conclusion based on their study.15
Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended to help reduce pain during the first two weeks of injury.9,14 NSAIDs assist in reducing the inflammation stage during the acute phase of injury with a rapid return to activity.3,4 Ankle braces, elastic bandages, and ankle tape are sometimes used initially after injury to help in the PRICE treatment. Using ankle braces during the acute phase has shown to have less pain/tenderness 2-3 years after injury and better functional outcomes 3 months after injury compared to any other functional treatment.16
Exercises that the patient can do during the acute phase are ankle pumps and ankle circles. These movements should be done within a pain-free range.1 The amount of repetitions and sets should be tailored to each individual. The PT should perform anterior-posterior (AP) joint mobilization to the talocrural joint during the acute phase which has shown significant difference in decreasing pain and increasing dorsiflexion range of motion.17,18 Stretching the Achilles tendon in long sitting by pulling the foot with a towel should also be started early on to prevent the tissues from staying in a contracted state.19
Image taken from http://www.cyberpt.com/images/APGlide.jpg
Sub-acute Phase (2-4 days to 2 weeks)
The recommended modalities, cryotherapy and NSAIDs, will be continued to be used during the sub-acute phase in order to keep pain and swelling at a minimal. Pain-free range of motion and joint mobilization will continue until pain-free full range of motion has been achieved.1 Progression of the Achilles tendon stretch is to perform the stretch in standing. Next on the physical therapist’s problem list is to address the strength impairments. Strengthening rehabilitation can be initiated when pain and swelling is under control with full range of motion of the ankle joint. Isometric exercises in the direction of dorsiflexion, plantarflexion, inversion, and eversion should be performed and can be done against a wall or against the contralateral foot. Exercise bands are also a good tool to increase muscle strength of the muscles around the talocrual and subtalar joint.19
Image taken from http://www.physio-pedia.com/images/thumb/6/66/Theraband_Ankle_Composite.jpg/320px-Theraband_Ankle_Composite.jpg
Rehabilitative Phase (2-6 weeks)
Strengthening exercises can progress to close-chain activities. The following are some examples of strengthening exercises with progression:1
• Bilateral toe raises, progressing to single leg
• Bilateral squats, progressing to single leg squat
• Step-ups and step-downs, progressing to increasing the height of steps and/or increasing speed
Since the joint mechanoreceptors are injured which affects the proprioceptive nerve endings found within the ligamentous tissues, proprioceptive exercises are essential for the patient in order to reduce the rate of re-injury. Proprioceptive exercises that are appropriate for an ankle sprain should start with a single-leg standing activity for 30 second holds. Progression will be to do single-leg standing on unstable surfaces, eventually doing complex tasks while balancing. Having the patient close their eyes will increase the difficulty of balancing, challenging the ankle strategy. Proprioceptive exercises should be done 5 days a week, at least 10 minutes per day.3,20
Image taken from http://www.chiropractic-help.com/images/wobble2.jpg
Functional Phase (6 weeks post-injury)
The goal of this phase is to prepare the patient to return to their activities of daily living. Strengthening exercises should continue and progress accordingly as well the proprioceptive exercises. The exercises should be functional activities that meet the needs of the patient’s occupational or sport. Coordination and agility training that is primarily used for the athletic population are the following:1
• Hopping (progress bilateral, to injured leg only, whole foot to toes only)
• Step exercises – forward, side to side
• Running should be progressed when the patient can walk at a face pace without pain, starting on smooth surfaces and progressing to uneven surfaces
• Cutting exercises
• Figure 8’s, zig-zags
• Jump rope
• Stairmaster, treadmill, exercise biking
According to Brigham and Women’s Hospital Department of Rehabilitation Services, frequency and duration recommendations for a patient with an ankle sprain are 2x/week for 4-8 weeks (3x/week for first 2 weeks may be indicated for severe pain, swelling or functional impairment).1
1. Casby J. Standard of care: Ankle sprain. http://www.brighamandwomens.org/Patients_Visitors/pcs/RehabilitationServices/Physical%20Therapy%20Standards%20of%20Care%20and%20Protocols/Ankle-%20Ankle%20sprain.pdf. Published 2006. Updated 2010. Accessed 03/01, 2012.
2. American Physical Therapy Association. Guide to physical therapist practice. second edition. american physical therapy association. Phys Ther. 2001;81(1):9-746.
3. Dubin JC, Comeau D, McClelland RI, Dubin RA, Ferrel E. Lateral and syndesmotic ankle sprain injuries: A narrative literature review. J Chiropr Med. 2011;10(3):204-219. doi: 10.1016/j.jcm.2011.02.001.
4. Ivins D. Acute ankle sprain: An update. Am Fam Physician. 2006;74(10):1714-1720.
5. Pollard H, Sim P, McHardy A. Lateral ankle injury: Literature review and report of two cases. Australas Chiropr Osteopathy. 2002;10(1):21-30. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=17987171&site=ehost-live.
6. Chan KW, Ding BC, Mroczek KJ. Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Jt Dis. 2011;69(1):17-26. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=21332435&site=ehost-live.
7. Cohen RS, Balcom TA. Current treatment options for ankle injuries: Lateral ankle sprain, achilles tendonitis, and achilles rupture. Curr Sports Med Rep. 2003;2(5):251-254.
8. Puffer JC. The sprained ankle. Clin Cornerstone. 2001;3(5):38-49. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=11464730&site=ehost-live.
9. Polzer H, Kanz K, Prall W, et al. Diagnosis and treatment of acute ankle injuries: Development of an evidence-based algorithm. Orthop Rev. 2012;4(1):22-32.
10. Cameron M. Physical agents in rehabilitation: From research to practice. 3rd ed. Philadelphia, PA: Linda Duncan; 2009:134-139.
11. Bleakley CM, McDonough SM, MacAuley DC, Bjordal J. Cryotherapy for acute ankle sprains: A randomised controlled study of two different icing protocols. Br J Sports Med. 2006;40(8):700-5; discussion 705. doi: 10.1136/bjsm.2006.025932.
12. Zoch C, Fialka-Moser V, Quittan M. Rehabilitation of ligamentous ankle injuries: A review of recent studies. Br J Sports Med. 2003;37(4):291-295.
13. Shanks P, Curran M, Fletcher P, Thompson R. The effectiveness of therapeutic ultrasound for musculoskeletal conditions of the lower limb: A literature review. Foot (Edinb). 2010;20(4):133-139. doi: 10.1016/j.foot.2010.09.006.
14. Lin CC, Hiller CE, de Bie R,A. Evidence-based treatment for ankle injuries: A clinical perspective. J Man Manip Ther. 2010;18(1):22-28. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=21655420&site=ehost-live.
15. Man IO, Morrissey MC, Cywinski JK. Effect of neuromuscular electrical stimulation on ankle swelling in the early period after ankle sprain. Phys Ther. 2007;87(1):53-65. doi: 10.2522/ptj.20050244.
16. Kemler E, van dP, Backx F, van Dijk CN. A systematic review on the treatment of acute ankle sprain. Sports Medicine. 2011;41(3):185-197. http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=60905319&site=ehost-live.
17. Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001;81(4):984-994.
18. van der Wees PJ, Lenssen AF, Hendriks EJ, Stomp DJ, Dekker J, de Bie RA. Effectiveness of exercise therapy and manual mobilisation in ankle sprain and functional instability: A systematic review. Aust J Physiother. 2006;52(1):27-37.
19. Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of ankle sprains. Am Fam Physician. 2001;63(1):93-104.
20. Slimmon D, Brukner P. Sports ankle injuries - assessment and management. Aust Fam Physician. 2010;39(1-2):18-22. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=20369129&site=ehost-live.