Ankle sprains are one of the most common sport injuries. They are due to an injury involving the ligaments of the ankle Ligaments are strong "rope like" structures that hold the bones of the ankle in proper alignment, but allow necessary motion.

The most common mechanism of an ankle sprain is an inward twisting of the ankle. If this occurs faster or more forcefully than muscles can counteract, the ligaments are placed under undue tension. If stress on the ligaments continues they will tear or partially pull off of their insertion into the bone.

Ankle sprains are usually classified by the amount of ligament damage.

First Degree Sprain

involves stretching the ligaments with no actual tear. The ankle is slightly swollen but there is no instability. With proper rehabilitation, one can return to sports in one to two weeks.

Second Degree Sprain

is a partial tear of the ligament. It is associated with definite swelling due to bleeding from torn tissue. Since it is a partial tear, only a portion of the actual ligament is damaged and the remaining fibers remain intact to help prevent displacement. Initial treatment requires ice, elevation and compression; followed by a formal rehabilitation program. Sports are usually limited from four to six weeks and long term exercising and reconditioning is often required.

Third Degree Sprain

Third degree sprains are rare. They involve a complete tear of the ligament. The ankle will be partially unstable and often must be treated with a cast. This injury requires a long program of rehabilitation and it

may lead to chronic instability. In some individuals this may require surgery to obtain an optimal result.

CONTRIBUTING FACTORS

1. Prior ankle instability.

2. Weak improperly conditioned or "cold" muscles.

3. Improper shoe wear.

4. Poor playing surface.

5. Altered alignment (e.g. hyperpronation; low or high arches.)

TREATMENT

Initial treatment

For the first two to three days ice, elevation and a compression wrap are used. Ice should be applied for fifteen to twenty minutes at a time, four times a day. This can be done by placing ice into a zip-lock plastic bag, using a reusable cold pack, or a package of frozen vegetables. The ankle may need to be supported in a brace while walking to protect it from further instability. The ankle should be elevated above the level of the heart frequently throughout the day. Anti-inflammatory or analgesic medication such as Naprosyn or Motrin is often used to decrease pain. These medications should be taken with milk or meals two to three times a day. The most common side effects of anti-inflammatory medications are stomach disturbances (they may be especially dangerous for patients with ulcer disease). They should not be taken by people with known kidney disease. There are new prescription anti-inflammatory medications on the market now which will not cause stomach complications.

After the initial acute symptoms subside a rehabilitation program should begin.

Early Rehabilitation

Early rehabilitation consists of slow progressive range of motion exercises, especially stretching. As the motion returns to normal, progressive strengthening exercises are performed. These may be done with a stretch cord.

Late Rehabilitation

Exercises involving the peroneal muscles and proprioceptive conditioning are added as shown below. Prior to returning to formal sports one should be able to run and sprint straight ahead with ease, as well as do figure of eights and side to side cuts without pain.

EXERCISES

I. STRETCHING

Achilles stretches:

1. Stand two to three feet back from the wall and lean forward with both hands.

2. Place one foot forward and the other one behind.

3. Keep your rear knee straight and slowly move your hips forward towards the baseboard without arching your back.

4. Be sure to keep your heel of the back leg firmly on the floor.

5. Stretch forward until tightness is felt in the back of the knee. Hold this for ten seconds.

6. Unlock the knee and slowly drive the knee toward the baseboard until a stretch is felt just above the heel. Hold this for ten seconds.

7. Repeat this stretch both with the knee straight and knee bent for a total of ten times each.

8. All stretches should be done slowly without bouncing.

Alphabet Diagram:

1. Sit comfortably with your shoes and socks removed and slowly trace large alphabets on the floor.

I. STRENGTHENING

Toeraising:

1. Stand with both feet placed on the edge of a telephone book.

2. Hold on to a counter or door jam for support.

3. Slowly lower yourself down until your heels are resting on the ground and the balls of your feet are still on the telephone book and then slowly raise up to the very tiptoes and hold this for ten seconds

4. Repeat twenty times.

5. Once you can comfortably do twenty of these with two feet begin placing only one foot on the telephone book.

Stretch cord exercises:

1.A three to four foot length of stretch cord is placed with the knot outside the door with the door carefully closed and locked.

2. Sit on a chair with your injured leg crossed on top of your other leg in a comfortable position.

3. Place the end of the stretch cord around the ball of your foot and sit far enough from the door so that moderate tension is placed on the stretch cord.

4. You can now do resistive exercises in all three positions.

a. Inversion:

With the loop of the stretch cord around the ball of your foot slowly rotate your foot inward pulling the cord tight until moderate resistance is felt. Hold this fifteen seconds and relax. Slowly repeat this fifteen times.

b. Eversion:

Now turn your chair completely around and with your injured leg crossed over your other leg. Put the loop of the stretch cord on the outside of your foot and rotate your foot outward against resistance. Hold for fifteen seconds.

Repeat fifteen times.

c. Extension:

Now pull your chair straight back and place the stretch cord over the top of your foot and work on extending your ankle straight back against resistance. Hold this for fifteen seconds and then relax. Repeat fifteen times.

II. PROPRIOCEPTIVE EXERCISES

Ankle Tilts (Skiing Exercises):

1. Stand next to a counter or the back of a chair with your feet shoulder width apart.

2. Carefully hold on to the counter or the back of the chair for support.

3. Slowly bend and rotate your knees laterally and downward until you are standing on the sides of your ankle. Hold this position for ten seconds. Slowly rotate your knees the other direction until you are standing on the other side of your ankle and hold for ten seconds. Repeat twenty times.

Balance board:

A balance board can be fashioned by buying a two foot diameter circular piece of 3/4" plywood which can be picked up at a local lumberyard. Set the plywood on a round ball approximately the size of a softball. While holding carefully on to a counter for balance stand with your feet shoulder width apart and balance on the plywood. While holding on to the counter begin pivoting and see-sawing on the disk.

General Exercises

Swimming, bicycle riding, jogging are all excellent exercises for your ankle.

Braces

A support wrap is often used to decrease and prevent swelling. In more severe ankle injuries, a rigid plastic functional brace is often prescribed. The brace is used full time during the day for 3 - 6 weeks. After that it should be used during sports or vigorous activities for 4 - 6 months.

Physical therapist

Physiotherapists are experts in developing the proper rehabilitation programs. They monitor the exercises to make sure you are doing them correctly. They develop new exercises and modify existing ones for maximal benefit. Other modalities they can employ include ultrasound, contrasting heat and cold, electrical stimulation and mobilization.

Persistent Pain

Most people respond well to the above program and with proper rehabilitation can eventually return to sports. There are cases where pain and swelling continue about the ankle. If this continues for more than six to eight weeks, further evaluation to rule out other complications may be required. This may involve a bone scan, MRI or

arthroscopy.

Surgery

It is very rare to require surgery following an ankle sprain. Occasionally patients with chronic instability may require a surgical reconstruction of the ligaments. Other individuals who have persistent pain due to any of the lesions noted above may respond well to arthroscopic evaluation and treatment.

Avoiding Future Pain

After you have successfully recovered from an ankle sprain it is very important to continue with an exercise program. This should include the stretching, strengthening and proprioceptive exercises mentioned above.