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Clinical practice guidelines for acute lateral ankle sprain and ankle instability

Understanding where to turn when your ankle is injured can be confusing and challenging. That is why we summarize as much as we can for you regarding up-to-date rehab principles. The following is a recent journal club subject WPT researched and studied as a group in our joint spine sport university. It is succinct and meant as a summary to clarify.

Acute Lateral Ankle Sprain

RISK FACTORS:  If you can understand risk factors of spraining your ankle, there is a better chance of avoiding a nasty ankle roll.  There is an inherent increased risk of acute lateral ankle sprain in individuals who (1) have a history of a previous ankle sprain, (2) do not use an external support (like a brace), (3) do not properly warm up with static stretching and dynamic movement before activity, (4) do not have normal ankle dorsiflexion range of motion, and (5) do not participate in a balance/proprioceptive prevention program when there is a history of a previous injury.

DIAGNOSIS/CLASSIFICATION: To regain proper levels of function, your therapist should diagnose properly before they prescribe. WPT uses the clinical findings of level of function, ligamentous laxity, hemorrhaging, point tenderness, total ankle motion, swelling, and pain to classify a patient with acute ankle ligament sprain.

Ankle Instability

RISK FACTORS: It is also helpful to recognize the increased risk for developing chronic ankle instability in patients who (1) have an increased talar curvature (technical jargon for posture of the ankle), (2) are not using an external support (like a brace), or (3) did not perform advanced balance or proprioception exercises following an acute lateral ankle sprain.

DIFFERENTIAL DIAGNOSIS: Wright Physical Therapy uses diagnostic classifications other than ankle instability when the patient’s reported activity limitations or impairments of body function and structure are not consistent with those presented in the Diagnosis/Classification section of this guideline.  This is important to ensure treatment is not done sloppily or hastily.

Examination

OUTCOME MEASURES: Your expert doctors of physical therapy should incorporate validated functional outcome measures, such as the FAAM, utilized before and after interventions. These outcome measures are intended to alleviate the impairments of body function and structure, activity limitations, and participation restrictions associated with ankle sprain and instability.

ACTIVITY LIMITATION AND PARTICIPATION RESTRICTION MEASURES: WPT follow these guidelines when evaluating a patient in the period following a recent or recurring lateral ankle sprain. We assess activity limitation, participation restriction, and symptom reproduction.  This assessment includes objective and reproducible measures, such as single-limb hop tests that assess performance with lateral movements, diagonal movements, and directional changes.

PHYSICAL IMPAIRMENT MEASURES: When evaluating a patient with an acute or sub-acute lateral ankle sprain over an episode of care, assessment of impairment of body function should include objective and reproducible measures of ankle swelling, ankle range of motion, talar translation and inversion, and single-leg balance.  We ensure this all happens for the patient to experience optimal results.

Intervention

EARLY WEIGHT BEARING WITH SUPPORT PHASE:  Individuals with acute lateral ankle sprains should use lace up style external supports and progressively bear weight on the affected limb (We offer a complimentary screen to help you know braces that are very effective and how much weight you can bear on your limb). The type of brace and gait assistive device recommended should be based on the severity of the injury, phase of tissue healing, level of protection indicated, extent of pain, and patient preference. In more severe injuries, immobilization ranging from semi-rigid bracing to below-knee casting may be indicated. We utilize a mobility to stability inverse diagram to help guide this process for quicker and effective healing.

MANUAL THERAPY: Manual therapy procedures can be very useful for healing, such as lymphatic drainage, active and passive soft tissue and joint mobilization, and anterior-to-posterior talar mobilization procedures.  These procedures are performed within pain-free movement, to reduce swelling, improve pain-free ankle and foot mobility and normalize gait parameters in individuals with an acute lateral ankle sprain.  IASTM (Instrument Assisted Soft Tissue Mobilization) Techniques may be used to remodeling tissues if required.

THERAPEUTIC EXERCISES: We implement rehabilitation programs that include high-skilled and progressive therapeutic exercises for patients with severe lateral ankle sprains.  We utilize phases of progressions and test out criteria to guide this process.

PROGRESSIVE LOADING PHASE: WPT includes high-skilled manual therapy procedures, such as graded joint mobilizations, manipulations, non–weight-bearing and weight-bearing mobilization with movement, to improve ankle dorsiflexion,
proprioception, and weight-bearing tolerance in patients recovering from a lateral ankle sprain.

THERAPEUTIC EXERCISE AND ACTIVITIES: We use progressive therapeutic exercises and activities, such as weight-bearing functional exercises and single-limb balance activities (activity and sport specific) using unstable surfaces in order to improve mobility, strength, coordination, and postural control in the post-acute period of rehabilitation for ankle sprains.

Summary

MILD TO MODERATE ANKLE SPRAINS ARE OFTEN HEALED WELL IF THE P.O.L.I.C.E. PRINCIPLE IS APPLIED AT HOME (See our blog on the POLICE principle).  FOR CHRONIC INSTABILITY OR SEVERE ANKLE SPRAINS, ADVANCED PHYSICAL THERAPY IS IMPERATIVE FOR LONG TERM SUCCESS OF DAILY ACTIVITIES OR SPORTS.

If you would like more information regarding rehab principles of ankle sprains and instability, please contact bryan@wrightpt.com or tyler@wrightpt.com. We take the management of patients with ankle pathology seriously and are available to assist where needed.