Follow These Critical Steps to Resolve Ankle Sprains

Did you know: 

1/3 of patients with inversion ankle sprains continue to have symptoms for 1 year. (1)

25% of patients report pain, instability, crepitus, weakness, stiffness, or swelling for the next 3 years. 

75% of active patients re-injure the same ankle. (2)

These numbers are staggering.  Fortunately, evidence-based chiropractors are on the front line to manage these patients to full recovery and limit re-exacerbation with three proven stages to rehabilitation. Successful management of ankle sprains and prevention of re-injury depends on a couple of fundamental principles—each is equally important.

STEP 1: Recognize Which Patients are Susceptible to Chronic Ankle Pain

Specific patient populations are predisposed to chronic pain. Disability questionnaires, like the Fear-Avoidance Beliefs Questionnaire, can identify patients that may require extra help from your office due to their fear of movement therapy.  This form will monitor your progress with ankle rehabilitation before and after treatment. (3) This form and scoring instructions are found within ChiroUp.  

STEP 2: Teach Patients How to Move

The literature supports an early return to activity after acute inversion sprains.  Exercises and treatments that promote joint motion and early recovery to weight-bearing are more effective than immobilization.  Grade III sprains (ligament rupture) often require immobilization. However, grade I and II ankle sprains should forego complete immobilization and focus on regaining full range of motion. Early rehab and return to weight-bearing will increase ankle range of motion, decrease pain, and reduce swelling sooner than immobilization.

In a study by Linde et al., 150 patients with inversion ankle sprains were treated with early motion and weight-bearing. After one month, 90% of the patients treated with early motion and weight-bearing demonstrated pain-free gait, and 97% had increased workability. (4) Early mobility exercises would typically include:

Ankle Alphabet

Standing Gastroc Stretch

Standing Soleus Stretch

Single-Leg Stance

These four exercises promote balance and increased ankle dorsiflexion—a pivotal contributor to an ankle injury. Patients who have lost an average of 11 degrees of dorsiflexion are five times more likely to suffer lateral ankle sprains. (5)

In-office care should also include mobilization and manipulation for restoring function. Joint mobilization decreases pain, increases dorsiflexion, and improves ankle function. (6) Instrument-assisted soft tissue manipulation or transverse friction massage to the affected ligament may help mobilize scar tissue and increase flexibility. Myofascial release may help release tightness or adhesions in the gastroc and soleus. 

Knowing when to treat and when to refer is critical. Whitman’s clinical prediction rule identifies four variables to predict the success of manipulation and exercise for treating inversion ankle sprains. (7) The presence of three out of four of the following variables predict greater than a 95% success rate for manual therapy and exercise:

• Symptoms worse when standing

• Symptoms worse in the evening

• Navicular drop greater than 5 mm

• Distal tibiofibular joint hypomobility

Prevention of re-injury is not as simple as putting on an elastic brace.

Stotz and associates observed “no significant effects of elastic ankle support on Landing Error Scoring System, Balance Error Scoring System, or Y Balance Test performance in the chronic ankle instability or control group.” (8)

STEP 3: Prevent Re-Injury

The most crucial variable in the successful prevention of future ankle sprains is improving BALANCE. Balance training reduces the incidence of ankle sprains and increases dynamic neuromuscular control, postural sway, and joint position sense in athletes. A study by de Vasconcelos et al. (2018) found that balance training reduced the incidence of ankle sprains by 38% compared with the control group.  (9)

Two of the most common exercises used for balance and proprioception include the single-leg stance exercise and Veles.  A simple explanation stressing the importance of balance training may be necessary to promote patient compliance.

Finally, encourage your patients to start walking “normal” as soon as possible. As evidence-based chiropractors, we need to return patients to their normal gait as soon as tolerable. Patients with foot and ankle pain will often favor a supinated gait to unload the soft tissues of the foot and arch in favor of their bony architecture on the lateral foot. The lateral column of the foot affords stability but at the expense of a very inefficient gait. Over an extended period, these patients may develop a Tailor’s bunion, i.e., 5th metatarsal head bursitis. However, in the case of ankle sprains, a rapid increase in activity may overload the metatarsal fast enough to cause a Jones Fracture. Return to normal gait will minimize these compensations.

This data illustrates how simple exercises and patient education can significantly affect our ability to thrive in an outcomes-based reimbursement world. Check out the ChiroUp Condition Reference on Inversion Ankle sprains to review a complete, up-to-date best practice recipe.

If you’re not yet a subscriber, click here to start your free trial today, then practice with confidence, knowing that your patients have the best possible collective advice and rehab, fully customizable to your preferences.

• References

  1. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basket¬ball: injury rate and risk factors. Br J Sports Med. 2001;35:103-108

  2. Suttmiller AM, McCann RS. Injury-Related Fear in Individuals With and Without Chronic Ankle Instability: A Systematic Review. Journal of Sport Rehabilitation. 2021 Sep 20;1:1-0. Link

  3. Linde F, Hvass I, Juergensen U, Madsen F. Early mobilizing treatment of ankle sprains: A clinical trial comparing three types of treatment. Scan J Sports Sci.1971;8:71-7

  4. de Noronha M, Refshauge KM, Herbert RD, Kilbreath SL, Hertel J. Do voluntary strength, proprioception, range of motion, or postural sway predict occurrence of lateral ankle sprain? Br J Sports Med. 2006;40:824-828

  5. Janice K Loudon, Michael P Reiman, and Jonathan Sylvain The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review Br J Sports Med doi:10.1136/bjsports-2013-092763

  6. Whitman, Julie M., et al. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther 2009,39(3): 188-200.

  7. John C, Stotz A, Gmachowski J, Rahlf AL, Hamacher D, Hollander K, Zech A. Is an Elastic Ankle Support Effective in Improving Jump Landing Performance, Static and Dynamic Balance in Young Adults With and Without Chronic Ankle Instability?. Journal of Sport Rehabilitation. 2019 Jan 1;1(aop):1-21. Link

  8. de Vasconcelos GS et al. Effects of proprioceptive training on the incidence of ankle sprain in athletes: systematic review and meta-analysis. Clin Rehabil. 2018