So, you’ve “rolled” your ankle in a weekend basketball game when stepping on another player’s foot. You’ve turned you ankle stepping in a pothole after the winter thaw when walking with a friend. You “turned” your ankle when you slipped on the edge of sidewalk or curb. You got over the initial pain and injury but, now your ankle continues to “give-out” unexpectedly and not when you are doing anything strenuous. You may be experiencing the symptoms of chronic ankle instability.
Ankle sprains are categorized in severity by Grades I, II and III. The injury primarily affects the ligaments on the outer side of the ankle that connect or maintain the talus bone of the foot to the outside ankle bone or malleolus. Injury results when the ligament is stressed beyond its available range of motion. Grade I is a slight stretch of the ligament with no compromise. Grade II is worse in severity and results in partial tearing of the ligament. And Grade III is complete rupture or tear of the ligament connecting the talus and lateral ankle bones. All three grades can lead to long-term issues if not treated properly early and all can lead to instability.
Ankle sprains have the highest occurrence rate of resultant chronic symptoms such as weakness, instability, repeated sprains and disability. Associated injuries to the peroneal tendons (running behind the lateral ankle) and joint cartilage injury are often times undiagnosed and if not addressed properly lead to chronic pain. However, one of the most significant consequences of ankle sprain can be instability of the ankle, and this instability can be as significant as giving way with just normal walking on flat surfaces. This instability can also be functional or structural.
Functional Instability occurs when the ankle is giving out with no structural compromise such as in Grades I and II and is often the result of inadequate restoration of motion, strength and balance retraining following the initial injury. Structural instability occurs in a Grade III tear due to the compromise of the ligament.
So, what is the best treatment for the three different grades of injury? How long should you be on crutches? Should I be in a cast or a walking boot? Do I need surgery if I have a Grade III tear? Will I need to wear a brace in the future to prevent re-injury? According to Bucky Whiteman, Physical Therapist at Progressive Physical Therapy, treatment for all three grades revolves around early and appropriate activities to reduce pain and swelling. This reduces additional trauma in secondary tissues and allows for early return to weight bearing which is critical in the prevention of further dysfunction.
The PRICE approach is still applicable immediately following the injury for all levels of sprain. P-Protection, which can be achieved through an array of appliances: tape, casting, braces, walking cast, plastic shell brace with inflatable bladder, or semi-rigid support. R-Rest, use of assistive devices for walking. I-Ice, to be used 15-20 minutes with 1-2 hour rest period between each application for the first 24-72 hours. C-Compression, with the use of ace wrap for the first 24-36 hours, E-Elevation, raise the lower extremity above your heart 2-3 hours a day to decrease swelling and bruising.
As soon as possible and for all grades of ankle sprain, the key is early, appropriate and protected activities that promote restoring range of motion, strength and most importantly balance and proprioception which is basically the ability to stabilize your foot and ankle while doing functional activities. A high percentage of ankle injuries will heal independent of specific treatment but, often times result in functional instability issues when the proper restorative activities are not performed early.
Semi-rigid ankle braces are recommended for ankle sprain early in the recovery process to prevent further injury and sometimes in return to sport or function. Immobilization in a boot is only recommended in Grade III sprains and typically not longer than 10 days due to the negative long-term effects of immobility. Crutches are used in patients that cannot weight bear due to pain, but, crutches are only recommended for a short time as early weight bearing greatly assists in the recovery process by stimulating the elimination of swelling and providing sensory input that promotes stabilization by the muscles that support the foot and ankle.
Grade III tears where the ligament is completely torn resulting in true structural instability do not always require surgical intervention. The need for surgical correction is multi-factorial. Age and activity levels are surgical considerations but, the key element in the surgical decision is based upon the level of instability reported by the patient regardless of age and activity level. Surgical correction may also negate the long-term effect of arthritic changes that occur over time with structural instability.
If you have experienced a recent ankle sprain or if you are dealing with issues from a previous injury, Progressive Physical Therapy with offices in Cumberland, Keyser and Romney can provide you with a therapeutic hands-on treatment and provide you with a therapeutic exercise program specific to your needs. Contact Progressive Physical Therapy and Rehabilitation Center for an assessment or visit our website (www.progressive-pt.net).