Chronic Ankle Sprain by Jon Tobey
Chronic Ankle Sprain by Jon Tobey
Chronic Ankle Sprain by Jon Tobey
Chronic Ankle Sprain by Jon Tobey
A chronic ankle sprain is one of the most common musculoskeletal injuries that can occur in people of all ages and is caused by many different events. Ankle sprains are often seen in sports and can be caused by landing on a surface awkwardly, twisting the ankle the wrong way or any type of action that suddenly forces the ankle out of its normal position. (Smith, 2003) Even a sudden misstep can cause an ankle sprain. The most common type of ankle sprain is caused by an inversion stress, this could result in a tear of the anterior talofibular ligament. (Colby & Kisner, 576) Ankle sprains should be taken seriously when it causes pain and swelling of the ankle, if the ankle does not heal properly the patient could lose their range of motion and stability, causing more frequent sprains.
There are several different types of ankle sprains, the most common type is when the anterior talofibular ligament is torn due to an inversion stress. When the posterior talofibular ligament is torn this is usually due to a massive inversion stresses. (Colby & Kisner, 576) When the foot rolls inward this damages the ligaments on the outer ankle including the anterior and posterior talofibular ligament and the calcaneofibular ligament. Ankle sprains that are less common are medial ankle sprains, and syndesmotic sprains, which both affect the inner ankle. These two sprains injure the tibiofibular ligaments, which attatch the tibia and fibula. Syndesmotic sprains usually occur in contact sports and usually will cause chronic ankle instability and sprains. (Recovering Ankle Sprain, 2007)
When a person sprains their ankle they will usually know immediately. They will feel pain at the site at which the sprain has occurred and the sprained ankle often swells immediately and may develop bruising. Depending on how serious the sprain is the individual may not be able to bear any weight on the sprained ankle and the ankle may feel unstable. A sign of a chronic ankle sprain is when the individual hears or feels a popping or snapping sensation when the injury occurs. (WebMD Ankle Sprain) The individual will also lose range of motion in the ankle injured, and a proprioceptive deficit is manifested as decreased ability to perceive passive motion and development of balance impairments. (Colby & Kisner, 576)
When a patient sprains their ankle they will usually use a protective brace to support the ankle for the first 24 to 36 hours. The patient will rest their ankle and crutches will be used to take pressure off ankle while walking until there is no pain in the ankle when walking. Ice will be recommended for the first 24 to 72 hours to keep the swelling down. Nonsteroidal anti-inflammatory drugs including ibuprofen, naproxen and acetaminophen drugs including Tylenol will be used to reduce the swelling and decrease the pain. A compression wrap should also be work for the first 24 to 36 hours to help decrease the swelling. These techniques will be used and the sprained ankle will usually heal on its own. If the ligament tear is severe or ankle remains unstable after rehabilitation then surgery will be used to repair the torn ligament. (WebMD treatments)
There are several open and arthroscopic methods that can be used to repair the torn ligament. These include the modified Brostrom, Chrisman-Snook, Evans and Watson-Jones procedures. (Colby & Kisner, 577) A direct end to end suturing combined with a imbrication of lax ligaments may be used during the procedure as a double layer of reinforcement. Stability will be repaired by pulling the fascia of the extensor retinaculum proximally over the repaired structures and suturing it to the fibula. After the arthroscopy has been performed a vertical incision is made at the lateral aspect of the ankle. This is to repair and reinforce torn or ruptured structures that could cause associated joint pathology. (Colby & Kisner, 578)
After surgical intervention a rehabilitation program will be needed to regain strength, stability and range of motion in the injured ankle. During the first 1 to 2 weeks after surgery a walking cast is used to progressively begin weight bearing exercise. This cast is removed at 3 to 4 weeks and replaced with an air splint or ankle brace for an additional 4 to 8 weeks. The patient will be involved in two exercise phases. The maximum protection phase and the moderate and minimum protection phase. During the maximum protection phase the patient will focus on resistive exercises involving the hip and knee musculature to maintain strength in the lower extremity. Pain free muscle setting techniques of the ankle musculature will be used during this phase. The patient will also begin to perform dorsiflexion and planterflexion motions to regain range of motion once the immobilizer has been removed. Once the patient is able to bear weight on the ankle with immobilizer they will begin to perform mini-squats to strengthen the lower extremities. (Colby & Kisner, 578)
The moderate protection phase usually begins around 6 to 8 weeks postoperatively and the minimum protection phase usually begins 12 to 18 weeks postoperatively or when the strength of the ankle musculature reaches 80 to 90% of the non-injured ankle. During these phases the patient will begin to increase the strength of the ankle in both open and closed chained positions. The will work on regaining neuromuscular control, balance and stability, and continue ankle range of motion exercises. Self-stretching exercises will be added to their program to increase flexibility along with cardiovascular exercises like swimming, bicycling to improve muscular and cardiovascular endurance. Last closed chain functional activities will be added to the routine to improve a client's full functional capabilities on the injured ankle.
Chronic Ankle Sprain Exercises
When the patient has regained pain free range of motion in their ankle they will then begin to work on their cardiovascular endurance. They need to begin with non-impact types of cardiovascular exercises and then progress to low impact cardiovascular exercises.
A) Water walking: 20-30 minutes. 2x a week. This will increase the patient's cardiovascular endurance while performing a very low impact exercise in the pool. It will also help cushion the joints in the ankle and allow the patient to work on the ankles stability.
B) Recumbent bike: 20-30 minutes. 1-2x a week. The recumbent bike will allow the patient to regain dorsi and plantar flexion in the ankle and also work on the cardiovascular system with no impact on the ankle joint. This will allow for improvement in endurance without the risk of re-injury.
The patient will be involved in flexibility exercises to regain range of motion that may have been lost due to the disuse of the ankle. Without proper stretching exercises the patient will not regain full range of motion in the injured ankle. The patient will need to work on dorsiflexion, inversion, plantar flexion and eversion to regain flexibility and full range of the joint in order to prevent a future sprain.
A) Dorsiflexion Stretch: This will stretch the gastrocnemius and the soleus of the lower leg. Have the patient put one foot forward, while keeping the other foot in back with the heel on the floor. Keeping the knee of the back leg extended, have the client push off a wall and shift all their body weight forward putting the stretch in the back leg. Hold 20 seconds, 2 sets. (Colby & Kisner, 584)
B) Inversion Stretch: The patient will be long sitting with a towel or belt under the foot. The patient will then pull on the medial side of the towel causing the heel and foot to turn inward. Hold 20 seconds, 2 sets. (Colby & Kisner, 582)
C) Plantar Flexion Stretch: This will stretch the tibialis anterior of the lower leg. With the patient long sitting, they will attach tubing to a fixed object and then to the tip of their foot. They will then move back until the tubing is tight pulling the tip of the foot toward the floor. Hold 20 seconds, 2 sets. (Colby & Kisner, 584)
Once the patient is beginning to regain range of motion in their ankle without pain, they will begin strengthening exercises. These exercises will help them improve strength and muscular endurance along with improving coordination in the injured ankle. Exercises working the gastrocnemius, soleus and tibialis anterior will be included in the strength training plan.
A) Plantar Flexion with Tubing: With the patient long sitting and the injured leg resting on a rolled towel they will begin to elevate their heel off the ground and pull the tubing wrapped around their foot tight. The patient will then hold both ends of the tubing and have the patient perform plantar flexion against the tubing resistance. 12-15 reps, 2 sets. (Colby & Kisner, 584)
B) Isometric Inversion: With the patient long sitting, they will put the medial sides of the feet together and press the medial borders of the feet against each other. Hold 10 seconds, 5 reps, 2 sets. (Colby & Kisner, 584)
C) Dorsi Flexion with Tubing: With the patient long sitting and the injured leg resting on a rolled towel they will elevate their heel off the ground. They will then tie elasticized material to a fixed object and put the other end at the top of the foot. The patient will then perform dorsi flexion against the tubing resistance. 12-15 reps, 2 sets. (Colby & Kisner, 585)
D) Eversion with Elastic tubing: With the patient long sitting, have the patient place a loop of tubing around both feet and have them evert both of their feet against the resistance of the tubing while keeping the knees still. 12-15 reps, 2 sets. (Colby & Kisner, 585)
E) Adduction with Inversion: With the patient sitting with their foot on the floor. Place a towel under the front foot and a weight at the end of the towel on the lateral side of the leg. Then have the patient pull the weight medially along the floor. 5 reps, 2 sets. (Colby & Kisner, 585)
The last phase that will be added to a patients program is a functional program will improve their balance, coordination and allow them to be involved in regular activity with less risk of re-injury. During this phase the client will work on different weight bearing exercises which will challenge their coordination, strength, balance and function of the injured ankle joint.
A) Ankle Stabilization Exercise: With the patient standing and maintaining a tight core and upright posture they will hold on to a wooden dowel with both hands. The therapist will then apply resistance to the rod in several different directions, intensities and speeds, while the patient remains stable. (Colby & Kisner, 586)
B) Balance Board Exercise: The patient will be standing on a balance board and will begin by holding on to a wall or parallel bars. The patient will then maintain their balance without letting the board hit the ground. The patient will also begin with both feet and progress to one foot. (Colby & Kisner, 586)
C) Resisted Walking: Have the patient walk on their heels and on their toes against resistance, apply the resistance against the patient's pelvis by using tubing. The resistance should be applied in all directions to work on full stability of the ankle. (Colby & Kisner, 586)
In order for the patient to prevent future complications they need to understand the proper techniques and ways to progress their ankle. If the ankle is not progressed properly after a sprain it is likely that it will lose range of motion and strength and eventually will be sprained again. The patient should be sure to use taping or an ACE bandage when involved in activities that involve fast foot work and increased impact on the ankle joint. The patient should continue to work on their functional program to provide an increased level of stability in their ankle. The patient should also hire a certified personal trainer to make sure that they are progressing at a steady rate and that they are not involved in activities or exercises that will provoke a future ankle sprain. For more information go tohttp://jontobeyfitness.com/. The patient should be encouraged to purchase proper footwear for specific activities, for instance if the patient is a racquetball player he or she should wear high-top racquetball sneakers to improve the stability of the ankle. Most important the patient should always be aware of their walking surface and have control of their stride. With these tools and a proper rehabilitation program the patient will be able to return to regular activity without future complications occurring.
References
Colby, L.A. Kisner, C (2002) Therapeutic Exercise foundations and Techniques. F.A. Davis Co. Philadelphia.
Smith, Mike (2003) Emergency Nurse: Ankle Sprain: A Literature Search. Vol.11 (3) pg. 12.
Harvard Womens Health Watch(2007) Recovering from an Ankle Sprain. Vol. 14 (6) pg. 4-6.
WebMD. Ankle Sprain: Symptoms (2006) http://www.webmd.com/a-to-z-guides/Ankle-Sprain-Symptoms
WebMD. Ankle Sprain: Treatments(2006) http://www.webmd.com/a-to-z-guides/Ankle-Sprain-Treatment-Overview
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