Evidence Based Protocols for Therapeutic Intervention Ankle Sprain Description: Acute injury to ankle, most commonly resulting from forced inversion mechanism. It frequently involves one or more lateral ligaments. More severe injuries might include involvement of medial (deltoid) ligament or avulsion fracture of fifth metatarsal. Three grades of ankle sprains: Grade I (First Degree) sprain is the most common and requires the least amount of treatment and recovery. The ligament damage has occurred without any significant instability developing. Grade II (Second Degree) injury is more severe and indicates that the ligament has been more significantly damaged, but there is no significant instability. Grade III (Third Degree) sprain is the most severe. This suggests that the ligaments have been torn, and that instability has resulted. Overview: Rehabilitation for an ankle sprain starts with the RICE principle (Rest, Ice, Compression, Elevation). The severity of the sprain determines the speed of recovery. Maintaining range of motion and reducing swelling are two keys to early rehab. As pain decreases we must start strengthening to help protect the ligaments that have been stretched. Balance exercises will then be initiated in order to help get feedback from the ligaments, tendons, and muscles. When range of motion, strength, and balance are “back to normal” you will be able to return to your normal activities. Levels of Evidence All studies are categorized using the: Oxford Centre for Evidence-based Medicine Levels of Evidence as summarized below. Levels of Evidence Level I (*L1*) Evidence obtained from high-quality randomized controlled trials, prospective studies, or diagnostic studies Level II (*L2*) Evidence obtained from lesser-quality randomized controlled trials, prospective studies, or diagnostic studies (improper randomization, no blinding >80% follow-up) Level III (*L3*) Case controlled studies or retrospective studies Level IV (*L4*) Case series Level V (*L5*) Expert Opinion Phases of Healing: Evidence Based Protocol for Progression of Activities Inflammatory Phase (0-3 days) Phase I Goals Reduce pain and swelling Improve circulation Promotion of partial to full weight bearing Weight Bearing WB as tolerated Crutches may be used if necessary Exercise (Van der Wees et al, 20061) Early mobilization (DF/PF, ABC’s/circumduction) *L2* Bracing (Kerkhoffs et al, 20022) Apply compression bandage to reduce swelling *L1* Ice and Elevation (Bleakley et al 20043) Ice frequently during first 48 hours avoid heat • 15-20 minutes every 2 hours Elevate to reduce swelling *L2* Criteria to Start Phase II No pain at rest Proliferation Phase (4-10 days) Phase II Goals Restore function and activities Improve load-bearing capacities Prevent increase in inflammation Prevent muscle atrophy Weight Bearing Stimulate symmetrical WB Instruct on heel-toe walking Exercise Strength (Blackburn et al 20004, Kannus et al 19925, Tropp et al 19856, Uh et al 20007, Wojtys et al 19968) • Foot intrinsics • Isometrics→Concentrics ♦ Sub-max→max ♦ Pain free • Lower extremity strengthening ♦ Quads, Hamstrings, etc Proprioception (Stomp et al 20059, Van der Wees1 et al 2006, Verhagen et al 200010) • BAPS board ♦ Non WB→full WB • Single leg stance ♦ Even surface as tolerated ROM (Van der Wees et al 20061) • Seated calf stretching • PNF patterns • AROM in all planes ♦ Alphabets Bracing (Kerkhoffs et al, 20022) Continue elastic bandaging, bracing, or taping Criteria to Start Phase III Full WB No increased edema with activity Normal gait pattern *L3* *L2* *L2* *L1* Early Remodeling Phase (11-21 days) Goals Improve muscle strength, ROM, and functional stability Phase III Weight bearing Full increasing stress Exercise (Bahr et al. 199712 Heidt et al. 200013, Holme et al. 199914, Söderman et al. 199115) Strength (Blackburn et al 20004, Kannus et al 19925, Tropp et al 19856, Uh et al 20007, Wojtys et al 19968) ♦ Continue progressing ex as tolerated ♦ Initiate eccentric ex ♦ Toe Walks Neutral→Inversion→Eversion ♦ Heel raises ♦ Toe raises ♦ Squats Proprioception (Stomp et al 20059, Van der Wees1 et al 2006, Verhagen et al 200010) • Progress to uneven surfaces ♦ Airex ♦ Dyna Disc ♦ Single plane balance board ♦ Single leg rebounder drills ROM (Van der Wees et al 20061) • Stretching ♦ Standing calf • Mobilizations ♦ Ant/post mobs for Dorsiflexion Bracing (Handoll et al 200111, Stomp et al 20059, Verhagen et al 200010) Tape or brace for sports or other strenuous activities Criteria to Start Phase IV No increased edema with activity Ability to balance on injured leg for 60 seconds Full AROM Ability to jog without pain *L3* *L3* *L2* *L2* *L3* *L1* Phase IV Late Remodeling Phase (3-6 weeks) Goals Increase load bearing capacity Improve balance and coordination Improve strength Weight bearing Increase so capacity equals usual loads performed prior to injury Jumping/hopping drills Exercise (Bahr et al. 199712 Heidt et al. 200013, Holme et al. 199914, Söderman et al. 199115) Continue progressing ex as above Static→dynamic Simple→functional Bracing (Handoll et al 200111, Stomp et al 20059, Verhagen et al 200010) Tape or Brace for Sports *L3* *L1* Criteria to Start Phase V No increased edema with exercise Single leg hop test on injured leg 80% of non-injured leg 5/5 strength in all motions of the ankle Ability to run in a straight line with normal gait pattern Phase V Return to Sport Goals Achieve required load bearing capacity Design sport specific treatment and training program Weight bearing Continue until load bearing capacity pre-injury capacity attained Agility drills Exercise Work with Coach/ATC to develop training program Continue sport specific strengthening References 1. Van der Wees PhJ, Lenssen AF, Hendriks HJM, Stomp DJ, Dekker J, de Bie RA. Effectiveness of exercise therapy and manual mobilization in acute ankle sprain and functional instability: a systematic review. Aust J Physiother 2006;52:27-37. 2. Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly K, Struijs PA, van Dijk CN. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev 2002;(3):CD003762 3. Bleakley C, McDonough S, MacAuley D, The Use of Ice in the Treatment of an Acute Soft Tissue Injury. Am J Sport Med 2004; 32; 251-261 4. Blackburn T, Guskiewicz KM, Petschauer MA, Prentice WE. Balance and joint stability: The relative contributions of proprioception and muscular strength. J Sport Rehab 2000;9:315-28. 5. Kannus P, Alosa D, Cook L, Johnson RJ, Renstrom P, Pope M, et al. Effect of onelegged exercise on the strength, power and endurance of the contralateral leg. A randomized, controlled study using isometric and concentric isokinetic training. Eur J Appl Physiol Occup Physiol 1992;64(2):117-26. 6. Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med 1985;13:259-62. 7. Uh BS, Beynnon BD, Helie BV, Alosa DM, Renstrom PA. The benefit of a singleleg strength training program for the muscles around the untrained ankle. Am J Sports Med 2000 Jul;28(4):568-73. 8. Wojtys EM, Wylie BB, Huston LJ. The effects of muscle fatigue on neuromuscular function and anterior tibial translation in healthy knees. Am J Sports Med 1996 Sep;24(5):615-21. 9. Stomp DJ, Hendriks HJM, Heemskerk MAMB, van der Wees PJ, de Bie RA. Effectiviteit van fysiotherapie bij patiënten met chronische functionele instabiliteit van de enkel: een systematisch literatuuroverzicht. Ned Tijdschr Fysiother 2005;115(2):26-31. 10. Verhagen EALM, van Mechelen W, de Vente W. The effect of preventive measures on the incidence of ankle sprains. Clin J Sports Med 2000;10(4):2916. 11. Handoll HHG, Rowe BH, Quinn KM, De Bie R. Interventions for preventing ankle ligament injuries. The Cochrane Library 2001. 12. Bahr R, Lian O, Bahr IA. A twofold reduction in the incidence of acute ankle sprains in volleyball after the introduction of an injury prevention program: a prospective cohort study. Scand J Med Sci Sports 1997;7:172-7. 13. Heidt RS, Jr., Sweeterman LM, Carlonas RL, Traub JA, Tekulve FX. Avoidance of soccer injuries with preseason conditioning. Am J Sports Med 2000 Sep;28(5):659-62. 14. Holme E, Magnusson SP, Becher K, Bieler T, Aagaard P, Kjaer M. The effect of supervised rehabilitation on strength, postural sway, position sense and reinjury risk after acute ankle ligament sprain. Scand J Med Sci Sports 1999 Apr;9(2):104-9. 15. Soderman K, Werner S, Pietila T, Engstrom B, Alfredson H. Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? A prospective randomized intervention study. Knee Surg Sports Traumatol Arthrosc 2000;8(6):356-63.