Useful guidelines in Arthritis Research UK (Summer 2012) – the idea is first to return the injured body part to full strength and function, then work through a graduated return-to-play strategy. Suggestions:
Initially – Review re. need for X-ray as per Ottawa ankle rules.
1st 72 hours – RICE & analgesia. Advice is to avoid NSAIDs for first 24 hours as can inhibit clotting.
After 72 hours – review and check for anterior talofibular ligament or calcaneofibular ligament damage. Then advise on rehabilitation.
- ATFL damage – anterior drawer test. Immobilise lower leg with one hand, cup heel with other hand, hold foot in slight plantarflexion, apply anterior force. Compare to other side – greater ROM implies ATFL injury, especially if no ‘end-feel’. Can often be managed conservatively.
- CFL damage – talar tilt test. Immobilise lower leg with one hand, invert hindfoot with the other, compare to other side. Greater ROM implies CFL injury. Referral may be needed.
Next 6 – 12 weeks – rehabilitation.
- Range of movement – write alphabet with great toe.
- Eversion – use elastic fitness band looped round table leg or other foot and evert against resistance. Aim for low resistance, high reps – 3 sets of 10, twice daily
- Proprioception. Start by balancing on affected leg & slowly increase duration. Then try on an unstable surface – cushion or wobble board. Then add in movements.
When pain is settled, ROM is full, eversion strength is good and proprioception is as good as the other ankle, start progressing through the stages of return-to-sport planning:
- Straight-line jogging
- Running with changes in direction (e.g through cones)
- Repeat actions with a ball
Try each of these first on a flat hard surface, then on grass/uneven surfaces when proprioception OK.
Obviously, these stages aren’t as clear-cut as all this – will be overlap, some will progress more quickly than others, and needs to be dynamic process.