Inversion ankle sprains are common among physically active people,with an annual incidence of 7 injuries per 1000 people. It has been reported that nearly 23 000 individuals in the United States experience an ankle sprain every day. Ankle sprains account for 75% of all ankle injuries and between 10-30% of all youth sports-related injuries including 31% of soccer injuries and 45% of basketball injuries. Often at initial physiotherapy sessions it can be difficult to test due to increased swelling. After 4-5 days however, the anterior drawer test has been shown to have specificity of 0.74 and sensitivity of 0.86.
Typically at the clinic we try to initially promote general movement and good mechanics, reduce inflammation and provide education. The following visits we progress manual therapy toward reducing impairments. Glides that we will typically use are talocrural/subtalar distraction, dorsiflexion/plantar flexion mobs and subtalar inversion/eversion. We progress towards higher intensity mobilization as the visits progress.
Over the years we have pondered who might benefit most from Manual Physical Therapy? The CPR by Whitman et al tried to answer this question. They found in a study of 85 patients that 75% of patients had a successful outcome by their definition. The self-report measures included the NPRS, Foot and Ankle Ability Measure (FAAM),36 the Lower Extremity Functional Scale (LEFS), 48 and the Beck Anxiety Index (BAI). The four predictor variables were: Symptoms worse with standing, symptoms worse in evening, a navicular drop of >5 mm, and distal tibiofibular hypomobility. They found that patients were 95% successful if they met 3 out of the four variables. It was remarkable that if 4 of the 4 variables were present the likelyhood of success 56% vs 50%. It must be noted that only a small percentage of candidates fit into these groupings, but it does question the definitive value of the CPR. We would like to see this done with a larger sample size. Another interesting point from the study was that it seems as though in the group where there was non-success there was a history of ankle pain 62% vs the success group 40%. In this grouping there might indeed be some type of neurophysiological dysfunction, anatomical derangement or sensitivity. In a similar vein, studies have proposed that patients with ankle sprains may exhibit “positional faults” or abnormal accessory joint mobility at the distal tibiofibular joint. I’m curious of whether having a navicular drop of >5mm and distal tibiofibular hypomobility might be good *predictors* of ankle inversion sprains. Intrinsic Risk factors or re-injury are: History of ankle injuries, Decreased ability to flex you ankle upwards and postural sway. Regardless, this study shows that patients will typically get positive treatment effects from manual therapy.
The effectiveness of manual therapy was reinforced in a study by Cleland et al. of seventy-four patients that compared the effects of manual therapy and exercise with a home exercise program. They found hugely significant early gains with manual therapy that decreased somewhat over time. There were a few items that caught my attention in this study however. The Physical Therapists in the HEP group spent 50% of the time with patients versus the manual therapy group and at no point was the HEP group was there any physical contact with the patient. I believe that education, interaction and engagement plays a positive role in healing. Again there is a positive result for manual therapy from the study, but perhaps not as strong as the numbers might indicate.
Exercise and eduction is the second component that is necessary for superior improvements. Considering the magnitude of this problem and its prevalence in commonly played sports we should try to prevent them in the first place. Bahr et al. prospectively studied the effects of an injury prevention programme on the rate of ankle sprain in 719 men and women in the Norwegian Volleyball Federation. The programme consisted of an injury awareness educational session, technique training (that included jumping and lateral movement drills), and ankle disk training. The results showed a 47% reduction in the incidence of ankle sprains over 1 year compared with the year prior to. This sounds great from a numbers perspective however how much of this might be up to chance? Could this be replicated? How many were recurrences? What variables were the most effective in predicting ankle sprains? In the presentation by Dr. Teyhan it was suggested that potential chronic symptoms exist with > 40% of all sprains and that recurrent sprains common 2º functional instability.These two points are debated in the Cochrane review but a systematic review from Australia showed “It is likely that exercise therapy, including the use of a wobble board, is effective in the prevention of recurrent ankle sprains”. So it seems that dynamic stability and proprioceptive training are effective and can be suggested to athletes in sports as a later component of treatment and also as a preventative strategy.
The research supports the use of manual therapy, education, and specific exercise. The paper by Vincenzino shows that we can significantly improve ankle function in chronic cases. We spend a lot of time with sub acute patients focusing on stability training- as it can be extremely frustrating to take these patients along the spectrum only for recurrance to happen for everyone! From this perspective we often try to modulate with taping I peform upon return to sport. Initially we will try to really prevent all inversion then as time goes on we decrease support. Sequentially the patient can eventually return to full function without any taping needed.
Wolfe MW. Ankle Sprains. American Family Physician, 63 (1) 2001
Vicenzino. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. J Orthop Sports Phys Ther, 36 (2006), pp. 464– 471
Cleland J et al. Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial.journal of orthopaedic & sports physical therapy 43:7 july 2013.
Osborne MD, Rizzo JD. Prevention and Treatment of AnkleS prain in Athletes. Sports Med 2003; 33 (15)
Bahr R, Lian O, Bahr IA. A twofold reduction on 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