Acute Ankle Sprain

with Phase II Rehab

ExitCare ImageAn acute ankle sprain is a partial or complete tear in one or more of the ligaments of the ankle due to traumatic injury. The severity of the injury depends on both the number of ligaments sprained and the grade of sprain. There are 3 grades of sprains.

  • A grade 1 sprain is a mild sprain. There is a slight pull without obvious tearing. There is no loss of strength, and the muscle and ligament are the correct length.

  • A grade 2 sprain is a moderate sprain. There is tearing of fibers within the substance of the ligament where it connects two bones or two cartilages. The length of the ligament is increased, and there is usually decreased strength.

  • A grade 3 sprain is a complete rupture of the ligament and is uncommon.

In addition to the grade of sprain, there are 3 types of ankle sprains.

ExitCare Image Lateral ankle sprains. This is a sprain of one or more of the 3 ligaments on the outer side (lateral) of the ankle. These are the most common sprains.

Medial ankle sprains. There is one large triangular ligament on the inner side (medial) of the ankle that is susceptible to injury. Medial ankle sprains are less common.

Syndesmosis, "high ankle," sprains. The syndesmosis is the ligament that connects the two bones of the lower leg. Syndesmosis sprains usually only occur with very severe ankle sprains.

SYMPTOMS

  • ExitCare ImagePain, tenderness, and swelling in the ankle, starting at the side of injury that may progress to the whole ankle and foot with time.

  • "Pop" or tearing sensation at the time of injury.

  • Bruising that may spread to the heel.

  • Impaired ability to walk soon after injury.

CAUSES

  • Acute ankle sprains are caused by trauma placed on the ankle that temporarily forces or pries the anklebone (talus) out of its normal socket.

  • Stretching or tearing of the ligaments that normally hold the joint in place (usually due to a twisting injury).

RISK INCREASES WITH:

  • Previous ankle sprain.

  • Sports in which the foot may land awkwardly (basketball, volleyball, soccer) or walking or running on uneven or rough surfaces.

  • Shoes with inadequate support to prevent sideways motion when stress occurs.

  • Poor strength and flexibility.

  • Poor balance skills.

  • Contact sports.

PREVENTION

  • Warm up and stretch properly before activity.

  • Maintain physical fitness:

  • Ankle and leg flexibility, muscle strength, and endurance.

  • Cardiovascular fitness.

  • Balance training activities.

  • Use proper technique and have a coach correct improper technique.

  • Taping, protective strapping, bracing, or high-top tennis shoes may help prevent injury. Initially, tape is best. However, it loses most of its support function within 10 to 15 minutes.

  • Wear proper fitted protective shoes. Combining high-top shoes with taping or bracing is more effective than using either alone.

  • Provide the ankle with support during sports and practice activities for 12 months following injury.

PROGNOSIS

  • If treated properly, ankle sprains can be expected to recover completely. However, the length of recovery depends on the degree of injury.

  • A grade 1 sprain usually heals enough in 5 to 7 days to allow modified activity and requires an average of 6 weeks to heal completely.

  • A grade 2 sprain requires 6 to 10 weeks to heal completely.

  • A grade 3 sprain requires 12 to 16 weeks to heal.

  • A syndesmosis sprain often takes more than 3 months to heal.

RELATED COMPLICATIONS

  • Frequent recurrence of symptoms may result in a chronic problem. Appropriately addressing the problem the first time decreases the frequency of recurrence and optimizes healing time. Severity of initial sprain does not predict the likelihood of later instability.

  • Injury to other structures (bone, cartilage, or tendon).

  • Chronically unstable or arthritic ankle joint are possible with repeated sprains.

TREATMENT

Treatment initially involves the use of ice, medicine, and compression bandages to help reduce pain and inflammation. Ankle sprains are usually immobilized in a walking cast or boot to allow for healing. Crutches may be recommended to reduce pressure on the injury. After immobilization, strengthening and stretching exercises may be necessary to regain strength and a full range of motion. Surgery is rarely needed to treat ankle sprains.

MEDICATION

  • Nonsteroidal anti-inflammatory medicines, such as aspirin and ibuprofen (do not take for the first 3 days after injury or within 7 days before surgery), or other minor pain relievers, such as acetaminophen, are often recommended. Take these as directed by your caregiver. Contact your caregiver immediately if any bleeding, stomach upset, or signs of an allergic reaction occur from these medicines.

  • Ointments applied to the skin may be helpful.

  • Pain relievers may be prescribed as necessary by your caregiver. Do not take prescription pain medicine for longer than 4 to 7 days. Use only as directed and only as much as you need.

HEAT AND COLD

  • Cold treatment (icing) is used to relieve pain and reduce inflammation for acute and chronic cases. Cold should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or an ice massage.

  • Heat treatment may be used before performing stretching and strengthening activities prescribed by your caregiver. Use a heat pack or a warm soak.

SEEK IMMEDIATE MEDICAL CARE IF:

  • Pain, swelling, or bruising worsens despite treatment.

  • You experience pain, numbness, discoloration, or coldness in the foot or toes.

  • New, unexplained symptoms develop. (Drugs used in treatment may produce side effects.)

EXERCISES

PHASE II EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Ankle Sprain, Acute-Phase II, Weeks 3 to 4

After your physician, physical therapist, or athletic trainer feels your knee has made progress significant enough to begin more advanced exercises, he or she may recommend completing some of the following exercises. Although each person heals at different rates, most people will be ready for these exercises between 3 and 4 weeks after their injury. Do not begin these exercises until you have your caregiver's permission. He or she may also advise you to continue with the exercises which you completed in Phase I of your rehabilitation. While completing these exercises, remember:

  • Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

  • An effective stretch should be held for at least 30 seconds.

  • A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue.

ExitCare Image RANGE OF MOTION - Ankle Plantar Flexion

  • Sit with your right / left leg crossed over your opposite knee.

  • Use your opposite hand to pull the top of your foot and toes toward you.

  • You should feel a gentle stretch on the top of your foot/ankle. Hold this position for __________.

Repeat __________ times. Complete __________ times per day.

ExitCare Image RANGE OF MOTION - Ankle Eversion

  • Sit with your right / left ankle crossed over your opposite knee.

  • Grip your foot with your opposite hand, placing your thumb on the top of your foot and your fingers across the bottom of your foot.

  • Gently push your foot downward with a slight rotation so your littlest toes rise slightly

  • You should feel a gentle stretch on the inside of your ankle. Hold the stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image RANGE OF MOTION - Ankle Inversion

  • Sit with your right / left ankle crossed over your opposite knee.

  • Grip your foot with your opposite hand, placing your thumb on the bottom of your foot and your fingers across the top of your foot.

  • Gently pull your foot so the smallest toe comes toward you and your thumb pushes the inside of the ball of your foot away from you.

  • You should feel a gentle stretch on the outside of your ankle. Hold the stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRETCH - Gastrocsoleus

  • Sit with your right / left leg extended. Holding onto both ends of a belt or towel, loop it around the ball of your foot.

  • Keeping your right / left ankle and foot relaxed and your knee straight, pull your foot and ankle toward you using the belt/towel.

  • You should feel a gentle stretch behind your calf or knee. Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

ExitCare Image RANGE OF MOTION - Ankle Dorsiflexion, Active Assisted

  • Remove shoes and sit on a chair that is preferably not on a carpeted surface.

  • Place right / left foot under knee. Extend your opposite leg for support.

  • Keeping your heel down, slide your right / left foot back toward the chair until you feel a stretch at your ankle or calf. If you do not feel a stretch, slide your bottom forward to the edge of the chair while still keeping your heel down.

  • Hold this stretch for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

ExitCare Image STRETCH – Gastroc, Standing

  • Place hands on wall.

  • Extend right / left leg and place a folded washcloth under the arch of your foot for support. Keep the front knee somewhat bent.

  • Slightly point your toes inward on your back foot.

  • Keeping your right / left heel on the floor and your knee straight, shift your weight toward the wall, not allowing your back to arch.

  • You should feel a gentle stretch in the calf. Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

ExitCare Image STRETCH – Soleus, Standing

  • Place hands on wall.

  • Extend right / left leg and place a folded washcloth under the arch of your foot for support. Keep the front knee somewhat bent.

  • Slightly point your toes inward on your back foot.

  • Keep your right / left heel on the floor, bend your back knee, and slightly shift your weight over the back leg so that you feel a gentle stretch deep in your back calf.

  • Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

ExitCare Image STRETCH – Gastrocsoleus, Standing

Note: This exercise can place a lot of stress on your foot and ankle. Please complete this exercise only if specifically instructed by your caregiver.

  • Place the ball of your right / left foot on a step, keeping your other foot firmly on the same step.

  • Hold on to the wall or a rail for balance.

  • Slowly lift your other foot, allowing your body weight to press your heel down over the edge of the step.

  • You should feel a stretch in your right / left calf.

  • Hold this position for __________ seconds.

  • Repeat this exercise with a slight bend in your knee.

Repeat __________ times. Complete this stretch __________ times per day.

STRENGTHENING EXERCISES - Ankle Sprain, Acute-Phase II

Around 3 to 4 weeks after your injury, you may progress to some of these exercises in your rehabilitation program. Do not begin these until you have your caregiver's permission. Although your condition has improved, the Phase I exercises will continue to be helpful and you may continue to complete them. As you complete strengthening exercises, remember:

  • Strong muscles with good endurance tolerate stress better.

  • Do the exercises as initially prescribed by your caregiver. Progress slowly with each exercise, gradually increasing the number of repetitions and weight used under his or her guidance.

  • You may experience muscle soreness or fatigue, but the pain or discomfort you are trying to eliminate should never worsen during these exercises. If this pain does worsen, stop and make certain you are following the directions exactly. If the pain is still present after adjustments, discontinue the exercise until you can discuss the trouble with your caregiver.

ExitCare Image STRENGTH - Plantar-flexors, Standing

  • Stand with your feet shoulder width apart. Steady yourself with a wall or table using as little support as needed.

  • Keeping your weight evenly spread over the width of your feet, rise up on your toes.*

  • Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

*If this is too easy, shift your weight toward your right / left leg until you feel challenged. Ultimately, you may be asked to do this exercise with your right / left foot only.

ExitCare Image STRENGTH – Dorsiflexors and Plantar-flexors, Heel/toe Walking

  • Dorsiflexion: Walk on your heels only. Keep your toes as high as possible.

  • Walk for ____________________ seconds/feet.

  • Repeat __________ times. Complete __________ times per day.

  • Plantar flexion: Walk on your toes only. Keep your heels as high as possible.

  • Walk for ____________________ seconds/feet.

Repeat __________ times. Complete __________ times per day.

ExitCare Image BALANCE – Tandem Walking

  • Place your uninjured foot on a line 2 to 4 inches wide and at least 10 feet long.

  • Keeping your balance without using anything for extra support, place your right / left heel directly in front of your other foot.

  • Slowly raise your back foot up, lifting from the heel to the toes, and place it directly in front of the right / left foot.

  • Continue to walk along the line slowly. Walk for ____________________ feet.

Repeat ____________________ times. Complete ____________________ times per day.

ExitCare Image BALANCE - Inversion/Eversion

Use caution, these are advanced level exercises. Do not begin them until you are advised to do so.

  • Create a balance board using a sturdy board about 1 ½ feet long and at 1 to 1 ½ feet wide and a 1 ½ inch diameter rod or pipe that is as long as the board's width. A copper pipe or a solid broomstick work well.

  • Stand on a non-carpeted surface near a countertop or wall. Step onto the board so that your feet are hip-width apart and equally straddle the rod/pipe.

  • Keeping your feet in place, complete these two exercises without shifting your upper body or hips:

  • Tip the board from side-to-side. Control the movement so the board does not forcefully strike the ground. The board should silently tap the ground.

  • Tip the board side-to-side without striking the ground. Occasionally pause and maintain a steady position at various points.

  • Repeat the first two exercises, but use only your right / left foot. Place your right / left foot directly over the rod/pipe.

Repeat __________ times. Complete this exercise __________ times a day.

ExitCare Image BALANCE - Plantar/Dorsi Flexion

Use caution, these are advanced level exercises. Do not begin them until you are advised to do so.

  • Create a balance board using a sturdy board about 1 ½ feet long and at 1 to 1 ½ feet wide and a 1 ½ inch diameter rod or pipe that is as long as the board's width. A copper pipe or a solid broomstick work well.

  • Stand on a non-carpeted surface near a countertop or wall. Stand on the board so that the rod/pipe runs under the arches in your feet.

  • Keeping your feet in place, complete these two exercises without shifting your upper body or hips:

  • Tip the board from side-to-side. Control the movement so the board does not forcefully strike the ground. The board should silently tap the ground.

  • Tip the board side-to-side without striking the ground. Occasionally pause and maintain a steady position at various points.

  • Repeat the first two exercises, but use only your right / left foot. Stand in the center of the board.

Repeat __________ times. Complete this exercise __________ times a day.

ExitCare Image STRENGTH – Plantar-flexors, Eccentric

Note: This exercise can place a lot of stress on your foot and ankle. Please complete this exercise only if specifically instructed by your caregiver.

  • Place the balls of your feet on a step. With your hands, use only enough support from a wall or rail to keep your balance.

  • Keep your knees straight and rise up on your toes.

  • Slowly shift your weight entirely to your toes and pick up your opposite foot. Gently and with controlled movement, lower your weight through your right / left foot so that your heel drops below the level of the step. You will feel a slight stretch in the back of your calf at the ending position.

  • Use the healthy leg to help rise up onto the balls of both feet, then lower weight only on the right / left leg again. Build up to 15 repetitions. Then progress to 3 consecutive sets of 15 repetitions.*

  • After completing the above exercise, complete the same exercise with a slight knee bend (about 30 degrees). Again, build up to 15 repetitions. Then progress to 3 consecutive sets of 15 repetitions.*

Perform this exercise __________ times per day.

*When you easily complete 3 sets of 15, your physician, physical therapist, or athletic trainer may advise you to add resistance by wearing a backpack filled with additional weight.