Why should you see a physiotherapist after an ankle sprain?

Ankle sprains are one of the most commonly occurring joint injuries.  This blog will look at the main benefits of physiotherapy intervention and some of the problems which can develop if an ankle sprain is left untreated.

How bad is your ankle sprain?

Ankle sprains are usually graded from 1-3. The grading refers to the proportion of fibres torn of the ligament. A grade 1 sprain implies a few fibres only of a ligament have been stretched or torn whereas a grade 3 tear is usually a complete ligament rupture. Lateral ankle sprains, which involve the ligaments on the outside of the foot, are more common as the foot is more likely to twist inwards, placing this area under stress.

The following structures may be implicated in a lateral ankle sprain.

– Anterior Talo-Fibular Ligament
– Anterior Tibio Fibular Ligament
– Calcaneal Fibular Ligament
– Posterior Talo-Fibular Ligament
– Tibiofibular Syndesmosis (interosseous fibrous joint between the tibia and fibula)
– Subtaler joint –this can be compressed on the inside when the ankle turns inwards and is sometimes associated with nerve damage.
– Peronei tendons –the tendons which attach the muscles of the outside of the leg.
– Peroneal nerve
– Fibula, talus bones –can be fractured or suffer from osteochondral damage –impact damage to the cartilage or bone.

Diagnosis and Prognosis

Seeing a physiotherapist helps to diagnose exactly what type of injury has taken place at the ankle. Some patients go straight to A&E to get an X-ray, particularly if the ankle is very swollen and bruised. If the X-ray doesn’t show an obvious fracture, the injury is usually diagnosed as a ‘sprain’. However this diagnosis does not necessarily give an accurate prognosis for the injury.  A physiotherapist can use movement tests to look at the involvement of the different ankle structures and give a better estimate of your recovery time based on their careful assessment. In severe cases you may be referred to an orthopaedic physician and an MRI scan may be requested to get a more accurate image of the damage to the soft tissues at your ankle.

Treatment Approaches

Regardless of the structures involved in your ankle injury the most common initial problems are often:

-pain
-swelling
-stiffness
-Instability- although sometimes this is only felt later as the swelling and stiffness in the joint reduces.
-reduced mobility/altered gait (walking)

1. RICE??

Many people self-treat their ankle sprain at home using the classic RICE –Rest Ice Compression Elevation- approach. However there is conflicting evidence to support this approach, since using ice as an anti-inflammatory may inhibit the initial inflammatory stage required to heal the damaged ligament tissue (Van den Bekerom et al 2012). Your physiotherapist can advise you on when and where to apply ice and how long to continue this process based on their assessment.

2. Taping, Strapping, Supports?

There has been a recent movement towards using kinesiotaping techniques to help drain swelling and offer support at the ankle. Examples of this often brightly coloured tape are often seen on professional athletes at major sporting events.

Rigid taping has long been a method of controlling mobility at the joint to protect healing ligament tissues. If there is a large degree of instability detected then your physiotherapist may recommend you invest in an ankle brace to support you for the first few weeks following your sprain.   Whilst some patients’ worry that wearing a support will weaken their ankle, the aim during the early stages of healing is to prevent overstretching the ligament so that it restricts the joint appropriately. There is evidence that it can take 3 months to see significant improvements in mechanical instability after an ankle sprain (Hubbard & Hicks-Little 2008). Wearing a support can also make it easier for a patient to put weight on the foot and avoid limping. This is thought to be helpful in aligning new collagen and preventing stiffness. Your physiotherapist can advise you on the appropriate level of support needed for your specific injury.

3. Improving mobility

One movement that is particularly important to look at after an ankle sprain is ankle dorsiflexion. This is the range of movement in your ankle joint when you bend your knee without lifting the heel off the floor in standing. This movement is integral to maintain a normal walking pattern initially and later on in your recovery to be able to run.  Stiffness is common especially if there has been a large effusion in the ankle joint. Your physiotherapist can help you improve this mobility significantly, which can be important in both your recovery and in preventing other injuries in the future. It is not uncommon to see clients complaining of knee or shin pain who have a past history of an untreated ankle sprain. The stiffness in their ankle joint can cause reduced shock absorbance in the leg and increase pressure on the knee joint. If you have had an ankle sprain and notice that the range of movement on that side is stiffer when you bend your knees with your heels on the floor then think about consulting a physiotherapist. A combination of manual therapy and exercise therapy can make a significant difference.

4. Managing Instability, Balance and Proprioception

Apart from the initial stiffness, there is also the question of instability of the ankle joint. If ligaments have been overstretched in a severe ankle sprain this can also affect the resting position of the joint in standing. It may look as if the arch has collapsed on the side of the ankle sprain. This can have consequences for the biomechanics of the leg once activity levels increase and again can be linked to a higher incidence of shin splints, anterior knee pain, Iliotibial band friction syndrome, hip pain and back pain.

Even in minor ankle sprains, the proprioceptive input from the ligament tissue can be affected. That is to say that the information from nerve endings in the ligament which inform us about the position of the joint and therefore stimulates appropriate muscle contraction is affected. This can affect both the resting foot posture, walking-particularly on uneven surfaces and the confidence to perform higher level activities such as running, jumping and changing direction further down the line.

Your physiotherapist will assess your balance on the affected leg as well as making a careful assessment of the resting ankle position and your biomechanics on movement. This may be done after a few sessions if pain is a large limiting factor. They will then advise on appropriate exercises to both strengthen the ankle and improve your balance and proprioception. Taping can be useful to help provide the correct feedback about the position of the joint. Occasionally orthotics may be recommended either temporarily or more long term if it is felt that a sufficient change in the stability of the joint has occurred. In these cases your physiotherapist may also recommend you see a podiatrist.

Preventing re-occurrence

All these interventions early on can help to avoid future problems with the ankle. The biggest risk factor for an ankle sprain is a previous history of an ankle sprain. Even if you did not see a physiotherapist initially following your injury, they could still be very helpful later especially if you have gone on to have other niggles which you suspect may be related. Interventions to improve mobility and proprioception of the joint can still be effective although it may take longer to rehabilitate the ankle at a later stage so where possible the earlier you get advice the better.

By Nikki Richards MPHTY(Sports) BSc(Hons)Physio MCSP

References

Van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, Van Dijk CN, & Kerkhoffs GM (2012). What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? Journal of Athletic Training, 47 (4), 435-43 PMID: 22889660

Tricia J Hubbard, PhD ATC and Charlie A Hicks-Little, MS ATCAnkle Ligament Healing After an Acute Ankle Sprain: An Evidence-Based Approach. Athl Train. 2008 Sep-Oct; 43(5): 523–529. doi:  10.4085/1062-6050-43.5.523

Denegar CR1, Hertel J, Fonseca J.

(2002). The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. J Orthop Sports Phys Ther.;32(4):166-73.

See comment in PubMed Commons belowHoch MC1, McKeon PO. (2010). The effectiveness of mobilization with movement at improving dorsiflexion after ankle sprain. J Sport Rehab. 19(2):226-32.