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Physiotherapy Interventions in Sprain Ankle

Kadek S Prima Dewi S1,*, Ni Kadek Yuni Fridayani2
1Bachelor and Professional Program of Physical Therapy, College of Medicine, Universitas Udayana, Bali, Indonesia
2Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University

ABSTRACT
Background: An ankle sprain is an injury to the joint, with a tear in the ligament due to excessive, and repetitive joint stretching.
In general, sprains are caused by falls, slips, or pressure on the body that causes cartilage to cause problems in the feet. Ankle
sprains occur due to muscle weakness and ligament laxity by exercising muscles and increasing LGS using exercise therapy,
and can help improve muscle weakness caused by damage to the lateral ligament complex.

Objective: This study aims to summarize secondary data related to sprain ankle.

Methods: The research method used is a literature study using secondary data in the form of journals related to the sprain
ankle topic obtained through Google Scholar, Science Direct, and PubMed.

Results: Several studies have shown that someone with ankle sprains can be given physiotherapy according to their condition.

Conclusion: Based on the results of the literature review, it can be said that someone who has an ankle sprain can experience
pain and a decrease in LGS.

Keywords: Sprain ankle, physiotherapy

Received: May 5, 2022. Accepted: June 5, 2022. *Corresponding author: Kadek S Prima Dewi S, Bachelor
Type: Literature Review and Professional Program of Physical Therapy, College of
Medicine, Universitas Udayana; Email:
[email protected]

Background ligaments. In approximately 65% of cases, the anterior

Ankle sprains are a common musculoskeletal injury talofibular ligament (ATFL) injury is isolated and in about 20%
in the highly active and inactive population.1 The most involves damage to the ATFL and calcaneofibular ligament.
common ankle injury is the Lateral Ankle sprain (LAS), which Posterior talofibular ligament injuries are rare. The remaining
accounts for 10% to 30% of all athletic injuries. LAS can have 15% involve syndesmotic and medial ankle sprains. A
significant consequences for injured athletes regarding syndesmotic ankle sprain is an injury to one or more of the
treatment costs and time lost from sports. The incidence rate ligaments comprising the distal tibiofibular junction. It is
for such an injury is 0.93/1000 athlete exposure. This often known as a “high ankle sprain”.5 Ligament tears can
condition even though only approximately 50% of patients occur at the proximal attachment, the middle substance, or
are treated.2 Every day, nearly one ankle sprain occurs per the distal attachment. The severity of ankle sprains is
10,000 people in Western countries, and over two million classified into three levels. Grade 1 is the mildest injury,
ankle sprains are treated annually in emergency departments defined as lateral ligament stretching without tearing. Grade
in the United States and the United Kingdom. In sports, the 2 indicates a partial tear of one or more ligaments. Grade 3 is
incidence is even higher, accounting for 16%-40% of all cases the most severe of the spins and classifies the injury with total
of sports-related trauma. Approximately 40% of all traumatic disruption of all ligaments of the lateral ligament complex.4
ankle injuries and nearly half of all ankle sprains occur during Several parameters were defined as potential risk
athletic activities, with basketball (41.1%), American football factors for ankle sprains. These are classified as intrinsic or
(9.3%), and soccer (7.9%) having the highest percentage.3 extrinsic. Some intrinsic risk factors can be modified, and
Ankle sprains are more common in women, children, and identifying these risk factors can assist in preventing potential
athletes who participate in indoor and field sports.4 injury. Several studies have investigated the proposed risk
Besides bone and muscle structure, several factors in athletic and military populations. These include
ligaments significantly contribute to the ankle joint's stability, demographics (including age, sex, weight, height, body mass
which are distributed in the lateral, medial, and syndesmotic index, limb dominance), anatomy (foot type, foot and ankle
regions. Nearly 85% of ankle sprains involve the lateral alignment, including foot hyper-pronation), weakness
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(generalized joint weakness, ankle joint weakness), range of and participation. The home exercise program is carried out
motion (ROM), including ankle and first metatarsophalangeal as many as 4 sessions a week for 4 weeks.
ROM, muscle strength, muscle reaction time, balance (single Prabhakaradoss et al. explored the effect of manual
leg balance and star excursion balance test) and therapy and conventional physiotherapy on pain, movement,
proprioception, history of previous ankle sprain, and and function following acute and sub-acute lateral ankle
exercise-related parameters (including the type of sport, level sprain.2 There were two groups in this study. Manual therapy-
of competition, playing on artificial turf, playing position, type mobilization with movement (MWM) group. MWM was given
of sports shoe, lack of warm-up stretch, and landing to this group for 5 minutes without PRICE and exercise
technique after the jump). There is no convincing evidence of therapy. The second group was given conventional PRICE
how significant or effective this parameter is. However, a guidelines and was encouraged to perform only free, pain-
history of previous ankle sprains, overweight, ankle joint free movements. The exercise was given for 30 seconds in 3
weakness and balance disorders are some exceptions with sets with 5 repetitions. Both groups had eight treatment
which most studies have agreement on their importance. For sessions over four weeks. All patients received standard
example, it has been shown that overweight players with a orthopaedic care, which included compression bandages
previous ankle sprain are 19 times more likely to develop a around the injured ankle and foot extended above the ankle
non-contact ankle sprain compared to normal weight players and immobilization in the posterior ankle brace for no more
without a previous ankle sprain.5,6 than two weeks. Patients were also instructed to elevate their
Injuries such as these lead to lost time in the field affected leg on a pillow while sleeping to apply ice to the
and decreased ability to function at school and work. Medical affected ankle for 20 minutes at least three times a day after
costs associated with ankle sprains are estimated at $3.65 removing the brace and bandage. The patient is taught to
billion. Therefore, it is important to speed up the recovery continue walking as soon as possible, using a walking aid if
time associated with these injuries to reduce medical costs necessary.
and improve the return of function.7 Based on the description, Wainwright et al. tested does neuromuscular
some literature discusses ankle sprain interventions. electrical stimulation improve recovery following an acute
ankle sprain.10 In this study, there were two groups, the first
Methods group received standard therapy and the second group
The research method used is a literature study using received standard therapy and NMES. Standard therapy
secondary data related to ankle sprains obtained through included patient education, manual therapy if indicated, and
Google Scholar, Science Direct, and PubMed. personalized exercise prescriptions. Meanwhile, the group
receiving NMES will be trained to apply NMES to the injured
Results ankle.
There are five studies related to physiotherapy Iammarino et al. investigated the efficacy of the
intervention for ankle sprains. Cleland et al. examined the stretch band ankle traction technique in the treatment of
effects of manual physical therapy and exercise versus pediatric patients with acute ankle sprains.7 This study
supervised home exercise in managing patients with an consisted of two groups: PRICE and early elastic band
inversion ankle sprain.8 Manual therapy and exercise group mobilization. The PRICE group was instructed to do
was given manipulation techniques on the proximal compression wrapping on the ankle if a lace-up ankle brace
tibiofibular joint, distal tibiofibular joint, talocrural and had not been installed. If brace compression has been given,
subtalar joint. The intervention was carried out twice a week the patient was advised to compress during activities for at
for 4 weeks. Home exercise program group performed the least 8 hours a day. During the first 72 hours, the patient was
following exercises: 1) Mobility for the feet and ankles for 3 instructed to rest using ice and intermittent compression and
sets with 15 repetitions, 2) Strengthening for which to elevate the sore ankle at least 12 inches, and the patient
comprised isometric exercises such as pushing the foot was advised to do this for 20 minutes twice a day. The early
against the wall for inversion, eversion, and plantar flexion, elastic band mobilization group performed exercises using
using the other foot to dorsiflexion resistance (hold 5 seconds terabands such as horizontal elastic band traction, vertical
for 5 repetitions in all directions), and scrunching a towel elastic band traction and horizontal elastic band traction with
under the sole of the foot for intrinsic muscles, 3) Body weight an overpressure setup. The movement was performed 10
resistance: heel lifts and mini-squats in a bilateral position, 4) rounds clockwise, after a rest plus 30 seconds.
Calf and heel stretching, started by sitting for a long time, Witjes et al. conducted The ANKLE TRIAL (ANKLE
using a towel to give manual stretches (3 reps with a duration Treatment after Injuries of the Ankle Ligaments) to find out
of 30 seconds per rep), 5) Standing with one leg on the injured the benefits of external support devices in the functional
ankle, with arms abducted and eyes open (3 sets of 30 treatment of acute ankle sprain.11 There were three groups,
seconds per set), 6) Dynamic balance: standing on a balance the first group was given a pressure bandage and RICE (Rest,
board (or pillow) with eyes open (3 sets of 60 seconds Ice, Compression, Elevation) for 5-7 days, followed by tape
duration), 7) Functional weight-bearing activities: walking, treatment for 6 weeks. The second group was given a
running, jumps, and jumps, according to the patient’s activity pressure bandage and RICE therapy for 5-7 days and
continued with a brace for 6 weeks. The third group was given

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RICE and pure functional treatment. All three groups will conventional physiotherapy and conventional physiotherapy
receive the same ankle exercise schedule just two days after alone on pain, ankle ROM, and function in subjects with
the patient experiences an ankle trauma or sprain. All groups lateral ankle sprains. The experimental group received MWM
were allowed to take paracetamol for pain relief. and conventional physiotherapy for 4 weeks of treatment.
After the treatment, this group showed a significant
Discussions reduction in pain and improved ankle function and
An acute ankle sprain is the most common lower dorsiflexion in subjects with lateral ankle sprains. Other
extremity injury in athletes and accounts for 16%-40% of all studies suggest that the application of MWM and exercise
sports-related injuries. It is very common in basketball, therapy improves clinical and rapid improvement compared
American football, and soccer. Most sprains affect the lateral to exercise alone. Most (84%) patients with a dorsiflexion
ligaments, especially the anterior talofibular ligament. ROM deficit after a subacute lateral ankle sprain responded
Despite the high prevalence, most patients experience well to the mulligan MWM protocol. Incorrect fibula position
persistent sequelae and injury relapse. A detailed history and can cause pain and abnormal movement after a sprained
proper physical examination are the cornerstones of the ankle. MWM is applied to the fibula, and its biomechanical
diagnosis. Imaging is not indicated for the majority of ankle effects may be responsible for the increased ROM and
sprain cases. Several interventions have been recommended hypoalgesic effect, causing pain relief. Mechanical
in the acute management of ankle sprains, including rest, ice, hypoalgesia of MWM proposes a potential role of central
compression, and elevation, analgesic and anti-inflammatory mechanisms associated with nonopioid-mediated activation
drugs, bracing and immobilization, early walking and weight- of descending pain inhibitory systems, variations in muscle
bearing aids, foot orthosis, manual therapy, exercise therapy, activation, and behavioural mechanisms. In addition, exercise
electrophysical modalities and surgery (only in certain therapy concentrates on neuromuscular and proprioceptive
refractory cases). Exercise and braces have been exercises and joint mobilization to reduce pain and increase
recommended with a higher level of evidence and should be ROM in treating ankle sprains.9
included in the rehabilitation process. The exercise program Conventional physiotherapy administered for 4
should be comprehensive and progressive, including the weeks showed significant pain reduction and improved ankle
range of motion, stretching, strengthening, neuromuscular, function and dorsiflexion in subjects with lateral ankle sprains.
proprioceptive, and sport-specific exercises. Some literature The standard physiotherapy program for one week reduces
states that the interventions that can be given in cases of pain and increases the eversion to ankle inversion ratio in
ankle sprains include exercise therapy (mobility, grade I ankle sprains. The standard physiotherapy program
strengthening, body weight resistance, stretching, balance, consists of Protection, Rest, Ice, Compression, Elevation
dynamic balance and functional weight-bearing activities), (PRICE) exercises, anti-inflammatory medication and weight-
manual manipulation therapy, PRICE, therapeutic exercise bearing support. Furthermore, neuromuscular training and
NMES, elastic band mobilization, RICE and pressure balance training effectively manage muscle strength deficits.
bandage.5 Strengthening exercises for weak muscles are essential for a
Research conducted by Joshua et al. has reported speedy recovery, and such exercises prevent the recurrence
that patients with inverted ankle sprain often exhibit of ankle sprains. Static stretching exercises showed a strong
disorders of the joints that contribute to ankle mobility, effect in increasing ankle dorsiflexion after acute ankle
including the proximal tibiofibular, distal talocrural sprains. Generally, stretching exercises are applied to regain
tibiofibular and subtalar joints. Manual therapy helps restore full ROM by promoting flexibility of the calf muscles. This may
movement in these joints, leading to improved foot and ankle increase flexibility before pain perception and allow the
mechanics, reduced pain, and improved function. It is also viscoelastic properties of muscles and tendon joints to
possible that the effects of manual therapy are overcome the stretch reflex or increase stretch tolerance.9
neurophysiological. For example, it has been shown that the In a comparison of the two groups, there was a
soleus and peroneal muscles show simultaneous inhibition of significant difference between the effects of MWM along
the artrogenous muscles in patients with ankle instability. The with conventional physiotherapy and conventional
literature has suggested that this may result from altered physiotherapy alone on pain, ankle ROM, and function in
mechanoreceptors following ankle sprains, leading to an subjects with lateral ankle sprains. After four weeks of
impaired neural feedback system to ankle dynamic stabilizers. treatment, MWM with conventional physiotherapy was
Manual therapy interventions stimulate the found to be more effective than conventional physiotherapy
mechanoreceptors and thus aid in increased neural feedback, alone in reducing pain and improving ankle function and
which can aid in dynamic stability and maximize the benefits dorsiflexion. This difference may be due to the biomechanical
of therapeutic exercise. In addition, that manual therapy and hypoalgesic effects of MWM in combination with
intervention can result in a reduction in inflammatory exercises that reduce pain and improve ankle function and
cytokines, an increase in beta-endorphins, and hypoalgesia.8 dorsiflexion of lateral ankle sprains. This study stated that
Another study conducted by Prabhakaradoss et al. in Mulligan's MWM is more effective than Maitland
which this study aimed to compare the effects of Manual mobilization in reducing pain and increasing ROM in patients
therapy-mobilization with movement (MWM) along with with lateral ankle sprains due to the interaction of afferent

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and efferent reflex arcs and tensile forces of active and mobilization technique was a safer alternative for the
passive mobilization.9 pediatric population. Patients can perform the bandaged
Other literature also states that using ankle traction technique independently (as a self-
Neuromuscular Electrical Stimulation (NMES) in addition to mobilization) with minor modifications and instructions. Early
standard care reduces oedema after grade I or II ankle sprains mobilization appears to be a safe intervention in pediatric
and is statistically significant compared to standard care patients with acute ankle sprains. Early mobilization resulted
alone, as measured by volumetric displacement. However, in similar pain, range of motion, and self-reported function
this finding did not have a statistically significant effect on outcomes compared with traditional PRICE treatment.7
functional recovery, which was also the main outcome Currently, new guidelines regarding the acute
measure of this study. Although the clinical relevance of treatment of ankle sprains have been introduced in the
oedema reduction is questionable as no clinically significant Netherlands based on recent insights from the literature. The
changes between the two groups were found, large-scale developers of this guide concluded that the rehabilitation of
trials with long-term follow-up are needed to allow accurate athletes after an acute ankle inversion injury should consist
interpretation of the clinical implications of adjunctive NMES of various exercises to improve proprioception, strength and
use.10 coordination and maintain limb function. Furthermore, a
Reduces post ankle sprain oedema in improving the brace or tape is recommended in the subacute phase after
level of pain and dysfunction experienced by patients during the diagnosis of an acute ankle ligament injury.11
recovery. This study did not find significant changes in pain
and FAAM scores however, it is possible that this was due to Conclusion
the short timeframe in which NMES was evaluated. The pain Based on the literature review results, it can be
was decreased and ankle function improved in both concluded that someone who experiences ankle sprains can
treatment groups, indicating the value of each treatment plan. experience pain and decreased LGS.
However, the differences between the changes were not
significant. In this study, physiological effects were evaluated References
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