Document 136516

Evidence Based Protocols for
Therapeutic Intervention
Ankle Sprain
Description: Acute injury to ankle, most commonly resulting from forced inversion
mechanism. It frequently involves one or more lateral ligaments. More
severe injuries might include involvement of medial (deltoid) ligament or
avulsion fracture of fifth metatarsal.
Three grades of ankle sprains:
Grade I (First Degree) sprain is the most common and requires the
least amount of treatment and recovery. The ligament damage has
occurred without any significant instability developing.
Grade II (Second Degree) injury is more severe and indicates that the
ligament has been more significantly damaged, but there is no
significant instability.
Grade III (Third Degree) sprain is the most severe. This suggests that
the ligaments have been torn, and that instability has resulted.
Overview: Rehabilitation for an ankle sprain starts with the RICE principle (Rest, Ice,
Compression, Elevation). The severity of the sprain determines the speed of recovery.
Maintaining range of motion and reducing swelling are two keys to early rehab. As pain
decreases we must start strengthening to help protect the ligaments that have been
stretched. Balance exercises will then be initiated in order to help get feedback from the
ligaments, tendons, and muscles. When range of motion, strength, and balance are
“back to normal” you will be able to return to your normal activities.
Levels of Evidence
All studies are categorized using the: Oxford Centre for Evidence-based Medicine
Levels of Evidence as summarized below.
Levels of Evidence
Level I
Evidence obtained from high-quality randomized
controlled trials, prospective studies, or diagnostic
Level II (*L2*)
Evidence obtained from lesser-quality randomized
controlled trials, prospective studies, or diagnostic
studies (improper randomization, no blinding >80%
Level III (*L3*)
Case controlled studies or retrospective studies
Level IV (*L4*)
Case series
Level V (*L5*)
Expert Opinion
Phases of Healing: Evidence Based Protocol for Progression of Activities
Inflammatory Phase (0-3 days)
Phase I
Reduce pain and swelling
Improve circulation
Promotion of partial to full weight bearing
Weight Bearing
WB as tolerated
Crutches may be used if necessary
Exercise (Van der Wees et al, 20061)
Early mobilization (DF/PF, ABC’s/circumduction)
Bracing (Kerkhoffs et al, 20022)
Apply compression bandage to reduce swelling
Ice and Elevation (Bleakley et al 20043)
Ice frequently during first 48 hours avoid heat
• 15-20 minutes every 2 hours
Elevate to reduce swelling
Criteria to Start Phase II
No pain at rest
Proliferation Phase (4-10 days)
Phase II
Restore function and activities
Improve load-bearing capacities
Prevent increase in inflammation
Prevent muscle atrophy
Weight Bearing
Stimulate symmetrical WB
Instruct on heel-toe walking
Strength (Blackburn et al 20004, Kannus et al 19925,
Tropp et al 19856, Uh et al 20007, Wojtys et al 19968)
• Foot intrinsics
• Isometrics→Concentrics
♦ Sub-max→max
♦ Pain free
• Lower extremity strengthening
♦ Quads, Hamstrings, etc
Proprioception (Stomp et al 20059, Van der Wees1
et al 2006, Verhagen et al 200010)
• BAPS board
♦ Non WB→full WB
• Single leg stance
♦ Even surface as tolerated
ROM (Van der Wees et al 20061)
• Seated calf stretching
• PNF patterns
• AROM in all planes
♦ Alphabets
Bracing (Kerkhoffs et al, 20022)
Continue elastic bandaging, bracing, or taping
Criteria to Start Phase III
Full WB
No increased edema with activity
Normal gait pattern
Early Remodeling Phase (11-21 days)
Improve muscle strength, ROM, and functional stability
Phase III
Weight bearing
Full increasing stress
Exercise (Bahr et al. 199712 Heidt et al. 200013,
Holme et al. 199914, Söderman et al. 199115)
Strength (Blackburn et al 20004, Kannus et al 19925,
Tropp et al 19856, Uh et al 20007, Wojtys et al 19968)
♦ Continue progressing ex as tolerated
♦ Initiate eccentric ex
♦ Toe Walks
♦ Heel raises
♦ Toe raises
♦ Squats
Proprioception (Stomp et al 20059, Van der Wees1
et al 2006, Verhagen et al 200010)
• Progress to uneven surfaces
♦ Airex
♦ Dyna Disc
♦ Single plane balance board
♦ Single leg rebounder drills
ROM (Van der Wees et al 20061)
• Stretching
♦ Standing calf
• Mobilizations
♦ Ant/post mobs for Dorsiflexion
Bracing (Handoll et al 200111, Stomp et al 20059,
Verhagen et al 200010)
Tape or brace for sports or other strenuous activities
Criteria to Start Phase IV
No increased edema with activity
Ability to balance on injured leg for 60 seconds
Ability to jog without pain
Phase IV
Late Remodeling Phase (3-6 weeks)
Increase load bearing capacity
Improve balance and coordination
Improve strength
Weight bearing
Increase so capacity equals usual loads performed prior to
Jumping/hopping drills
Exercise (Bahr et al. 199712 Heidt et al. 200013,
Holme et al. 199914, Söderman et al. 199115)
Continue progressing ex as above
Bracing (Handoll et al 200111, Stomp et al 20059,
Verhagen et al 200010)
Tape or Brace for Sports
Criteria to Start Phase V
No increased edema with exercise
Single leg hop test on injured leg 80% of non-injured leg
5/5 strength in all motions of the ankle
Ability to run in a straight line with normal gait pattern
Phase V
Return to Sport
Achieve required load bearing capacity
Design sport specific treatment and training program
Weight bearing
Continue until load bearing capacity pre-injury capacity
Agility drills
Work with Coach/ATC to develop training program
Continue sport specific strengthening
1. Van der Wees PhJ, Lenssen AF, Hendriks HJM, Stomp DJ, Dekker J, de Bie RA.
Effectiveness of exercise therapy and manual mobilization in acute ankle
sprain and functional instability: a systematic review. Aust J Physiother
2. Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly K, Struijs PA, van Dijk CN.
Immobilisation and functional treatment for acute lateral ankle ligament
injuries in adults. Cochrane Database Syst Rev 2002;(3):CD003762
3. Bleakley C, McDonough S, MacAuley D, The Use of Ice in the Treatment of an Acute Soft
Tissue Injury. Am J Sport Med 2004; 32; 251-261
4. Blackburn T, Guskiewicz KM, Petschauer MA, Prentice WE. Balance and joint
stability: The relative contributions of proprioception and muscular strength. J
Sport Rehab 2000;9:315-28.
5. Kannus P, Alosa D, Cook L, Johnson RJ, Renstrom P, Pope M, et al. Effect of onelegged exercise on the strength, power and endurance of the contralateral leg.
A randomized, controlled study using isometric and concentric isokinetic
training. Eur J Appl Physiol Occup Physiol 1992;64(2):117-26.
6. Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med
7. Uh BS, Beynnon BD, Helie BV, Alosa DM, Renstrom PA. The benefit of a singleleg strength training program for the muscles around the untrained ankle. Am
J Sports Med 2000 Jul;28(4):568-73.
8. Wojtys EM, Wylie BB, Huston LJ. The effects of muscle fatigue on
neuromuscular function and anterior tibial translation in healthy knees. Am J
Sports Med 1996 Sep;24(5):615-21.
9. Stomp DJ, Hendriks HJM, Heemskerk MAMB, van der Wees PJ, de Bie RA.
Effectiviteit van fysiotherapie bij patiënten met chronische functionele
instabiliteit van de enkel: een systematisch literatuuroverzicht. Ned Tijdschr
Fysiother 2005;115(2):26-31.
10. Verhagen EALM, van Mechelen W, de Vente W. The effect of preventive
measures on the incidence of ankle sprains. Clin J Sports Med 2000;10(4):2916.
11. Handoll HHG, Rowe BH, Quinn KM, De Bie R. Interventions for preventing
ankle ligament injuries. The Cochrane Library 2001.
12. Bahr R, Lian O, Bahr IA. A twofold reduction in the incidence of acute ankle
sprains in volleyball after the introduction of an injury prevention program: a
prospective cohort study. Scand J Med Sci Sports 1997;7:172-7.
13. Heidt RS, Jr., Sweeterman LM, Carlonas RL, Traub JA, Tekulve FX.
Avoidance of soccer injuries with preseason conditioning. Am J Sports Med
2000 Sep;28(5):659-62.
14. Holme E, Magnusson SP, Becher K, Bieler T, Aagaard P, Kjaer M. The effect of
supervised rehabilitation on strength, postural sway, position sense and reinjury risk after acute ankle ligament sprain. Scand J Med Sci Sports 1999
15. Soderman K, Werner S, Pietila T, Engstrom B, Alfredson H. Balance board
training: prevention of traumatic injuries of the lower extremities in female soccer
players? A prospective randomized intervention study. Knee Surg Sports
Traumatol Arthrosc 2000;8(6):356-63.