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GRADE 2+ ANKLE SPRAIN IN COLLEGIATE ATHLETE

By Chelsey Toney

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GRADE 2+ ANKLE SPRAIN• Grade I

- Minimal tenderness and swelling- Slight stretching and some damage to fibers of the ligament

• Grade II - Tearing or popping sensation felt on the lateral aspect- Painful palpation - Positive anterior drawer and talar tilt test

• Grade III - Complete tear of the affected ligament- Tearing or popping sensation felt on lateral aspect, with diffuse swelling over entire

lateral aspect- Positive anterior drawer and talar tilt test

(Anderson, Parr, Hall, 2009)

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BONY/ SOFT TISSUE ANATOMY

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SOAP NOTEDate: 9/23/2013SUBJECTIVE: Athlete limped/ hopped out of the game at WPI 9/21/2013 c/o ankle pain in his L ankle. In the previous play he made contact with another player and states he may have felt a pop in his ankle but is unsure of the MOI. He said it was very painful to stand and walk on. Initial sideline evaluation was inconclusive so ice was applied and it was re-evaluated at half time. At that time he was placed in an air cast and crutches. OBJECTIVE: Initially he was tender to palpate over “tom, dick, and very nervous harry” running behind the medial malleoli but he was most tender over the anterior ankle around the anterior tibiofibular ligament. Initial swelling was over anterior ankle around the anterior tib-fib ligament as well but was not severe. No noticeable ecchymosis at this time. MMT 5/5 for all motions except 4+/5 for resisted ankle dorsiflexion for pain. Anterior drawer test (-), Kleigers test (-), Squeeze test (-), medial and lateral stress tests (-). ROM WNL but painful going into ankle dorsiflexion. Assessment: Potential sprain of anterior tibiofibular ligament, anterior retinaculum tear, r/o fracture of lower leg, syndesmosis injury?Plan: Air cast, and crutches NWB. RICE. Has an appointment to see infirmary for second opinion and potential x-ray.

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PROGRESS NOTES9/24/2013 – Athlete was placed in a walking boot following visit to infirmary and an xray, revealed small fx fragment at posterior malleolar tip9/25/2013 – Reports feeling “really good, sore but not painful,” decreased swelling and increased AROM & ecchymosis, treatment focused on swelling/ pain control & ROM return using therex9/26/2013 – Athlete reported haven taken a step back this day from a fall the night before WB on injured foot, primary point of pain located at anterior ankle10/1/2013 – Athlete saw Orthopedic specialist over the weekend who told him he had a ‘grade 2, possible grade 3 ankle sprain’. Instructed to stay in walking boot for 2 weeks. Swelling has decreased but noticeable when compared bilaterally, pain decreased with motion. Some pain at end ranges of motion and lacks strength. Estimated to be out of walking boot on 10/5, rehab for ankle begins today10/4/2013 – Athlete goes to training room for treatment and rehab daily, has show gains in ROM, strength, and balance, and pain and swelling have gone down considerably, progressed to stage 2 therapeutic exercises10/10/2013 – Athlete shows gains in ankle strength, ROM, and proprioception. Stage 3 rehabilitation began on 10/9 , he stated all exercises feeling good except for heel raises, during practice on 10/9 he ran around the track after being taped and stated it being mildly sore10/18/2013 – Slightly more swollen than normal creating some pain 10/15 but it was back to normal the following day, dynamic rehab 10/17, participating in dynamic warm up w/o pain, receiving ultrasound and heat for treatment10/21/2013 - Athlete participated in non-contact practice in his helmet. Minimal pain with some motions. Heated and taped prior to practice and ice bathed and stimmed following practice11/1/2013 - RTP

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PATIENT X RAY

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PATIENT X RAY

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Orthopedic Evaluation

Radiology x-rays:- Posterior mal fx. Avulsion mortise intact

Findings/Impression/Plan:- L ankle fx (avulsion), sprain w/ instability- Boot continue- Taping for stability in several wks

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INITIAL – 10 DAYS

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25 DAYS

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REHABILITATION Stage 2- early rehab

- ROM│Flexibility Exercises- Balance│Proprioception Exercises- Progressive Strength Exercises

• WWP 10 min – ROM/ ↓pain• Heel Raises 2x8, 2x15, 3x12 – Strength/ balance• ABC’s 3x – ROM/ strength• Marble pick up – strength/ ROM• Single Leg Ball Toss 2 x 10 – balance/ strength• Heisman 30 sec – balance/ strength

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REHABILIATION Stage 3- late rehab

• SLS off step 2x10• SL lunge on bosu ball 2x12• BAPS board 2x10• 4 way ankle 2x10

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STAGE 4 ANKLE REHABFunctional Rehab

• Agility Exercises• Plyometric Exercises• Sport specific skills and drills

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REHABILIATION Stage 4- functional rehab

• Bike • Monster walk• Mountain climber• Dynamic• - During practice on 10/9 he ran around the track after

being taped • - 10/17 dynamic rehab with quick movements

(jumping, ladder drills, and cardio)• - 10/21 participated in non-contact practice with

helmet

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RESEARCH

According to Simon and Donahue- Ankle taping or bracing creates an increased sense of

confidence, stability, and reassurance when performing a dynamic-balance task

According to Basnett, Hanish, et al- Available motion at the ankle, specifically dorsiflexion ROM

contributes to dynamic balance measures in individuals with CAI

According to Bleakley, O’Connor, et al- An accelerated exercise protocol during the first week after an

ankle sprain will improve ankle function

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WORKS CITED• Anderson, Marcia K., Parr, Gail P., Hall, Susan J. (2009). Foundations of Athletic Training Prevention, Assessment,

and Management. Pennsylvania: Lippincott Williams & Wilkins. • Basnett, Curtis R., Hanish, Michael J., Wheeler, Todd J., Miriovsky, Daniel J., Danielson, Erin L., Barr, J.B., et

al. Ankle Dorsiflexion Range of Motion Influences Dynamic Balance In Individuals with Chronic Ankle Instability. The International Journal of Sports Physical Therapy. 2013. 8. 2.

• Bleakley, Chris M., O’Connor, Sean R., Tully, Mark A., Rocke, Laurence G., MacAuley, Domhnall C., Bradbury, Ian., et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. British Medical Journal. 2010. 340.

• Klykken, Lindsey W., Pietrosimone, Brian G., Kim, Kyung-Min, Ingersoll, Christopher D., Hertel, Jay. Motor-Neuron Pool Excitability of the Lower Leg Muscles After Acute Lateral Ankle Sprain. Journal of Athletic Training. 2011. 46. 3.

• Mattacola, Barl G., Dwyer, Maureen K. Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. NATA Journals. 2002. 37(4).

• Puls, Alecia, Gribble, Philip. A Comparison of Two Thera-Band Training Rehabilitation Protocols on Postural control. Journal of Sport Rehabilitation. 2007. 16.

• Simon, Janet, Donahue, Matt. Effect of Ankle Taping or Bracing on Creating an Increased Sense of Confidence, Stability, and Increased Sense of Confidence, Stability, and Reassurance When Performing a Dynamic-Balance Task. Journal of Sports Rehabilitation. 2013. 22.

• Wahnert, Dirk, Gruneweller, Niklas, Evers, Julia, Sellmeier, Anna C., Raschke, Michael J., Ochman, Sabine. An unusual cause of ankle pain: fracture of a talocalcaneal coalition as a differential diagnosis in an acute ankle sprain: a case report and literature review. Biomed Central Musculoskeletal Disorders. 2013. 14. 111.