Sprained ankle

Ankle sprain is one of the most common sites for acute musculoskeletal injuries and most of them are sport-related. Most ankle sprain can be recurrence if not handle it properly.

Classification of Ankle Sprain

Ankle sprain can be classified from grade I to grade III depending on it severity (Table 1).

Mechanisms of Injury

The most common mechanism of injury in ankle sprains is a combination of plantar flexion and inversion. The lateral collateral ligaments, including the anterior talofibular, calcaneofibular and posterior talofibular ligament, will be damaged. The anterior talofibular ligament is the most easily injured. Concomitant injury to this ligament and the calcaneofibular ligament can result in appreciable instability. The posterior talofibular ligament is the strongest and is least injured.

The anterior drawer test can be used to assess the integrity of the anterior talofibular ligament, and the talar tilt test can be used to assess the integrity of the calcaneofibular ligament (Figure 3).

Diagnosis

Diagnosis includes evaluation of injury history (situation and mechanism of injury) and physical examination (observation, palpation, weight-bearing status, tests).

Tenderness along the base of the fifth metatarsal may indicate an avulsion of the peroneal brevis tendon.

Initial Management

As swelling decrease range of motion in the ankle joint, the first aim of physiotherapy is to reduced swelling and maintain range of motion.
It includes RICE (rest, ice, compression and elevation). Ice therapy should be used immediately after the injury. Heat is contraindicated because it increases swelling and inflammation.

Once ice therapy is used, exercises should be started to maintain range of motion and assist lymphatic drainage. Lymphatic drainage technique should be used to assist drain out of congested lymph
Taping and ankle support is effective in supporting the injured part and preventing from further injury. The injured extremity should also be elevated above the level of the heart to facilitate venous return and lymphatic drainage to help resolve swelling.

Functional Rehabilitation

After initial treatment, a rehabilitation program is important to facilitate functional return.

Early mobilization of ankle sprains is a extremely important part of rehabilitation program. Proper stress is required to stimulate the laid down of collagen fibers. Range-of-motion exercises, muscle-strengthening exercises, stretching exercises proprioceptive training and activity-specific training should be prescribed to patient by physiotherapist precisely according to patient’s situation and time frame of healing process.

Range of Motion

ROM exercises should be started once swelling is subsided. Different direction of ankle movement such as dorsiflexion, plantarflexion, inversion and eversion should be performed in pain-free manner. This can improve and mobility to prevent adhesion and stiffness caused by immobilization.

Muscle-Strengthening Exercises

Once swelling and pain are subsided, strengthening exercises is important to strengthen the weakened muscles to allow early recovery. Peroneal muscle which is commonly injured during ankle sprain should be strengthened to protect the ankle joint and prevent further injury and chronic instability. begins with isometric exercises performed against an immovable object in four directions of ankle movement. The patient then progresses to dynamic resistive exercises using ankle weights, resistance bands or elastic tubing (Figure 9).

Achilles tendon stretching using a towel.	Use of therband in strengthening exercises for evertor.
Single-leg toe raises done on a step.	FIGUSingle-leg wobble board exercise to increase proprioception.

Proprioceptive Training

The aim of training is to regain the joint position senses and balance. This is an effective exercise to prepare patient to a higher functional level. Propriocetive training starts by standing of KAT machine with eyes opened. Training can be progressed by having the patient perform this exercise with eyes closed.

Training for Return to Activity

Once patient have no longer pain when walking, rehabilitation may progress to more advanced state. Less demanding exercise such as jogging can be prescribed by physiotherapist to patient in different direction such as forward, backward, sideway figure-of- six and figure-of-eights.

Sports athletics may require more intense rehabilitation to meet their needs. Cardiovascular fitness is also extremely important to prepare them for their sports activities. Advanced training should be sport-related.