In the last couple of posts we've been discussing the details of ankle sprains and rehab. The major issue with the treatment of this injury is that it's often left incomplete before athletes head back into action. The good news is that there is a better way to rehabilitate this injury. We hope that by shedding light on the issue we can get everyone rehabbed the right way and send our athletes back to sport more confident and safe.
We spoke extensively about the RICE protocol last post, and while it's a good start this protocol needs an update. In an editorial in the British Journal of Sports Medicine, C.M. Bleakley suggests we adapt the RICE protocol to include protection and optimal loading and call it POLICE.
Protection Optimal Loading Ice Compression Elevation
Let's talk about the two new terms here: protection and optimal loading.
Protection: This concept is similar to the idea of rest. In the previous paradigm rest meant staying off the injured foot as to protect the area from too much stress, which might disrupt the healing process. That sounds like it makes sense right? We don't want to setback any progress; however, too much rest can be a bad thing. When you don't give your muscles and ligaments load it actually weakens the structure of the tissue.
Optimal Loading: While too much rest can be a bad thing, too much activity is still a bad thing too. Ideally it's about finding the right balance of rest and activity or in other words - the optimal load. Load is necessary to restore the strength and structure of collagen, the main tissue in ligaments. We've got to find the happy medium, enough load to stimulate your tissues without overloading them.
So when it comes to designing an effective rehab program we have to consider the big picture. What effect has the injury had on the damaged tissue itself? To the joint mechanics of the ankle? To the nervous system and communication with the brain? Considering these components and incorporating what we've learned from current research, its important we go beyond RICE. We need to implement manual therapy and appropriate exercise in to ankle rehab protocols. Of course, every injury is unique and will require it's own assessment and treatment plan, but all three of the following components should be included in ankle sprain rehab in some capacity.
1. POLICE - Ice, compression and elevation is a good place to start but it's important not to be afraid of load. Loading is important and safe if applied correctly. Animal studies have shown that giving load to tissues actually helps them synthesize the proteins needed for soft tissue healing. Applying the right load helps you functionally too, by getting you moving comfortably sooner.
2. Restoring Biomechanics - This is an important step in making sure that the involved bones and joints are positioned well and moving correctly. The most common dysfunction involves the talus bone (although other bones like the fibula and cuboid can also be affected.) In this case the talus can be sitting slightly forward, limiting motion of the ankle. A number of techniques can be used to restore motion of this joint, including hands-on ankle mobilizations, taping or even exercises. This can alleviate pain and make sure that athletes head back to sport with full range of motion. A review article by Bekerom in 2012 reported that patients who had manual therapy on their ankle had faster walking speed and better range of motion compared to those who only received RICE. Without treatment this dysfunction has been shown to persist for up to 6 months.
Here are some examples of what these treatments and exercises
could look like:
Additionally, we should be looking at restoring correct movement patterns in the foot, knee, hip and trunk. More and more studies are showing that an ankle sprain injury can actually cause changes up the chain. This creates movement dysfunctions in the knee, hip, and even back. There is evidence that these changes outside of the ankle can also contribute to future ankle sprain injuries. So it's important to ensure that we don't just look at the mechanics of the ankle in isolation.
3. Exercise - This is probably the most important component of ankle rehab. Multiple studies have shown that exercises reduce the incidence of future injury. The right exercises at the right time can help decrease swelling, increase range of motion, increase strength, improve joint position sense and improve your confidence and performance.
Exercises early on in the injury can be particularly important. In these early phases the muscles around the injury site actually are inhibited from functioning optimally. This inactivation has a direct impact on muscle strength, balance and the brain-muscle connection. So not moving the ankle just makes things worse. A 2010 study by Bleakley and collegues showed that those who initiated simple exercises in the first week (you can see the exercises below) after the injury were able to be significantly more active. They spent more time walking and were able to do more light intensity activities. These exercises included a simple circular range of motion exercises, isometric strength exercises, a functional movement pattern and stretch.
Getting active quickly, under the right guidance, is nothing to fear after an ankle sprain. In fact, it's really good for you!
In the longer term, 4 studies have shown that training balance and coordination actually helps prevent the reoccurrence of ankle injuries for up to 12 months. Another long-term effect of ankle injury is reduced strength, so including strengthening exercises is also important.
Here are some examples of exercises that were used in these studies. Single leg knee flexion on a disc, toe raises, a static single leg stance on a balance disc, knee swing-throughs on a disc, lateral knee swings on a disc, and toe walking.
As you can see, these exercises are pretty simple and don't require much equipment; but taking the time to include them in your rehab can make a big difference. Not only will you feel better sooner, but also it can actually affect whether or not you suffer future injuries. It's a win-win.
So if you suffer an ankle sprain, know that there's more you can do than just wait. In fact, there are a lot of good reasons to be more active about properly rehabilitating this type of injury. Begin with identifying the type of injury you've suffered so that you can be specific about what is included in your rehab. From there remember to go beyond the RICE acronym and think about what is included in POLICE. Finally, it's important to have a biomechanical assessment and treat the injury with a targeted exercise program. We hope that sheds some light on the importance of correctly managing this common and often poorly managed injury.
What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? journal of athletic training Bleakley, C. M. et al. Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ 340, c1964-c1964, 10.1136/bmj.c1964 (2010)
http://physioworks.com.au/injuries-conditions-1/high-ankle-sprainKerkhoffs, G. M. et al. Diagnosis, treatment and prevention of ankle sprains: An evidence-based clinical guideline. British Journal of Sports Medicine 46, 854-860, 10.1136/bjsports-2011-090490 (2012)
Van der Wees, P. J. et al. Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review. Australian Journal of Physiotherapy 52, 27-37, 10.1016/s0004-9514(06)70059-9 (2006)
Hupperets, M. D. W., Verhagen, E. A. L. M. & Mechelen, W. v. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: Randomised controlled trial. BMJ 339, b2684-b2684, 10.1136/bmj.b2684 (2009)