Lateral Ankle Ligament Sprains Part 2

If you missed Part 1 of my Lateral Ankle Ligament Sprain deep dive please click HERE>> to gain an insight into the acute rehabilitation, diagnosis, and mechanisms of injury for lateral ankle sprains.

If you have already read Part 1 then I hope you find Part 2 also of interest and use.

Must know sub-acute ankle rehabilitation for your sprained ankle

Lateral ankle sprains are very common and completing the full rehabilitation process is essential in preventing ongoing recurrence of ankle sprains. Today’s blog is part 2 of a lateral ankle ligament sprain series and I will explore sub-acute ankle sprain rehabilitation following lateral ankle ligament sprains.

Unfortunately, physiotherapists see far too many clients presenting 6-8 weeks after their initial lateral ankle sprain with persisting ankle pain or dysfunction, These clients have usually done the first part of their acute ankle management by applying the RICER principles, however, have often just left their ankle to “see how it goes.”

Please do not be one of these patients. Not only does delayed ankle rehabilitation increase your risk of re-injuring your ankle, it further makes it more difficult to fix and restore it to a full functioning, healthy status, costing you more money to fix it, and taking more time away from you doing the things you love doing.

Completing the full rehabilitation process for lateral ankle sprains is essential in preventing ongoing recurrence of ankle sprains #physio #ankle #injury Click To Tweet

Acute lateral ankle ligament sprain recap

As discussed in the part 1 blog, acute lateral ligament ankle sprains must be treated well to ensure full ligament recovery. The acute rehabilitation phase involves firstly applying the RICER principles; Rest, Ice, Compression, Elevation, Referral. Secondly, gentle physiotherapy is commenced to reduce swelling, restore full joint range of motion, and tape and support the ankle joints for mobility. The better a lateral ankle sprain is managed in the acute phase, the faster the patient will be able to get pain-free and move into the sub-acute phase. The sub-acute phase kicks off once the sprained ankle is able to weight-bear and is relatively pain-free in walking. If this is where you are up to in your sprained ankle rehab, fantastic, read on; it’s time for the fun part of your rehabilitation.

Physios see far 2 many clients presenting 6-8 weeks after their initial lateral ankle sprain with persisting ankle pain #physio #ankle #sprain Click To Tweet

The Sub-acute phase:

First – know thy body!

Your ankle is relatively pain-free and you can walk again! The sub-acute phase of lateral ankle ligament sprains is all about restoring your ankle to pre-injury status so you can get back to doing the things you love to do pain and worry free.

Everyone has a unique body type and generally falls into one of 3 categories; having hyper-mobile ankle joints (floppys), having hypomobile ankle joints (stiffys), or having ankle joints with moderate mobility (flippys). Click HERE>> to read  more about this concept.

Understanding your body is important in knowing how to best address the contributing factors and complete the sub-acute rehabilitation phase. People who are floppies (too much ankle joint movement) will require less mobility work and more stability work, while people who are stiffys (globally stiff joints), will require more mobility work along with stability work in the rehabilitation process. Your physiotherapist should first assess what your natural body type is in regards to mobility so they can best cater to your ankle’s needs.

The sub-acute phase of lateral ankle ligament sprains is all about restoring your ankle to pre-injury status #physio #injury Click To Tweet

The 7 elements of sub-acute ankle sprain rehabiltation

Interestingly, as you will notice in the steps below, the sub-acute phase of lateral ankle ligament rehabilitation involves not only rehabilitation of the ankle complex, but the whole kinetic chain, including core, hip and knee stability and endurance and foot posture.

All of these contributing factors must be addressed to ensure a healthy, strong ankle for return to training and competition. If the physiotherapist you are seeing only treats your ankle joint itself, and not the rest of your body as a whole unit, my advice would be to see someone else, otherwise you risk only getting a short-term fix of your ligament sprain.

The sub-acute phase of lateral ankle sprain rehabilitation involves the following 7 steps listed below, several of which are addressed at the same time in the sub-acute phase.

1) Regain full and optimal range of ankle motion and muscle function

In most patients, after lateral ligament ankle sprains, usually the talocrural and subtalar joints often become quite stiff, as do the midfoot, and forefoot joints. The calf muscle complex and other muscles surrounding the ankle are often tight or high in tone and need releasing. Physiotherapy treatment often involves ankle and foot joint mobilisation techniques, deep tissue massage, transverse friction techniques, dry needling for regaining optimal muscle length and tone and stimulating ligament healing.

Restoring optimal range of ankle motion and muscle length is important for force distribution and optimising future strength training. Often in hypermobile patients, muscle length and joint range are not so much of an issue, so manual therapy to further increase excessive range of movement is unwanted. In these patients, your physiotherapist will often jump straight to step 2 and just address any increased or inappropriate muscle tone via manual therapy.

2) Restore and improve optimal ankle balance and proprioception

Balance and proprioception exercises begin as soon as possible. In the acute phase this involves activities like spelling the alphabet with your injured ankle. In the sub-acute phase, as soon as a patient can weight-bear relatively pain-free, 1 leg balance exercises are commenced for proprioception retraining. The balance and stability exercises get harder and harder by reducing the base of support, reducing sensory input (ie. eyes closed), and adding in dynamic movements such as hops, directional changing, etc. Your treating physiotherapist will know which exercise is best for you and when to progress you onto harder, more challenging exercises.

3) Restore and improve optimal calf and ankle muscle strength and endurance

The pain involved with lateral ankle sprains and time away from regular activities often causes there to be a loss in calf strength after ankle sprain. Calf raises are routinely employed to help build calf strength and endurance. The calf complex attaches in close proximity to the ankle joints and helps provide stability to the ankle complex. Specific exercises to help strengthen the peroneal muscles, tibialis posterior and tibialis anterior also help to provide further inversion and eversion ankle control and stability. Theraband exercises are often helpful for these and can be progressive by increasing the resistance. A usual progression for calf raises is as follows:

• 2 leg calf raises; 1 leg calf raises; 1 leg hopping; 2 leg jumps; skipping; cross hops; box jumps; box jumps with 1 leg landing, sport-specific drills
• To view calf raises being performed see below

4) Restore and improve optimal hip and core stability and strength

As our bodies work as one kinetic chain, it’s important to address contributing factors above and below the injured area being rehabilitated. Hip and core stability is one of the most important areas to get right in both preventing future ankle sprains and rehabilitating a sprained ankle ligament. Assessment of hip stability usually involves manual hip muscle testing and also functional tests such as a one-leg squat. Often gluteus medius activation or endurance will be reduced in those patients prone to ankle sprains. Hip stability and core stability is addressed through core and hip exercises including the following:

• Double of single leg bridges, fire hydrants, hip circles, hip abduction theraband exercises, clam shells and squatting exercises.
• Click HERE>> to view a video of commonly prescribed hip strength and stabilitly exercises we prescribe to runners (applicable to non-runners also).

5) Ensure the right footwear for training and match-play are selected for optimal foot placement and ankle support

If a patient has a pronated (flatter arch) or a supinated (higher arch) foot, this will lead to changes in loading patterns of the ankle while walking and running. Determining what type of foot posture your foot takes as it weight-bears in running or walking is important in ensuring the lateral ankle ligaments have the support they need. Podiatry input can be useful on this one. Your physiotherapist or podiatrist should be able to asses what type of foot you have to help determine what sort of shoe will be best for your desired activities.

For the runners check out the 6 foot-wear consideration needed to select the correct pair of running shoes HERE>>

6) Address current running technique and movement patterns to optimize foot placement and running technique to reduce future injury risk and maximise performance.

The majority of people I treat who have sustained a sprain lateral ligament injury to their ankle, have done so from running or sport participation. It makes sense then, in completing full ankle rehabilitation to make sure optimal running technique is being employed.

Foot placement while running, cadence, running posture and several other factors all come together to make good running technique. If you’ve sprained your lateral ankle ligaments doing some sort of running activity, make sure you get your running technique assessed and do a running screening with your local physiotherapist. A running screening and technique assessment will help you better discover your running machine, how to improve your running technique and how to reduce your risk of future ankle and running injuries. Personally, adapting my running technique by applying good running principles helped me improve my running speed and performance and has helped me remain more injury free over my running lifespan so far.

If you are serious about improving your running technique and enjoying injury-free running be sure to purchase a copy of Brad Beer’s Amazon Best seller You CAN Run Pain Free! Click HERE>>

7) Re-commence functional activities

Functional exercises are great for incorporating and integrating the above parts of your ankle rehabilitation. Functional activities are most helpful when they are sport-specific and research has found that specific functional training can accelerate a patient’s return to their sport or desired activities and can substantially reduce the risk of re-injury. Functional activities always require a good base level of ankle stability, proprioception and ankle muscle strength and can include the following higher level activities:

• Cross hops on 1 leg
• Jumping exercises – 2 feet and 1 foot exercises
• Skipping exercises
• Hopping
• Light jogging
• Twisting
• Figure of eight runs
• Zig-zags

When am I ready to return to my sport and competition?

This is the question every client wants to know; when will be ready to train/compete/play again?” Your physiotherapist will help you decide whether you are ready for return to training or competition and this will set in your plan towards reaching your rehabilitation finish line. Generally speaking, a number of tests are applied to ensure your ankle is ready for the specific demands of your training or sport. These tests can include (but are not limited to):

• Ankle and calf range tests – ie. Knee to wall test – minimum 10cm and ideally L = R
• Calf muscle endurance – 30 1 leg calf raises pain-free
• 30 seconds eyes open 1 leg balance or 30 seconds eyes closed 1 leg balance
• Functional tests such as shuttle runs, zig zags, etc
• Jumping and landing activities and testing

Should I strap or brace my ankle to prevent recurrence or neither?

Many recreational athletes and professional athletes look to external supports for their ankle ligaments to reduce the risk of re-injury. Ankle braces and taping may help improve ankle stability and proprioception, however, some argue that they can lead to a dependence upon such support developing.

The decision to strap or utilise a brace for your ankle for return to training and competition should be made in conjunction with a physiotherapist who knows your ankle and understands the demands of your sport or activity. Typically, such a decision is based upon a number of variables including the following:

• The severity of the ankle ligament sprain and ligaments involved
• The demands of the sport – high impact and directional changing sports and activities may require additional preventative support ie. soccer or basketball
• Any past history of lateral ankle ligament sprains
• The timing in the season of competition or training
• The risk of re-injuring the ankle

Be proactive and get a long-term fix!

If you have recently sprained your ankle, see your local physiotherapist to get started on your rehabilitation plan straight away. Alternatively, if you have sprained your ankle in the past and never did the full rehab process to get it back to 100%, I urge you also to be proactive and do some ankle rehab to prevent future ankle sprains.

Happy training, walking, running, surfing, or doing whatever you love to do!

Jacob Taylor (APAM)

Physiotherapist

References:

Brukner, P. & Khan, K. (2007). Clinical Sports Medicine (3rd ed). McGraw-Hill, Sydney.

Holme, E., Magnusson, S. P., Becher, K., Bieler, T., Aagaard, P., Kjaer, M. (1999). The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scandanavian Journal of Medicine and Science in Sports, 9 (2), 104-9.

O. McKeon, P. & Hertel, J. (2008) Systematic Review of Postural Control and Lateral Ankle Instability, Part II: Is Balance Training Clinically Effective? Journal of Athletic Training, 43 (3), 305-315.

Van der Wees, P. J., Lenssen, A. F., Hendriks, E. J., Stomp, D. J., Dekker, J. & de Bie, R. A. (2006). Effectiveness of exercise therapy and manual mobilization in ankle sprain and functional nstability: a systematic review. Australian Journal of Physiotherapy, 2006 52 (1), 27-37.