Summer has finally arrived and people are outside playing sports, going for a jog, going
to the beach, and parents are playing with their children out in the yard. During all that
fun activity especially those that occur on uneven terrain such as the sand on the beach or
a field of grass, ankle sprains can be a common injury. There are 3 classifications of
ankle sprains: grade I where the ankle is painful but mobility is normal, grade II where
the ankle is painful and the joint is unstable or hyper mobile, and grade III where the
ankle is pain free and the joint is hyper mobile.
When someone initially sprains their ankle, the first form of treatment in this acute phase
is called RICE (rest, ice, compression and elevation). This will help limit the amount of
swelling (inflammation) that occurs in the ankle joint/foot and help assist in minimizing
pain. The next step depends upon the individual and the degree of the ankle sprain. Some
people may not require any form of rehabilitation after the acute phase of the sprain if the
RICE treatment restores pain free function and has returned them to all previous activity
levels. If RICE does not allow for the return of previous functional level, physical therapy
would be the next course of action.
During the physical therapy evaluation, the physical therapist will evaluate the range of
motion, strength, flexibility, balance, and gait pattern of each individual. Based on the
findings of the evaluation, the physical therapist will develop a treatment plan to fit your
individual needs.
For example, take the patient Steve L. who was accidentally tripped and fell on his left
ankle resulting in an ankle sprain that was very painful. Steve L. walks into the clinic for
an initial visit and the physical therapist notices he is limping as he enters the clinic.
During patient interview, Steve describes the cause of injury and reports that later that
evening his left ankle began to swell and was very painful to walk on. He then reported
that he started to notice bruising on the lateral part of his ankle the next morning. During
the acute phase of the injury, Steve had followed the RICE treatment as instructed by the
athletic trainer of the high school. Although the swelling went down and some of the pain
subsided, Steve continued to report pain when walking and weakness in the ankle that
was preventing him from running and returning to track. During the initial evaluation,
ankle measurements were taken for ROM and flexibility, joint play (degree of movement
in the ankle joint to help determine grade of sprain), manual muscle testing was
performed for strength of the ankle, Steve was asked to balance on his left while standing
on the floor (a level surface) and on a dynadisc (uneven surface), and a gait analysis was
performed through observation.
Based on the evaluation, Steve was found to have tightness in the calf as measured by
ROM of 10 degrees into dorsiflexion (normal ROM= 20 degrees), increased mobility
when turning the ankle in (inversion) but normal ROM when turning the ankle out
(eversion), pain in the lateral ankle when he was asked to resist movement of the ankle
against physical therapists pressure, strength testing revealed weakness in the ankle
stabilizers as determined by a measurement of 4-/5 into ankle inversion and eversion, as
well as weakness into ankle dorsiflexion, and inability to balance on an even and uneven
surface for longer than 20 seconds. When asked to walk within the clinic, the physical
therapist noted decreased ability of Steve to weigh-bear on the left foot, decreased pushoff
with the foot and asymmetrical step length and stance time on the left. These are all
signs of an antalgic (painful) gait.
A treatment plan was developed by the physical therapist to include exercises that would
address the evaluation findings so that Steve could return to running in his track events.
Steve’s exercise program consisted of ankle stretches to improve ROM into ankle
dorsiflexion (see below for specific calf stretches) and strengthening exercises.
Strengthening exercises consist of using a theraband for resistive training, squats, heel
raises against own body weight and progressed towards using a weight bar for added
resistance, forward and backward walking with resistance coming from a cable column
machine, and manual resistance from the physical therapist. An integral part of the
rehabilitation process is to improve balance on both even surfaces and uneven surfaces
because when running your foot has to adjust to any changes in the terrain, ie. a rock on
the ground or running on the grass which requires good ankle strength, flexibility and
proprioceptive input. Balance activities can include standing on one leg on both the floor
and an uneven surface such as a dynadisc or trampoline, walking with one foot in front of
the other (known as tandem walking), walking backwards using the tandem stance,
marching or running in place on a trampoline for work on balance while in motion and on
an uneven surface, as well as working on improving the proprioceptive input into the
ankle joint by use of a BAPS board.
After receiving physical therapy focusing on the assessed deficits in the ankle, Steve was
able to return to running track for high school. By incorporating all of the above exercises
in your treatment regimen, you should be on your way to a full recovery. If you or a
loved one suffers from an ankle sprain that is not healing, contact your MD and inquire
into getting a prescription for physical therapy so that you can return to an active
lifestyle.
Stretches for the Ankle to Improve Flexibility
- Standing at a wall with on leg behind the other in a lunge position, maintain the
back knee straight and the heel on the ground while leaning forward until you feel
a stretch in the back of the calf. - Same position as above, however keep a slight bend of the knee behind your
body. - Sitting, place a towel/belt underneath the ball of your foot and while maintaining
your leg straight, pull up on the foot bringing it up toward your body and hold that
stretch.
*All stretches should be held for at least 10 seconds so that the muscle gets used to
that lengthened position.
