Three-Phase Rehab for High Ankle Sprains

Ankle sprains can be very debilitating -- especially for sports athletes who are eager to get back into action. Since most ankle sprains are treated conservatively (without surgery), physical therapists study the best ways to go about getting athletes back into full participation.

In this article, physical therapists at the University of Iowa describe their approach to high ankle sprains. Anatomy, mechanisms of injury, and assessment of the problem are also covered.

A high ankle sprain refers to tearing of the connective tissue that connects the lower part of the tibia to the fibula. The tibia is the larger of the two bones in the lower leg. Your shin is the front of the tibia.

The fibula is the smaller bone (along the outside of the leg). Syndesmosis is the name of the connecting tissue between these two bones. Another word used to describe high ankle sprains is syndesmotic.

The syndesmosis is actually more than just a single layer of connective tissue between the tibia and fibula. That's certainly part of it but there are also four strong ligaments involved (anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, interosseous ligament, transverse tibiofibular ligament).

With that much ligamentous support, you can imagine the kind of force it takes to tear them. Most of these high ankle sprains occur when the player collides with another player or gets hit with enough speed and force to fracture one or both of the bones and the ligaments. In all cases, the foot is planted on the ground while load is applied above the ankle.

A similar mechanism (pathway to injury) occurs in skiers or skaters who have the foot planted firmly, then twist or torque suddenly. Pressure applied along the top of the rigid boot from the sudden force is enough to tear the stabilizing soft tissues (ligaments and connective tissues) just described.

Without a normal, healthy, intact syndesmosis, the ankle becomes unstable. Of course the athletes who need a stable ankle the most are the very ones who injure this area: ice hockey players, soccer players, and football and rugby players.

Syndesmotic of high ankle sprain injuries are fairly easy to diagnose. There's the expected history of trauma along with typical symptoms. Pain is the main symptom but bruising, swelling, and tenderness over the injured ligaments and interosseous membrane are often present. Any of those symptoms plus an inability to put weight on the foot is an additional telltale symptom of high ankle sprains.

Diagnostic clinical tests can be applied to stress each ligament. Either the examiner applies a manual force to each soft tissue structure or the patient assumes certain positions to create similar loading patterns.

The amount of pain and length of tenderness are important findings to predict results. For example, the farther up the leg tenderness is felt, the longer the athlete will be away from participation in sports. Likewise, the amount of pain matches how much of the ligamentous support has been damaged (severe pain likely means more damage).

Therapists have devised new ways of testing for syndesmotic damage. Rather than stressing the potentially unstable joint, they tape the lower leg and provide external support. If the painful symptoms are reduced or go away with taping, it's considered a positive test for a high (syndesmotic) sprain.

But these clinical tests are not the end of the evaluation. It's important to find out exactly what's injured and the extent of that injury before beginning rehab. X-rays and MRIs provide additional information needed along these lines. If there are any other injuries (e.g., fractures, damage to the bone or cartilage), they will show up with imaging studies.

The three-phase rehab program proposed by and studied at the department of Physical Therapy and Rehabilitation Science at the University of Iowa is made up of 1) the acute phase, 2) subacute phase, and 3) advanced training phase. Each phase has its own goals, treatments, and criteria for progression (moving along to the next phase or getting back into sports participation).

Every athlete is evaluated individually in order to determine the best treatment approach. Once the three-phase program is tailored for the athlete, the therapist carefully monitors symptoms, concerns, goals, and each part of the program.

In the acute phase, the goal is to protect the joint and decrease symptoms, especially pain, swelling, weakness, and loss of motion. A variety of tools are used to accomplish these goals such as immobilization in a cast or brace and limiting weight-bearing if needed. Modalities such as ice, compression, electrical stimulation, manual therapy, and/or complementary therapies (e.g., acupuncture) may be used.

When the patient can walk with minimal difficulty on different types of surfaces (uneven ground, stairs, grass, curbs), then they are progressed to the subacute phase. Now the goal is to get normal joint motion, strength, and motor control back.

The early phase of a strength-training program is started during the subacute phase. The foot and ankle will be challenged with balance activities (e.g., rocker board, wobble board, air cushion). A foot cycle, aquatic therapy, ankle weights or elastic resistance, and weight machines are just a sampling of the many ways training continues.

Advanced training is begun when the athlete can jog and hop with little discomfort and can perform all daily activities. The goal, of course, is to get back into sports action. Running, hopping, figure-8, and jumping drills are an important first step in the advanced training series of exercises.

The athlete will progress through advanced strengthening, plyometrics, speed drills, and running patterns. Plyometrics involve making fast changes with momentum (speed). This is kept up until they can perform sport tasks at game speed without pain or discomfort. Correct movement patterns and quality motor control are also required. That's when they are released to return to full participation in whatever sport they want to participate in.

The authors conclude by saying that this three-phase rehab program is one sample of how the problem of high ankle sprains in athletes can be handled. There is a need for research to validate the best treatment for this problem. Comparing techniques and modalities in each phase of healing and recovery with results will help guide future treatment recommendations.

Reference: 

Glenn N. Williams, PhD, PT, ATC, and Eric J. Allen, MS, PT, ATC. Rehabilitation of Syndesmotic (High) Annkle Sprains. In Sports Health. November/December 2010. Vol. 2. No. 6. Pp. 460-470.

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