Acute Phase
Rehabilitation Program
Physical Therapy
Initial treatment of all grades of lateral ankle sprains consists of rest, ice, compression, and elevation (RICE), as well as nonsteroidal anti-inflammatory drugs (NSAIDs). [17, 18, 13] Ice should be applied to the injured ankle for approximately 20 minutes, 3-4 times per day. Compressive dressings should be used to control swelling. Weight bearing should be encouraged as soon as it is tolerated. With grade III injuries, an ankle brace should be worn at all times till the patient can ambulate pain free. Ankle braces can be used for support in all ankle sprains and may help promote earlier ambulation. Studies have found an air stirrup brace and ACE wrap are beneficial in grade 1 ankle sprains and may help in grade II and III sprains as well. [13]
The early phase of rehabilitation is begun approximately 48 hours postinjury. [19] Icing is continued and range of motion exercises are initiated. Writing the alphabet with the great toe moves the ankle through full range of motion in all planes. Stationary biking and stretching of the Achilles tendon are also beneficial.
As strength and mobility improve, isometric exercises for ankle dorsiflexion, plantar flexion, inversion, and eversion are initiated. The isometric exercises are followed by resistance exercises (initially using a Thera-Band strap) and then heel and toe raises. Agility training also aids in returning the athlete to sports. Proprioceptive and balance training are also extremely important to help the patient heal fully, especially in jumping athletes. Proprioceptive training should be incorporated into all rehabilitation protocols.
In grade III ankle sprains, some studies have shown that early mobilization and rehabilitation may provide earlier functional recovery relative to surgery, and there is general agreement to try a 6-week period of conservative management, including early, controlled mobilization and rehabilitation before considering surgery. [19, 20]
Also, no difference is found in long-term outcome when comparing early surgical repair with delayed surgical repair following failed conservative therapy. [20] Therefore, there is no indication for routine early surgical repair.
Related Medscape Reference topics:
Nonsteroidal Anti-inflammatory Agent Toxicity
Related Medscape resources:
Resource Center Adverse Drug Events Reporting
Specialty Site Surgery
Surgical Intervention
Primary repair of acute lateral ligament tears is rarely indicated. Open repair seems to offer no advantage over closed management at the time of the initial injury. Delayed repair may be necessary in patients with chronic mechanical instability on clinical examination and functional instability; however, surgical intervention in these cases should only be considered after an aggressive rehabilitation program has been unsuccessful.
Consultations
An emergent consultation is rarely required.
Consultation with an orthopedic surgeon should be obtained for patients with unstable ankles, dislocations, or associated fractures.
Recovery Phase
Rehabilitation Program
Physical Therapy
When the early phase rehabilitation goals of decreased swelling, full weight bearing, and no tenderness to palpation are met, more aggressive strengthening and proprioceptive training are added. Increased stretching of the Achilles tendon, as well as the gastrocnemius and soleus muscles, is performed using an incline board. Thera-Band exercises are continued for strengthening. Exercises such as one-leg stands and wobble board training are added for proprioception. This training continues until the ankle is at 80-90% of full strength and there are no deficits in proprioception. When these goals are met, the patient may be discharged from therapy.
Surgical Intervention
Maximum benefit from conservative therapy is reached after approximately 10 weeks of active rehabilitation. At this time, 20% of athletes continue to have symptoms secondary to either a functional or mechanical instability. If the patient has reached his or her maximal benefit from functional rehabilitation and has a persistent deficit, then surgical reconstruction should be considered. [20, 21, 22]
Maintenance Phase
Rehabilitation Program
Physical Therapy
The patient should be independent with a home exercise program with sport-specific activities and gradually return to play when the functional goals are met. The physician and/or physical therapist may recommend taping or bracing the ankle upon returning to activity. Taping or bracing a previously injured ankle during athletic activity has been shown to reduce the incidence of recurrent injury.
Return to play
Athletes may return to sports following a talofibular ligament injury when they are able to run and pivot without pain while the ankle is braced. Bracing and taping of the injured ankle is continued during athletic activities for 6 months.
Prevention
Completion of an adequate rehabilitation program, as well as functional bracing or taping for 6 months following the injury, minimizes the chance of recurrent injury.
