3 – Elevate the Ankle
Elevating the injured ankle as much as possible during the first 48 to 72 hours, in conjunction with appropriate focal and generalized compression, plays a very important role in the initial management of uncomplicated lateral ankle sprains. Having the patient place their injured ankle on a pillow is usually not sufficient; the foot inevitably falls off the pillow when the patient rolls over during sleep. One way patients can ensure that the ankle is maintained higher than the heart is to elevate the end of the bed by placing a large object between the mattress and the box spring.
4 – Regain Normal Ankle Range of Motion
The United States Naval Academy has clinically shown that early pain-free motion exercises, in combination with focal and generalized compression and elevation of the injured ankle higher than the heart, can safely expedite the patient's return to unrestricted activities.8
How early to start range of motion exercises. Some providers question the rationale of a lateral ankle sprain treatment program that advocates starting pain-free range of motion exercises on the day of the injury, perhaps because they are concerned that it may place unnecessary stress on the affected ligaments. However, early pain-free range of motion exercise can be justified for 2 reasons. First, ligaments limit the extreme of distraction between bones. Second, during the normal range of motion of a joint, ligaments are relatively unstressed. Thus, when performing early pain-free range of motion exercises, the stress on the affected ligaments is minimal and does not cause any harm.
Types of exercises. Range of motion exercises include plantar flexion and dorsiflexion and eversion and inversion.
Plantar flexion and dorsiflexion. For this exercise, the patient is instructed to repeatedly move the foot up and down, as if he or she were pushing on a gas pedal (Figure 3). This exercise can help regain or retain talar motion of the ankle.
Inversion and eversion. There are 2 types of eversion and inversion exercises that are equally effective if performed properly. Both exercises require that the patient hold the heel still. With the first exercise, the patient repeatedly rotates the forefoot inward and outward, similar to the motion of a windshield wiper (Figure 4). For the second exercise, the patient, using the big toe as a pen, writes each letter of the alphabet in capital letters; the goal is to increase the size of the letters each time the exercise is performed. These exercises can help regain or retain subtalar motion.
Frequency and duration of range of motion exercises. Ideally, range of motion exercises should be performed frequently throughout the day. Instruct patients to continue range of motion exercises until the talar and subtalar function of the injured ankle is equal to that of the noninjured ankle.
5 – Regain Normal Ankle Strength
Strengthening exercises can be started once the range of motion of the patient's injured ankle is painfree and equal to that of the noninjured ankle. A variety of techniques that exercise the peroneal and tibialis anterior muscles have been described. Of utmost importance is that the strengthening exercise must be performed solely with motion of the talar and subtalar ankle joints.
A sample strengthening exercise is shown in Figure 5. One way to ensure that the strengthening exercise is performed solely with the talar and subtalar ankle joints is to keep the knee and leg of the injured ankle stationary. In the exercise shown, locking the knees straight forward with the hands limits all the motion to the ankle. Patients repeat this exercise until they feel a burning sensation on the outside of the leg; this represents fatigue of the exercised muscles.
Patients should continue strengthening exercises throughout the day for as long as necessary until they can pass the “single leg balance test” (Figure 6). The goal is for the patient to be able to balance on the ball of the foot of the injured ankle for as long as possible. A positive test (weakness in the ankle) signals an increased risk of ankle sprain injury.
6 – Return to Unrestricted Activity
Once the above steps are achieved, the patient can safely return to regular activity wearing an ankle brace or support. A brace that is easy to put on, fits comfortably into a shoe, and supports and protects the ankle aids in preventing the recurrence of lateral ankle sprains.