In part one of this two-part article I discussed the mechanism of injury in an ankle sprain, the diagnosis and what structures were involved. In this article I will discuss the early management after an ankle sprain and the rehabilitation afterward.

Initial Management
Early management includes RICE (rest, ice, compression and elevation). Cryotherapy (ice) should be used immediately after the injury. Because increased swelling is directly associated with loss of range of motion in the ankle joint, the initial goals are to prevent swelling and maintain range of motion. Heat should not be applied to an acutely injured ankle joint because it encourages more swelling to the area.

Ice should be applied to the ankle for 20 minutes and can be done every hour and should be done in conjunction with elevation of the ankle above the level of the heart to promote lymphatic drainage.

To milk edema fluid away from the injured tissues, the ankle should be wrapped with an elastic bandage. The bandaging should start just behind the toes and extend above the level of maximal calf circumference.

In most patients, the use of two properly fitted crutches should be considered during the initial, most painful period after injury. The criteria for use of crutches is if the patient cannot weight bear equally and walks with a limp. Weight bearing should occur as tolerated. The patient should be weaned off the crutches as soon as possible and when they can show the ability to normalize their walking pattern.

To facilitate early rehabilitation an easily removable device, such as an air-cast ankle brace that restricts inversion-eversion and allows limited plantar flexion-dorsiflexion can be used to provide external stability and safety.

Functional Rehabilitation
The importance of proper rehabilitation after an ankle sprain cannot be overemphasized, especially when the debilitating consequences of decreased range of motion, persistent pain and swelling, and chronic joint instability are considered. After initial acute treatment, a rehabilitation regimen is pivotal in speeding return to activity and preventing chronic instability.

Prolonged immobilization of ankle sprains is a common treatment error.1,2 Functional stress stimulates the incorporation of stronger replacement collagen.1 Functional rehabilitation begins on the day of injury and continues until pain-free gait and activity are attained. The four components of rehabilitation are range-of-motion rehabilitation, progressive muscle-strengthening exercises, proprioceptive training and activity-specific training.

Ankle joint stability is a prerequisite to the institution of functional rehabilitation. Because grades I and II ankle sprains are considered stable, functional rehabilitation can begin immediately.

Range of Motion
Range of motion must be regained as soon as possible. Regardless of weight-bearing capacity, Achilles tendon stretching should be instituted within 48 to 72 hours after the ankle injury because of the tendency of tissues to contract following trauma. Mobility can also be increased initially through simple exercises as “ankle alphabets”.

Muscle-Strengthening Exercises
As long as ankle mobility and pain allow, the patient is ready to progress to the strengthening phase of rehabilitation. Strengthening of weakened muscles is essential to rapid recovery and important in preventing reinjury.3
We typically start the strengthening phase with use of theraband (resistive bands) to strengthen the ankle in three directions. We employ the high repetition/low resistance philosophy to build “tissue toughness”, as described in the August 2002 topic of the month. Single leg or double leg heel raises are also incorporated, as tolerated, to build calf strength and coordination.

Proprioceptive Training
As the patient achieves full weight bearing without pain, proprioceptive training is initiated for the recovery of balance and postural control. Proprioception is the bodies balance system. This system can be diminished after an ankle injury and must be restored to prevent reoccurrence of injury. Various devices have been specifically designed for this phase of rehabilitation. Use of these devices in concert with a series of progressive drills can effectively return patients to a high functional level.4 One of the simplest devices, which we utilize in our clinic, is the wobble or balance board (pictured in the equipment section). The patient is instructed to stand on the wobble board on both feet and shift his or her weight, causing the edge of the wobble board to move in a continuous circular path. Having the patient progress to one foot and also with closed eyes can advance training.

Training for Return to Activity
Once the patient has demonstrated the ability to walk without pain and has regained sufficient ankle strength, then the patient is progressed to increased impact activities e.g. double leg/single hops, jump rope. Once patient demonstrates the ability to perform those tasks without pain then they are progressed to running beginning from a light jog and progressing to full speed running as tolerated. Circles, figure eight running and change of direction line drills are commonly employed for pattern running. A patient who will be returning to sports participation may require additional sports specific therapy to complete the rehabilitation process. Use of a stabilizing orthotic device or tape, with subsequent weaning, may be recommended during the early period of activity-specific training.

References
1. Karlsson J, Lundin O, Lind K, Styf J. Early mobilization versus immobilization after ankle ligament stabilization. Scand J Med Sci Sports 1999; 9:299-303.

2. Dettori JR, Pearson BD, Basmania CJ, Lednar WM. Early ankle mobilization. Part I: the immediate effect on acute, lateral ankle sprains (a randomized clinical trial). Mil Med 1994; 159:15-20.

3. Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA. The prevention of ankle sprains in sports. A systematic review of the literature. Am J Sports Med 1999; 27:753-60.

4. Mattacola CG, Lloyd JW. Effects of a 6-week strength and proprioception training program on measures of dynamic balance: a single-case design. J Athl Train 1997; 32:127-35.