Efficient treatment of ankle sprains continues well after the pain subsides. While the majority of inversion (lateral) ankle sprains heal relatively quickly, up to 1/3 of patients, continue to note symptoms at one year, and up to 25% report pain, instability, crepitus, weakness, stiffness, or swelling at three years. (1) Re-injury is frequent, with rates reaching almost 75% in sports, like basketball. (2) Successful management of ankle sprains and prevention of re-injury are predicated on a couple of fundamental principles.
Management of ankle inversion sprains requires two steps; each is equally important.
- The first step entails the evaluation and treatment of acute pain.
- The second step involves preventing subsequent sprains – and new research validates the importance of chiropractic care to improve clinical outcomes in these recalcitrant cases.
STEP 1—Move for Pain Relief
Early return to activity for acute inversion sprains is supported by the literature. Exercises and treatments that promote joint motion and early return to weight bearing for acute ankle sprains have proven more effective than immobilization. While grade III sprains (ligament rupture) may require immobilization, grade I and II ankle sprains should forego complete immobilization and instead focus on regaining full range of motion. In fact, early rehab and return to weight bearing will increase ankle range of motion, decrease pain, and reduce swelling sooner than immobilization.
In a study by Linde et al., 150 patients with inversion ankle sprains were treated with early motion and weight bearing. After one month, 90% of the patients treated with early motion and weight bearing demonstrated pain-free gait and 97% had increased work ability. (3) Early mobility exercises would typically include:
These four exercises promote balance and range of motion – specifically dorsiflexion, which is a key contributor to ankle injury. Patients who have lost an average of 11 degrees of dorsiflexion are five times more likely to suffer lateral ankle sprains. (4)
In office care should also include mobilization and manipulation for restoring function. Joint mobilization has been shown to decrease pain, increase dorsiflexion, and improve ankle function. (5) IASTM or transverse friction massage to the affected ligament may help mobilize scar tissue and increase pliability. Myofascial release may help release tightness or adhesions in the gastroc and soleus. (Side note: The FAKTR concept seamlessly incorporates all of these tools to produce top-tier outcomes.)
Knowing when to treat and when to refer is critical. Whitman’s clinical prediction rule identifies four variables to predict the success of manipulation and exercise for the treatment of inversion ankle sprains. (6) The presence of three out of four of the following variables predict greater than a 95% success rate for manual therapy and exercise:
- Symptoms worse when standing
- Symptoms worse in the evening
- Navicular drop greater than 5 mm
- Distal tibiofibular joint hypomobility
STEP 2- Prevent Re-injury
The second step is shorter and easier than the first. The most crucial variable in the successful prevention of future ankle sprains is improving BALANCE. Balance training reduces the incidence of ankle sprains and increases dynamic neuromuscular control, postural sway, and joint position sense in athletes. (7) A study by de Vasconcelos et al. (2018) found that balance training reduced the incidence of ankle sprains by 38% compared with the control group. (7)
Two of the most common exercises used for balance and proprioception include the single-leg stance exercise and Veles. A simple explanation stressing the importance of balance training may be necessary to promote patient compliance.
Finally, encourage your patients start walking “normal” as soon as possible. As evidence-based chiropractors, we need to return patients back to their normal gait as soon as tolerable. Patients with foot and ankle pain will often favor a supinated gait in order to unload the soft tissues of the foot and arch in favor of their bony architecture on the lateral foot. The lateral column of the foot affords stability but at the expense of a very inefficient gait. Over an extended period, these patients may develop a Tailor’s bunion, i.e. 5th metatarsal head bursitis. However, in the case of ankle sprains, a rapid increase in activity may overload the metatarsal fast enough to cause a Jones Fracture. Return to normal gait will minimize these compensations.