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A quick guide to Ankle Rehabilitation

A common question I get from patients’ centres around what their process of rehabilitation from injury will look like. This means, how they are expected to improve and what progress will we see.

Did you know that ankle sprains are one of the most common things we see in the clinic. Usually, ankle sprains are inversion injuries, where someone has landed awkwardly or on the edge of a foot or hole and rolled their ankle outwards. This usually injures the soft tissue on the outside of the ankle (an occasionally the inside too), and very occasionally, breaks a bone in the ankle. Often when these injuries occur, they hurt a lot and get quite swollen, red and bruised. It may be difficult and painful to walk on your ankle at the time, and also the next couple of days.

So, what does rehab look like if you sprain an ankle? First, we need to determine if the ankle is broken. To do this, we use a series of tests called the Ottawa Ankle Rules. These rules tell us with a high level of certainty whether we need an x-ray to look at the bones. These assessments include whether you are able to walk on it at all (even with a limp), specific points of tenderness on your bones in your foot and ankle and how the rest of your leg reacts to testing. If we determine you do need an x-ray, your physiotherapist can refer you for this, and will access your results when they are available. This saves a trip to the emergency department or your GP.

If we determine you do NOT need an x-ray, rehabilitation can start immediately! Initially we start with some gentle soft tissue work to decrease the irritation in your joint and promote healing. This will assist with swelling, pain and stiffness that occurs in the acute stage of injury healing. This can consist of gentle joint mobilisations, soft tissue massage and dry needling and teaching your foot and ankle how to move smoothly.

If you are able, we will also re-teach parts of the walking pattern and start with some mobility and proprioception exercises.

These lay the groundwork for higher level, more complex (and exciting) exercises in the next stages of rehabilitation.

Your physio should also provide you with specific advice on compression, elevation and the use of ice or heat for pain relief (depending on the stage of healing). We don’t recommend using anti-inflammatory medication for 48-72 hours after injury, as this has been shown to slow the healing rate.

In this stage, you are able to safely participate in our Clinical Pilates classes if you wish. These assist in getting movement back in a gentle and active manner, whilst also keeping the rest of you strong and mobile.

You will be given some exercises to do at home in between your appointments. Completing these as instructed, will help you get better quicker.

In the early days, you may need a few appointments close together. This helps us to get optimal management of swelling, stiffness and pain, and progress your exercises quickly and effectively. This allows rapid return to normal walking, exercise and daily activities, and will mean less pain and less physio in future.

The next stage of your rehabilitation starts when the swelling and pain have reduced and you are able to do more with your ankle. In this stage, you may still require some soft tissue work through the joint and muscles (particularly if there is still stiffness), but the focus here is moving onto more normal movement and starting to get more strength through your leg.

Here we start to discuss injury prevention strategies, and give you more exciting and dynamic exercises to do. We start to discuss what we need

to achieve to return to running and jumping, and any return to sport or work movements we will need to achieve. Our treatment and exercises in this stage are getting harder but more interesting. It is likely you will need less appointments in this stage, but you will have more specific exercises to complete at home, in the gym or at training between appointments.

As we move through your rehabilitation, your pain should be decreasing and going away, and your ankle will be moving better and feeling more normal.

The next stage of your rehabilitation starts when you have full movement, no swelling and we are confident to load your ankle. This stage focusses on getting strong and commencing training that is specific to your sport or work.

Your physio will assess the strength in your whole leg and compare sides. They will look at the control of movement through your trunk and assess if there is anything higher in your kinetic chain that needs to be strengthened or improved. This is essential when we are retraining movement and strength, but also when we are thinking about keeping you healthy long term and preventing future injury. In this stage, you can think about entering our Intensive Rehabilitation classes.

You can also continue or commence Clinical Pilates, with a focus on strength and balance. Here you might need to strengthen your gastrocnemius, soleus, quadriceps, intrinsic foot muscles and gluteal muscles among other things.

When you are ready, your physio will assess your strength through decelerating and accelerating movements, and make the necessary changes to your home program. Here we are thinking specifically about progressive overload strength training and starting the basic jumping and landing movements.

As you become stronger and we see the changes in your muscle system, we start to think about adding more dynamic movements.

This next stage is where we add safe landing training, push off and slowing down, as well as change of direction and sport/work specific skills.

This is where i feel the fun really begins. We get creative with our assessments, and we start to work through speed and skills.

Learning safe landing strategies is vital to be able to confidently and safely return to sport. The last thing any of us want is for you to re-do this injury when you return to play. Some of your exercises in this stage may consist of jump and hop training, lateral movements and change of directions drills. As you become more proficient with this, we may add a ball and obstacle or opponents to retrain your body and mind for your sport. This is where your sport specific training really increases and by the end of this stage, you should be back at full training with your team.

Our last stage is our safe return to sport. You enter this stage when you have passed all of our return to sport assessments, and safely completed 3 full training sessions with your team. Our return to sport assessments may include a T-Test, an agility run and a hop for distance and height test. It will also look at objective measures for strength and may include a discussion with your coach around your skill-readiness. These systems allow us to determine your risk of reinjury upon returning. When we believe your risk is low, we will clear you for full return to sport.

Sometimes, we clear you for partial return (this may be half a game) before we clear you for full return.

Unfortunately, the risk of reinjury is never zero, so we will discuss some long term strategies you can use to further decrease your risk.

Taping or bracing may be appropriate for you, as well as ongoing strength, balance and landing exercises.

When you have completed 3 full games safely and you have no concerns, we happily discharge you from physiotherapy.

Being under the care of your physio until this point, doesn't mean frequent appointments. It means touching base and letting us know how you are going, then having a final review appointment after your third game so we can assess the health of your joint and its ability to tolerate your sport and loading. If anything goes wrong in the meantime, you are welcome to give us a call to discuss it, and we will be able to determine if you need to come in or not.


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