Summary of the Condition
Medial Ankle Sprain is an injury caused by an eversion trauma. Eversion trauma an occur from running downstairs, landing on uneven surfaces, or other activities involving rotation.1 Medial ankle sprains typically present with varying degrees. First degree sprains involve a partial tear to the medial ligaments. Second degree sprains involve a incomplete tear with moderate functional impairment to the medial ligaments. Last third degree sprains involving complete rupture of the deltoid ligaments or avulsion fracture of the medial epicondyle of the ankle and can occur with or without a syndesmosis injury.2
First and second degree sprains are typically managed with conservative treatment. Early stages of conservative treatment include RICE (rest, ice, compress, elevate) and mobilization to prevent range of motion loss. Once pain and inflammation are controlled, range of motion, stability, strength, proprioception and function can be increased through therapeutic exercise.2
Surgical treatment can involve suturing the ligaments in place, bone tendon bone grafts, or other procedures that resolve the structural damage. Post surgery the ankle is immobilized for 6 weeks. Following the immobilization from either conservative or surgical treatment for medial ankle sprains, impairments in range of motion, stability, strength, proprioception, and function are common. There may also be pain or edema which should be treated first.1,3
Guide to Physical Therapy Practice and Suggested Management4
The Guide to Physical Therapy Practice describes several diagnosis and treatment patterns. Medial ankle sprains have many different presentations depending on the degree, and can include soft tissue injury, ligamentous injury, syndesmosis injury and fractures. There are several impairment patterns that medial ankle sprains may present with. The following are the primary patterns related to medial ankle sprains.
• Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
• Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation
• Pattern 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery
Symptom Management
Initial treatment for medial ankle sprains includes symptom management for pain, inflammation and prevention of range of motion loss through range of motion exercises. Pain can be treated through application of cryotherapy. Edema can be treated with cryotherapy, elevation, and compression bandages. Active range of motion exercises such as ankle pumps can help to remove edema from the ankle. Range of motion can be maintained with active and passive range of motion exercises. 2
• Cryotherapy: Therapeutic ice can be applied with a thin cloth covering. The foot and ankle should be cooled for 20 minutes every 2 to 3 hours for the first 2 days post injury, until edema and inflammation are controlled, or to control inflammation post therapeutic exercise. Benefits are reduced pain, edema, and metabolism (to prevent hypoxic injury). Research showed that cryotherapy can help to reduce pain and swelling after injury.5
• Compression Bandage: Compression bandages can be applied to drain fluids away from the ankle. This should be applied starting distally to proximally going up just below the knee and should follow a figure 8 pattern which aids conformity. This should be applied to reduce any edema post injury or post therapeutic exercise. Research showed that with both compression and elevation, there was a temporary decrease in ankle swelling that lasted up to five minutes after return to gravity dependent position. Compression may also lead to discomfort and the need to analgesics.5
• Range of motion: It is important to begin range of motion exercises within pain free range as soon as possible. Active and passive range of motion exercises should be used to maintain range of motion for optimal function.
o Alphabet exercises: Move the ankle in all ranges of motion. Motions can emulate letters to help with adherence to the protocol.
• Ultrasound: There is no convincing evidence supporting the use of ultrasound for the treatment of ankle sprains. A literary review did not support the use of ultrasound for the treatment of acute ankle sprains. Findings implied that ultrasound was not significantly different from sham treatment in all placebo controlled trials reviewed. The average difference between treatments was from 0-6%.6
Joint Mobility
Once pain and inflammation are under control, proper range of motion must be restored. This can be done through stretching to increase range of motion or joint mobilizations.2 Proper range of motion should be restored before beginning training in stabilization, strength, proprioception and function.
• Ankle Stretches (dorsiflexion, inversion): Pain free stretch should be held for 15 to 30 seconds for five repetitions every day. Ankle stretches can be performed in weight bearing positions, or non weight bearing position with the use of a stretch rope. Passive ankle ROM stretches can also be performed by a therapist. It is important to begin ankle dorsiflexion stretches early due to the Achilles tendons tendency to contract following injury.2
• Joint mobilizations (anterior-posterior): Mobilization into restricted planes can help to regain lost range of motion. Research showed that mobilization in the anterior-posterior direction with RICE decreased the number of treatment sessions to acquire pain free dorsiflexion range of motion and stride speed improvements when compared to RICE alone.7
Joint Stabilization
Stabilization of the ankle joint should begin once full range of motion is achieved. Stabilization is achieved through muscle strengthening exercises, balance, and proprioception exercises.2
• Isometric Exercises: Resistance can be provided by an immovable object (wall or floor), elastic bands, or manual resistance. Exercises should be held for at least 6 seconds for maximal contraction, 10 repetitions and 3 sets daily. Exercise can be performed in dorsiflexion, plantarflexion, eversion, inversion, and eventually diagonals.
• Isotonic Exercises: Resistance can be provided by weights, theraband, or gravity. Exercises should be performed for 10-20 reps, 2-3 sets and up to 2 times a day depending on intensity. Each repetition should include concentric component and slow eccentric component. Exercises include plantarflexion push downward, dorsiflexion push upward, eversion and inversion.
• Motor Control Exercises: Some exercises include towel curls, and marble pickups. Exercises can be performed for 10-20 reps seconds at a time and 2-3 sets. Towel curls are performed by placing a damp towel on the floor and using the toes to curl and pull the towel towards the patient. Marble picks ups are performed by placing marbles on the ground and using the toes to pick them up and place them in a container.
• Proprioception training: is important to regain lost balance and prevent future ankle sprains. Equipment for training proprioception include wobble boards, hemispheres, balance pads or on flat ground. Once balance is established, proprioceptive training can be progressed by closing eyes, narrowing base of support, or other modifications. Once stance can be held for at least 30 seconds training can be progressed. Research showed that a home exercise program focusing on proprioception was effective in reducing the incidence of recurrent ankle sprains in athletes. The home exercise program included progression of balance exercises.8
- Balance on even surface
- Balance with eyes closed
- Balance on balance board
- High surface Balance
- High surface with eyes closed
- High surface on balance board
- Walking
- Jumping
Functional Training
Functional training should begin before return to previous activities. Functional training exercises should be designed to prepare the patient for specific activities such as walking, jogging, running, or recreational activities. Patients training for return to sport typically consult certified athletic trainers or sports physical therapists for sport re-entry training. Return to higher level activity should be controlled to avoid reinjury.2
Functional training examples:
- Gait Training
- Walk-Jog
- Jog-Run
- Single Leg Stance
- Lunges
- Dynamic Balance Training
References
1. Hintermann B, Knupp M, Pagenstert GI. Deltoid Ligament Injuries: diagnosis and management. Foot and ankle clinics. 2006;11(3):625. Available at: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:This+material+may+be+protected+by+copyright+law.+(Title+17+U.S.+Code).#0. Accessed November 26, 2011.
2. Wolfe MW, Uhl TL, McCluskey LC. Management of ankle sprains. American Family Physician. 2001;63(1):91-105. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19427949.
3. Hintermann B. Medial ankle instability. Foot and ankle clinics. 2003;8:723. Available at: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:This+material+may+be+protected+by+copyright+law.+(Title+17+U.S.+Code).#0. Accessed November 26, 2011.
4. (1921-)APTA. Guide to physical therapist practice. 1997. Available at: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Guide+to+Physical+Therapy+Practice#1. Accessed March 9, 2012.
5. Fong DT, Chan Y-Y, Mok K-M, Yung PS, Chan K-M. Understanding acute ankle ligamentous sprain injury in sports. Sports medicine, arthroscopy, rehabilitation, therapy & technology : SMARTT. 2009;1:14. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2724472&tool=pmcentrez&rendertype=abstract. Accessed August 18, 2011.
6. Van der Windt D, Van der Heijden G, Van den Berg S, et al. Therapeutic ultrasound for acute ankle sprains. Cochrane Database Systc Rev. 2002;1. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001250/pdf/standard. Accessed March 9, 2012.
7. Green T, Crosbie J. A Randomized Controlled Trial of a Passive Accessory Joint Mobilization. 2001;81(4).
8. Hupperets MDW, Verhagen E a LM, Mechelen WV. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. Bmj. 2009;339(jul09 1):b2684-b2684. Available at: http://www.bmj.com/cgi/doi/10.1136/bmj.b2684. Accessed March 10, 2012.
