Prehabilitation and Rehabilitation Initiatives for a Lateral Ankle Sprain
The ankle is the most commonly injured joint in the body and 85% of those are inversion sprains (Gutierrez et al., 2007). Lateral ankle sprains are common among both active and inactive individuals. They often happen with similar mechanics by plantar flexing and inverting the ankle, excessive stress in this position on these structures can cause damage to the ligaments on the lateral side of the ankle, which are known as the anterior talo-fibular ligament (ATFL) and the calcaneal fibular ligament (CFL). Once an initial injury to these ligaments has occurred, there is up to 74% recurrence rate, making the joint more susceptible to re-injury (Gutierrez et al., 2007).
The reason thought for such a high re-injury rate is due to poor prehabiliation or injury prevention and rehabilitation or injury management strategies. Here we will talk about ways in which you can go about helping to prevent this type of injury and useful ways to help to rehabilitate or manage this injury. Injury prevention strategies such as muscle strengthening and joint proprioception exercises will benefit you if you have previously suffered from a lateral ankle sprain as well as if you have no previous injury.
Prehabiliation/ Injury Prevention
Not only will injuries impact how an player performs, subtle biomechanical dysfunctions or deficiencies can impact the overall performance, especially in regards to coordination, balance, speed, power and agility (Akbari et al., 2006).
Injury prevention plays a huge role in modern day sport, I will briefly dicuss the importance of doing prehabiliation exercises and what benefits you will see from these.
Activation exercises improve a persons proprioceptive ability. Within skeletal muscles are specific sensory neurons called ‘proprioceptors’ that monitor tension in the body and send messages between muscle fibres and the central nervous system (CNS). There is a long-standing principle of ‘Use It or Lose It,’ which applies to the CNS and human movement. The body gets better at the movements it preactices most often and loses the ability to perform the other movements it does not practice. These prehabilitation exercises strengthen neuromuscular connections that are responsible for creating human movement. More specifically, these exercises can help to improve: coordination, balance, speed, power, reaction time and agility.
Treatment and early stages of rehabilitation of a lateral ankle sprain
There are many different components which make an effective rehabilitation program, each would be tailored dependent of what the extent of damage has occurred. In this article I will discuss a few general essentials which will help in the process of rehabilitation.
When a ligamentous structure is damaged, it is the body’s natural reaction for it to swell up, bruise and to emit pain. This is just the body’s own way of protecting the damaged structures further. In this case, when these symptoms are present, cryotherapy or the RICE (rest, ice, compression, elevation) principle can be used by applying ice and compression and elevating the leg to restrict the blood flow to the damaged area, thus reducing the inflammation and afterwards allowing for fresh, oxygenated blood to flow through the ankle delivering vital nutrients to help with the healing process Snyder et al., (2011). This can be done by simply a bag of ice and a compression bandage or, if available, a Game Ready machine.
If a grade 1 or 2 sprain, it is important to note that immobilisation of the joint should be avoided as it could result in local irritation, joint stiffness, muscular atrophy and extensive loss of proprioception (Terada et al., 2013). Finding out the extent of the damage is key to whether or not immobilisation is the correct thing to do. Further, statistically significant differences in favour of functional treatment as opposed to immobilisation showed a faster return to sport rate and return to work rate (Peterson et al., 2013).
After applying the RICE principle for the first 3-5 days post injury it is important to begin to mobilise the joint again. As long as symptoms allow, begin partial-weight bearing exercises. Early mobilisation helps the muscles, tendons and ligaments heal with stronger and encourages more organised collagen fibres Nuhmani and Khan (2013).
When a lateral ankle injury occurs, it can have significant deficiencies in strength and proprioception around the ankle (Doherty et al., 2015). Balance (or proprioception as it is known) training should be introduced when the patient can fully weight bear with minimal or no pain and have been proven to reduce the risk of re-injury (Heyward, 2010).
Maintaining Muscle Mass and Strength
In the early stages it is important to try and activate the surrounding muscles to prevent muscular atrophy. This can be done by some simple isometric contractions. These can be performed stood up with the foot placed flat on the floor, pushing the foot down towards the ground, contracting the surrounding muscles. Alternatively, this can be done sat down with the damaged leg elevated by wrapping a towel around the end of the foot and applying the same concept.
This can be performed x3 30 seconds.
Re-Gaining Balance
The way in which we improve our balance is to change from stable surfaces to unstable surfaces.
To begin with, bare-foot single leg stands can be done which can be done as an effective way of regaining proprioception; progressions from this could:
Single leg standing on a semi-inflated balance pad
Double leg standing a BOSU ball
Single leg standing on a BOSU ball
Double leg standing on a wobble board
Single leg stands on a fully inflated pad
Single leg stands on a wobble board
Further progressions of these can be:
Jumping from a stable surface (hard floor) to an unstable surface (balance pad, BOSU board, wobble board, Dyno Disc, a folded towel, sand)
Performing functional movements such as squats and lunges on an unstable surface
Each of these improve proprioception and balance as they cause an imbalance for the entire body, stimulating the proprioceptive system to activate in order to keep themselves balanced (Andrews, 2012).
Types of Unstable Surfaces:
Balance Pad
Wobble board
Dyno Disc
BOSU board
Folded Towel
Sand
These next few exercises can be done as a prehabilitation strategy and as a rehabilitation strategy, providing the joint is stable enough and the person is confident enough to perform the exercises with minimal or no discomfort.
Single-Leg Heel Lift on stable surface, progress onto an Unstable Surface (Kaminski et al., 2013)
Stand on one foot and lift the opposite knee to hip height. Next, press into the forefoot and attempt to lift the standing heel up into the air while maintain balance. This exercise will be much harder to perform on an unstable surface, yet each attempted rep will yield more effect in regards to activating the neuromuscular connections of the foot and ankle.
Perform 5-10 reps on each leg.
Single-Leg Rotation on a stable surface, progressing onto an unstable surface (Kaminski et al., 2013)
Stand on one foot and lift the opposite knee up to hip height as you hold the arms out in front and press the hands together. Make sure that the arms are parallel to the floor and focus your eyes on your hands. Next, rotate the arms 45 degrees to each side as you attempt to maintain balance and continue to focus the eyes on the hands. Again, this exercise will be more difficult to perform, but very effective at stimulating the proprioceptors and activating the neuromuscular connections in the foot and ankle.
Rotate the arms for 15-30 seconds.
Advanced Version: Eyes Closed- for further stimulation of the proprioceptors in the lower leg and foot, try this exercise all over again with the eyes closed.
Rotate from side-to-side for 15-30 seconds on each leg.
Single-Leg Toe Touch on an Unstable Surface (Kaminski et al., 2013)
Stand on one foot and reach down to touch the toes with the opposite hand while maintaining balance. Reach the opposite heel back towards the horizon and focus the eyes on the toes while touching. Then return to standing and shift the focus of the eyes back to the horizon while trying to maintain balance.
Perform 5-10 reps on each leg.
Once the patient is comfortable performing these exercises with an unstable surface, it would be appropriate to introduce some high resistance training to further develop the strength around the ankle.
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Doherty, C., Bleakley, C., Hertel, J., Caulfield, B., Ryan, J. and Delahunt, E. (2015) Laboratory Measures of Postural Control During the Star Excursion Balance Test After Acute First-Time Lateral Ankle Sprain. Journal of Athletic Training. Vol. 50, No. 6: 651-664.
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Heyward, V. (2010) Advanced Fitness Assessment and Exercise Prescription. (6th ed.) Stanningley: Human Kinetics.
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