Ankle sprains are probably the most common orthopedic injury (according to the Cleveland Clinic, they account for 15% of all athletic injuries). I estimate that I have probably managed anywhere from 200-300 ankle injuries during the first 12 years of my career. On the flip-side, personally speaking, I am the poster-child for chronic ankle instability. I know, I know – that sounds bad coming from a certified athletic trainer. I first sprained my left ankle during phys ed class in 8th grade. From what I remember, I didn’t take very good care of it from there throughout high school. Then it happened again. And again. And Again. My mismanagement led to long-term problems. I probably never took the proper amount of time off, and basically managed it by icing it and taping it. Thankfully, when I sprained it playing a pickup basketball game during my Chicago Bears internship, I was in an ideal place to receive treatment! Just imagine the flack I received from the players – the athletic trainer, who is supposed to be rehabbing the players, needs rehab. You try stretching Ted Washington with only one good base of support! The fact is, it wasn’t until I learned through my schooling, mentorships, and professional experience how to properly manage ankle sprains that I actually started taking care of my own instability. Now, when it does happen, I’m a champ at rehabbing myself (just ask Jeff and Mandie Buxton – my miraculous recovery prior to their wedding reception was stuff of legend). I was motivated – as you may know from my “dominate the dance floor” blog – and needed to be there to get Jeff and Mandie’s party started!
So, why is it that when people sprain their ankle, re-injury is so common? According to an America College of Sports Medicine report, “40 percent of ankle sprains are misdiagnosed or poorly treated, leading to chronic ankle pain and disability.” There are two concerning parts to this statistic. First, as healthcare professionals, are we accurately evaluating the injury and providing the right type of guidance both initially, throughout, and beyond recovery? Second, why the heck do injured people not keep up with their rehab exercises?
Let’s take a closer look at first of those two questions, and review what I believe we as healthcare professionals should do to address this. Thanks to my education, excellent mentors, and a constant desire for professional growth, I’ve been fortunate to have a track record showing consistent success in managing these injuries. Of course, I’ve made my share of treatment/management mistakes, but from those mistakes I have learned better approaches to take. As healthcare professionals, we must not be afraid to re-evaluate our approach to managing ankle sprains (or any other injury, for that matter). This could mean reflecting on our complete rehab protocol process and exercise selection, improving our hand placement and force direction when performing mobilizations, or changing up the reps/range/resistance level of our therapeutic exercises. We should make ourselves better so that we can better help others.
Here are my 10 personal keys to successfully managing ankle sprains:
- Walking boot: This allows for improved walking mechanics while still protecting the injured tissue. Make sure the person wears sneakers or thick-soled shoes on their other foot – don’t want significant leg length difference for the sake of their knees, hips, and backs. I wish I had enough of these on hand to put on every ankle sprain I evaluate for the initial inflammation phase.
- Early compression: ‘Nuff said. Keep that swelling to the minimum amount needed to bring in the healing goodies.
- Early assisted/active ROM in pain-free ranges: Other than the initial influx of “repair goodies” that the body sends to the area, excess swelling is not a good thing. Muscle contraction moves swelling, bottom line. Just keep the movement to only non-irritating ranges, for an increase in pain can lead to re-inflammation.
- Joint mobilizations (properly graded based on healing stage, of course!) to restore proper talo-crural, subtalar, forefoot, and tib-fib (both distal AND proximal) joint kinematics. Say that 3 times fast!
- Kinesiotaping for edema/swelling reduction (I tell the person to name their tape octopus): Trust me, with the right tension application (no more than 10-20%), it works wonders for reducing swelling and edema.
- Soft-tissue mobilization for the calf: Massage, foam roller, trigger point release – all things which can significantly improve ankle dorsiflexion flexibility in cases where the calf “locks up” to protect the injured area. Also, lack of dorsiflexion ROM post-injury is a risk factor for re-injury. Don’t let that happen.
- Gait-retraining after initial inflammation phase: Get rid of that limp ASAP. I’m a big fan of backwards walking, eccentric resisted forward walking, and “non-impact jogging”.
- Don’t neglect the hips and core: There is notable scientific evidence that when someone sprains their ankle, proprioceptive input and neuromuscular firing patterns are altered. The glutes can shut down (esp. glute med) due to a “protective” response of the body and altered walking mechanics. If we only coach ther-ex focused on the foot and ankle, we are missing a big part of the “restore normal function” and “prevent future re-injury” components.
- Dynamic, multidirectional, progressive-intensity balance training: This ranges from simply balancing on one leg and picking up cups at different reach angles to later-phase multidirectional single leg jumps (need to work on both sticking the landing as well as single movement cutting skills).
- Proper bracing during recovery period, and even after when dealing with a true ligamentous instability. I’m a BIG believer in the ASO ankle braces. Even with my history of ankle injuries, I’ve never injured my ankle while wearing these. (My injuries tend to come at stupid, random times when I’d least expect it – another frustration!) Make sure the brace is fitted properly. One last note on this – when using a brace with “figure 8” straps, a common mistake is to lay the straps down in the incorrect order. Use the “lateral to medial” pull, or “over–>under” strap first to provide arch support. Don’t pull this strap too hard so as to pull the rearfoot into eversion. Just use enough tension to reinforce the subtalar joint in neutral. Then, apply the “medial to lateral” or “under –> over” strap to limit excessive inversion ROM.
- A solid, easily manageable maintenance program after recovery. High rep (I promote total reps in a day vs “2 sets of 30”), simple exercises that can be performed throughout the day, with little or no “equipment”, that improve/maintain neuromuscular firing mechanisms needed for the body to stabilize the ankle during day-to-day movements. Promote independence and accountability. When instructing these, be creative, be empathetic, and be motivational! Tell them – DON’T BE LIKE EARLY TEENAGE RYAN! (unless they want to rock super awesome funky-fresh gear like I had!)
Take it from me, recurrent ankle sprains are downright frustrating. Still to this day, at random times I have visions of my ankle giving out on me when walking around outside on uneven terrain (yes, BIG psychological component to recurrent ankle sprains as well). Thankfully, I also now know how to significantly limit the chances that others will go through what I’ve dealt with when they sprain their ankle. Knowledge is power. Hindsight is 20/20. Now I just need a time machine to go back and take better care of myself (and make better clothing choices).
Ryan Stevens, MPS, ATC, CSCS