CHAPTER 62 • ANKLE INSTABILITY 369GRADING
- Grading of ankle sprains helps to guide treatment,
rehabilitation, and prognosis. The grade is based on
the number of ligaments injured, degree of ligament
tearing (partial vs. complete tear), and amount of
swelling and ecchymosis. - The west pointankle grading system is a useful tool
for grading ankle sprains (Gerber et al, 1998) (see
Table 62-1).
INITIAL TREATMENT
P.R.I.C.E., PROTECTION, REST, ICE,
COMPRESSION, ELEVATION (SAFRAN ET AL,
1999 A)
- Protection:Accomplished with the use of taping, a
lace up splint, a thermoplastic ankle stirrup splint, a
functional walking orthosis, or a short leg cast. Early
protected range of motion in a flexible or semirigid
orthosis is superior to rigid cast immobilization in
terms of patient satisfaction, return of motion and
strength and earlier return to function (Klein, Hoher,
and Tiling, 1993; Regis et al, 1995). Protected weight-
bearing in an orthosis is allowed with weight bearing
to tolerance as soon as possible following injury.
Crutches are used until pain free weight bearing is
achieved. - Rest:Interruption of training in running or jumping
sports is essential in limiting swelling and preventing
early reinjury. Length of time to return to sports
depends on injury grade (see Fig. 62-1). - Ice:Cryotherapy is the application of cold to the
ankle in the form of ice bags, a cold whirlpool or a
commercially available compressive cuff filled with
circulating coolant. Early use of cryotherapy has been
shown to enable patients to return to full activity more
quickly (Hocutt et al, 1982). - Compression: Compression can be applied to the
ankle by means of an elastic bandage, felt doughnut,
neoprene or elastic orthosis, or pneumatic device.- Elevation: This initial treatment along attempts to
limit the amount of hematoma and extracellular fluid
accumulation edema around the ankle in order to
speed ligamentous healing.
- Elevation: This initial treatment along attempts to
REHABILITATION—FIVE PHASES
(SAFRAN ET AL, 1999B)- Acute/P.R.I.C.E.:Goal is to limit effusion, reduce
pain, and protect from further injury. - Subacute:Focus is on eliminating pain, increasing
pain-free range of motion, continued protection
against reinjury with bracing, limiting loss of strength
with isometric exercises, and continued modalities to
decrease pain and effusion. - Rehabilitative:Emphasizes regaining full pain free
motion with joint mobilization and stretching,
increasing strength with isotonic and isokinetic exer-
cises, and propioceptive training. - Functional:Focuses on sports specific exercises with
a goal to return the patient to sports participation. - Prophylactic:Seeks to prevent recurrence of injury
through preventative strengthening, functional propio-
ceptive drills, and prophylactic support as needed.
TREATMENT OF SYNDESMOTIC LIGAMENT
INJURY—HIGH ANKLE SPRAIN•P.R.I.C.E.- If the mortise is not widened or fractured, protection
is in the form of a short leg cast or brace for 4 weeks,
followed by physical therapy. - In the presence of diastasis between the distal fibula and
tibia on X-ray, operative stabilization of the syndesmotic
is required with a syndesmotic screw placed through the
distal fibula and tibia parallel to the ankle joint. - The patient should be warned that these injuries result
in longer periods of disability than do injuries to the
lateral collateral ligaments. In one study, only 44% of
16 patients had an acceptable outcome at 6 months
(Gerber et al, 1998).
TABLE 62-1 West Point Ankle Sprain Grading System
STAGE 1 STAGE 2 STAGE 3Edema/ecchymosis Localized/slight Localized/moderate Diffuse/significant
Weight bearing ability Full or partial without Difficult without crutches Impossible
significant pain
Ligament pathology Ligament stretch Partial tear Complete tear
Instability testing None None or slight definite
Time to return to sporting 11 days 2–6 weeks 4–26 weeks
activities