By Rick Guter, Ralph Stephens, and George Salvaterra
Rick Guter, ATC, PT, is the Head Athletic Trainer with the MLS's D.C. United. Ralph Stephens, LMT, NCTMB, is a certified sports massage therapist who has worked with many All-American and Olympic athletes. George Salvaterra, PhD, ATC, is the Head Athletic Trainer at Penn State University.
Training & Conditioning, 11.3, April 2001, http://www.momentummedia.com/articles/tc/tc1103/ouch.htm
It’s a beautiful early fall day and you’re the athletic trainer assigned to cover a men’s college soccer game. Suddenly, a player goes down, and it doesn’t look like one of those theatrical dives perfected in the 1980s. No, you clearly saw this player sharply turn his ankle, and he’s not getting up.
You run out onto the field. The athlete affirms that it’s his ankle and you determine that it appears to be a serious sprain. Once off the field, a closer look leads you to assess that he has sustained a third-degree inversion sprain. You tape and pack the ankle in ice and have the athlete taken to the local medical center for x-rays and to be seen by the team physician, with instructions to see you the next day.
When he arrives the following day, you learn that the x-rays were negative for any osseous damage and that your assessment of a third-degree inversion sprain has been seconded. This injury is characterized by loss of integrity of several ligaments surrounding the ankle joint and can be treated on a conservative non-surgical basis. It’s now up to you to take this athlete through rehab and get him back out on the field as soon as possible—with as strong an ankle as possible.
You know that he is an experienced, highly trained varsity player in excellent physical condition, with no history of significant or chronic ankle sprains. How to proceed? The most comprehensive treatment plan includes modalities, massage, and movement. T&C asked three experts to provide a rundown of optimal treatment in each of these areas.
by Rick Guter
The return of this athlete can be broken down into six distinctive stages: immediate care, post-immediate care, early care, mid care, late care, and post-return care. This section addresses the use of various formal treatment modalities. These modalities will be used in all stages of treatment and will assist with controlling swelling, providing pain relief, and aiding in tissue healing.
The immediate care of this injury encompasses the first 24 hours post-injury. The goals of this first stage are to limit the amount and severity of any swelling, limit any pain, and, by immobilizing the joint and having the athlete use crutches, prevent any further injury.
Immediately after an evaluation of the injury, treatment consists of ice, compression, and elevation (ICE). This consists of repetitive bouts of ice for 15 to 20 minutes, with 30 or so minutes without ice in between bouts. Compression should be applied and the leg elevated continuously.
When the player is sent home for the day or night, he should continue this routine. At this time, it is also important that the joint be immobilized and the player is weightbearing to tolerance on crutches. Immobilization can be accomplished with a bandage, air cast, posterior splint, or tape. Open-gibney ankle taping in particular provides compression and allows the damaged tissue to begin healing in an approximated or shortened position. The tape can be removed during icing to better facilitate the transfer of cold to the injured area, but after the ankle has been iced or ice bathed, it should be rewrapped or taped.
This stage of treatment usually includes the time period of 24 to 96 hours post-injury. During this stage, there is still bleeding and swelling occurring within the joint, and the chance for additional injury is still high. The goals for this phase are to decrease any pain the athlete is having, decrease or hold steady the severity of swelling, and begin to restore range of motion. All of these can be accomplished simultaneously.
It is important to continue the repetitive bouts of ICE for 15- to 20-minute periods. Cold whirlpools (below 50 degrees F) can be used for 10- to 15-minute periods. While in the whirlpool, the athlete can begin gentle passive stretching of the calf with the use of a towel as well as active range of motion in plantarflexion and dorsiflexion.
Positive galvanic stimulation (bouts of 10 to 30 minutes at a tolerable setting), interferential current (20 to 60 minutes high pulses/second [pps]), and microcurrent (30 to 60 minutes high pps) have been shown to be successful in limiting pain and swelling post-injury. In addition, a portable TENS (transcutaneous electrical nerve stimulation) unit can be used to help with the athlete’s discomfort while away from the treatment room. A splint and crutches should be continued for ambulating with continued weightbearing to tolerance.
The early care phase usually runs from 96 hours post-injury to roughly days seven to 10. During this phase, the goals continue to be to control and reduce swelling, regain ROM, and facilitate healing, with the added goal of beginning to strengthen the area.
Because the active bleeding in the joint has decreased, you can now introduce heat into your treatment regime. This can be in the form of a “contrast bath,” where the athlete will alternate between hot and cold whirlpools or baths. The “contrast” will act to pump the swelling out of the joint. Alternating bouts of hot and cold in a 1:3 or 2:5 manner, sandwiched between 10 minutes of cold bath, are the most common (that is, start with 10 minutes cold, then one to two minutes warm followed by three to five minutes cold. This cycle should be repeated six to 10 times, finishing with 10 minutes cold). The athlete should perform passive stretching and active ROM while in the baths to help pump the swelling from the joint.
Use of negative galvanic stimulation (10 to 30 minutes), microcurrent, and interferential current, can also be used to facilitate swelling reduction, pain control, and tissue healing. All tissues in the body work on an electrical gradient (homeostatic exchange of positive and negative ions within the cells), and electrical stimulation has been used to mimic this exchange to aid healing. This is best accomplished through a high pps biphasic current and microcurrent. One can do five to seven minutes of biphasic current to help break down “resistance” and then follow up with 20 to 60 minutes of microcurrent (0.3 µA) at a barely sensed intensity.
Since there is still a chance of injury outside the treatment setting, it is important that the athlete continue using the splint and crutches with weightbearing to tolerance.
By the end of a week to 10 days post-injury, the swelling and pain in the ankle should be lessening. It is important to keep any swelling under control since its presence will retard healing. During this phase, which runs from week one to two to about six weeks, the bulk of the healing and tissue repair will be complete. The goals are a return to full ROM, reduction of any pain or swelling, and progressive restoration of strength to the joint.
Swelling and pain can be managed by continued use of contrast baths and ice. To promote tissue healing in the ankle, one can begin ultrasound as well as continuing electrical stimulation for tissue healing. Active movement during ultrasound treatment will mobilize the target scar tissue and reduce its adherence to adjacent tissues. At the end of this phase, which is usually 10 to 12 weeks post-injury, the athlete should be ready to return to practice.
Often during this phase, the athlete will be a bit stiff and sore as the treatment session begins because of the work done the previous day, as well as the act of breaking down adhesions developed during the healing process. So during this late stage, it is very important to thoroughly warm up the joint at the beginning of each treatment session, and before therapeutic exercise. The ankle can be warmed using a warm whirlpool, hot pack, or ultrasound.
Therapeutic exercises make up the bulk of treatment during this stage. It is always important to treat the athlete with ice at the end of each session to control any swelling that may occur.
At this point, the athlete has returned to soccer practice. His progression will be dictated by how he feels and performs, not by a calendar. It is imperative that when the athlete does return to practice, he has not only the physical strength, but also psychological confidence in the ankle. To aid in this, his ankle should initially be taped or splinted during practices.
The athlete should continue to ice his ankle after each practice or game. And, as mentioned previously, if he reports with soreness and stiffness from the previous practice day, it is important to thoroughly warm the joint prior to practice.
by Ralph Stephens
With this type of serious injury, there is more than the diagnosis may indicate. The ligaments in the athlete’s ankle have been stretched or torn. What is generally overlooked in treating ankle sprains is that when there is enough force to damage ligaments, there will be damage to weaker tissues as well.
It is all too common to focus exclusively on the ligaments, but the muscles and their tendons that cross the joint need to be examined and normalized as well. The superficial fascia must also be normalized throughout the entire lower extremity. If the athlete fell or, as in some cases, collided with another player, the lesser soft-tissue injuries resulting from these impacts also need to be normalized.
Further, if crutches or a foot brace affecting functional leg length are utilized for a significant period of time, the musculature of the shoulder girdle and pelvis should be examined to make sure trigger points resulting from unusual activity have not formed (see Controlling Spasms, below). These can negatively affect movement, timing, coordination, accuracy, and consistency as the athlete returns to activity.
Especially in the case of an athlete, where the injury takes him out of the game he presumably loves, there is an emotional component that massage can also help with. Massage can help reduce his overall stress level and help provide a more nurturing environment for healing to occur in. Stress depresses the immune system. The immune system needs to be functioning as fully as possible for the athlete to recover as quickly as possible.
There are three areas the sports massage therapist should focus on. First, reduction of swelling. Second, reduction of spasm in the muscles of the lower extremity and normalization of the fascial tissues in the area. Third, treatment of the actual ligaments of the ankle.
The ideal frequency of treatment would be every day, initially, for an hour each session. After the first week, this could be reduced to every other day for the next two weeks. Then, to twice a week until rehab is complete. When a schedule this frequent is not possible, treat the athlete as often as schedules and resources allow. Once the fascia and musculature are normalized, massage should concentrate mostly on the ankle ligaments and treatments can be reduced to 20 to 30 minutes in length.
Once the injury has been diagnosed as a sprain (no osseous damage), massage can immediately be incorporated as part of the treatment. This will likely be several hours after the occurrence, usually the next day.
The first sessions should focus on reduction of swelling. Deep massage on the injured area is not appropriate until swelling is minimal. Part of the reason it takes so long to reduce swelling in the ankle area is that the muscles of the leg are in spasm trying to protect the injury. This restricts the return flow of blood and lymph. Reducing spasm and trigger points in the entire lower extremity will facilitate circulation. Further, ischemia, caused by spasm, contributes to the pain experienced as the athlete begins to move and exercise the ankle. Massage can reduce this pain by eliminating the ischemia, thus allowing earlier mobilization.
Begin the initial sessions with myofascial techniques to normalize the fascia of the entire lower extremity above the injury. Again, it is important to not treat the swollen area with myofascial techniques. Treat it in later sessions once the swelling has gone down.
The initial sessions can consist of myofascial stretching in a variety of directions, including circular or torquing patterns. Another myofascial technique called “skin rolling” is very beneficial as well. To understand the objective of this, put a sheet on a treatment table. Stand at one corner. Grasp the sheet at that corner and twist your handful of sheet. Notice the ripples that go in all directions from your twisting grasp. This is a very simplistic representation of how the superficial fascia of the leg and thigh is distorted from an ankle sprain.
Let go of the sheet and notice how the ripples stay in the sheet. Smooth out just the ripples at the point of your grasp. This doesn’t normalize the rest of the sheet, does it?
At the top and bottom of each ripple there will be nerve and vessel entrapment. This will contribute to increased muscle tonus and ischemia. If not smoothed out it will maintain the injury pattern and contribute to re-injury.
Skin rolling treats the superficial fascia by effectively smoothing out these ripples. It involves rolling the athlete’s skin between the thumb and fingers, walking a wave of tissue along, in any direction, a step at a time.
Follow myofascial techniques with lymphatic drainage techniques if you are trained in them. Otherwise, use very light compressive effleurage. Always follow the dictum “Cause no pain.” Sports massage should never be painful, but it may be uncomfortable, in the range of five to seven on a 10-point scale, or such that the athlete is not tensing up or recoiling. However, in the area of the injury, stay in the three to five range.
Lymph moves with just ounces of pressure. The weight of your hand and arm will be sufficient. If it is comfortable for the athlete and practical for you, elevate the injured ankle. However, do not elevate it so far that it becomes uncomfortable for you to work on. Avoid working in the “shoulders around your ears” posture.
Apply lubrication to the foot and leg. Then, standing to the side and slightly inferior to the ankle, first allow one hand to gently conform to the foot. Glide that hand proximal eight to 10 inches. As you reach the end of this stroke, put your other hand on the foot and glide proximal. Continue alternating hands in a continuous, smooth, gentle, one-hand-after-the-other movement. After six to ten strokes, move up the leg in eight- to 10-inch increments. Visualize that you are moving a small wave of fluid up the leg. Work from foot to knee six to 10 times (reps). Then let the tissues rest. Repeat this four to six times (sets).
While the ankle tissues are resting, examine the muscles of the leg and thigh with effleurage. Pay particular attention to the peroneus muscles on the lateral fibula. They are usually strained. Also examine the anterior compartment. Using both thumbs held together, side by side, strip deeply through the tissues from just proximal to the hematoma to the knee. Also examine the tissues with cross-fiber friction. Engage the skin and shift it back and forth across the fibers of the muscle. Then, examine the muscles of the medial, anterior, and lateral thigh. Pay particular attention to the tensor fascia lata/iliotibial tract.
When tender points are encountered, stop and apply ischemic compression for eight to 12 seconds. Check with the athlete regarding appropriate pressure and for any referred sensations. If he experiences referred sensations (that is, sensation beyond right where you are working), it is probably a trigger point. Trigger points resulting from an injury of this severity are quite common. Treat accordingly (see “Targeting Trigger Points” in T&C 10.7, Oct. 2000).
It is generally best to begin each treatment with the athlete in the supine position for better communication, and then roll him over into the prone position to treat the posterior side. Elevate the injured leg while in the prone position as well. Use the same techniques on the posterior side. Begin with myofascial techniques, then alternate between the light effleurage over the swollen ankle, pushing the fluids proximally, and specific examination of the posterior leg, thigh, and hip muscles. Eventually, the side-lying position may be utilized when it is comfortable for the athlete.
Clinical Hint: The petrissage stroke of massage is a form of passive exercise. If done thoroughly and correctly every other day it can help prevent atrophy of the tissues.
Treating the Ligaments
Once the hematoma is reduced to minimal levels, you may begin to skin roll over the injured ankle joint. More pressure may be applied during effleurage, up to the athlete’s tolerance.
It is now time to begin to treat the actual ligament tissues. This requires use of the deep friction stroke. Engage the skin with your thumb or finger. Shift the skin back and forth, as far as it will move without your finger sliding on the skin. Initially, move parallel to the ligament fibers (longitudinal friction), as this will be the least painful to the athlete and can be done sooner in the recovery process. Advance to circular friction when sensitivity permits. Then go to cross-fiber or transverse friction, shifting the skin back and forth across the ligament fibers.
This treatment consists of a thorough examination all around the medial and lateral malleolus. Treat from the posterior side of the tibia (medial side) inferior and around the malleolus to the anterior side of the tibia. Make five to seven circles in each spot. If the athlete reports tenderness, hold the point for eight to 12 seconds, then slowly release, move a thumb width, and treat again.
Treat both medial and lateral sides. Then treat from the inferior aspect of one malleolus, across the anterior of the leg, following the joint line to the other malleolus. This treatment helps the body to build scar tissue whose matrix runs parallel to the direction of strain. It also prevents unwanted adhesions from developing in surrounding tissues and encourages reattachment of the ligaments. The sensitivity in the tissues around the injured joint will improve to the point that very firm pressure elicits no sensitivity.
Therapeutic massage can be discontinued once there is no ischemia and you can examine the athlete thoroughly (especially the tissues that cross the ankle) with no sign of tender points or trigger points.
by George Salvaterra
Motion—be it passive or active—is critical during the rehabilitation process. The goal is to try to keep the athlete’s ankle as mobile as possible within whatever range of motion he can tolerate. This will stretch out connective tissue as it heals, help to align injured fibers, increase circulation, and keep the muscles activated.
Although immobilizing the ankle may allow the ligaments to heal in a shortened position, you want them to be loaded as they heal so that maximum tensile strength and motion are restored. Immobilizing the ankle throughout the rehab process leads to dramatic muscle atrophy, shortened connective tissue, and inhibition of proprioceptors that are necessary for the athlete to comfortably move his ankle in the future.
Initially, the most important thing is for the athlete to ice, compress, and elevate (ICE) his ankle to reduce the swelling. Thus, acute management up to seven to 12 days post-injury focuses on compression and immobilization.
After this initial stage, the athlete should be non-weightbearing with the use of crutches. Once pain has decreased, a partial weightbearing crutch gait should be instituted. This enables early motion and strengthening to proceed at pain-free intensities. Partial weightbearing also provides proprioceptive input, which will assist in the return of a normal gait pattern.
To help the athlete maintain cardiovascular conditioning, pool exercises can also be used, progressing from deep-end non-weightbearing activities to shallow-end weightbearing activities. In addition, the upper-body cycle, or arm crank, can be used. The athlete may then progress to a stationary bicycle as tolerated. He should begin by cycling with the heel on the pedal, slowly moving to pedaling with the forefoot. Once increased weightbearing is tolerated, a stair-stepper machine can be used, progressing from flat-footed to heel-raised stepping.
Full weightbearing can proceed once the acute inflammatory phase has resolved. As the acute phase subsides, open-gibney taping and ice bathing prior to and following each therapy session is sufficient for cryotherapy and swelling control.
A reduction in swelling and pain will indicate progression into the sub-acute phase of tissue healing. The goals of this phase include increasing range of motion, strength, and proprioception. As the athlete enters this phase it is important to carefully reassess the joint for hyper- or hypo-mobility in order to restore normal joint play as soon as possible.
At this time, “pain-free” range of motion in planes that do not stress the healing ligaments is indicated. This can be accomplished in both an open- and closed-chain fashion. Ankle pump exercises are used to increase ankle plantarflexion and dorsiflexion in an open-chain fashion. An ankle roller (three- to four-inch wide dowel) or a tilt board can be used to increase ankle plantarflexion and dorsiflexion in a closed-chain fashion. An incline board can also be used to aid in full restoration of dorsiflexion.
Mobility of the ankle joint can be further challenged in a closed-chain fashion by using a wobble board (at this point, simply for stretching the joint more than balance), progressing from a smaller to a larger diameter ball. The athlete may then progress to a closed-chain leg press, which will further stimulate healthy joint play. The leg press will precede manual squatting and manual squatting with a calf raise.
An important consideration is restoration of ankle dorsiflexion to prevent re-injury or chronic irritation. However, if the athlete has sustained a “high” ankle sprain involving the interosseous tissue or anterior/posterior tibiofibular ligaments, then dorsiflexion should be avoided until the integrity of the ankle mortise is restored.
If normal joint play and range of motion have not been restored, then restricted motions can be increased with passive joint mobilization. Distal traction of the talus is the first mobilization that can be performed, followed by anterior and posterior gliding of the talus. Also, subtalar joint distraction with inversion and eversion may assist in regaining residual deficits in ankle plantarflexion and dorsiflexion.
Strengthening can be started as early as pain allows so that dynamic stabilization can begin. Isometric resistance applied in pain-free ranges will help maintain strength of the lower leg and foot. High repetitions with low force are recommended to also assist circulation. Then, lower reps are used with maximal force for strengthening.
Plantarflexion and dorsiflexion exercises are performed first. Inversion and eversion resistance are added as tolerated. Toe crunches with a towel and weights are valuable exercises directed at intrinsic muscle strengthening. Isotonic exercises can then be initiated in pain-free motions going from higher repetitions (20) to lower repetitions (10 to 12) with a maximal load. Proprioceptive neuromuscular facilitation (PNF) patterns can also be used to help develop strength through the entire range of motion and precede progression into balance training.
Approximately four to six weeks post-injury, and only after he has been cleared by the attending physician, the athlete can begin a walk-jog progression. Initially, this needs to be observed by the athletic trainer working with the athlete so that any gait anomalies can be addressed.
Lack of proprioceptive input resulting from damage of mechanoreceptors is very common when the joint capsule and ligaments have been injured. Proprioceptive training can be established once adequate muscular strength has been restored. This type of training will be important in regaining functional stability.
Proprioceptive training can begin with a series of closed-chain exercises that will overload the lower leg and ankle in a functional position while the environment around the athlete is manipulated. Single-leg standing, progressing from supported to unsupported, eyes opened to eyes closed, and hard surface to unstable soft surface is the typical progression.
A wobble board can also be utilized for proprioceptive training. Progressing from a smaller diameter ball to a larger diameter ball will increase the level of instability. Single-leg squatting is the next progression after this balance training. The athlete can then progress to single-leg squatting and reaching in a star pattern. Other proprioceptive challenges like rhythmic stabilization can be performed by doing elastic tubing kicks. More aggressive proprioceptive training can then begin with sport-specific activities on unstable surfaces.
During the initial phase of proprioceptive training, the athlete should continue to have his ankle taped or placed in a splint or brace during exercises. As he becomes stronger, toward the four- to six-week mark, the athlete can discontinue using the splint for exercise, but he should continue to use it while in public where the environment is less controlled.
Once the athlete has attained full ROM and strength with good proprioceptive ability, further functional training is indicated. Functional training begins with hops on a horizontal leg press or hip sled. The athlete progresses from double-leg hops to single-leg hops. Hops may then be performed on a trampoline with the same double- to single-leg progression. Low-impact hopping can be performed by skipping rope for increasing amounts of time. The athlete can then progress to power hops and diagonal power hops.
Next, the development of a functional gait sequence can begin with treadmill race walking at a 4.5- to 4.7-mph pace. The race walking can become more challenging by increasing the inclination of the treadmill up to a nine- to 11-percent grade. The addition of incline training will assist in maintenance of functional ankle and knee range of motion. Jogging is then initiated, progressing to striders, and, finally, to sprinting.
Increased stress is then added to the running program with a gradual incorporation of lateral movements. Drills that incorporate running lazy “S” patterns, large diameter circles, figure eights, carioca, and sharp cutting are introduced.
Finally, a sport-specific test is administered to determine the athlete’s level of function. This testing should take a player’s position into account. The athlete should also be supported—taped, braced (with a commercially available plastic ankle stabilizer), or “booted” (with a lace-up boot)—while performing these activities.
Back in the Game
Much like the athlete’s return to practice activities, his return to competition will be dictated by his response in terms of form and speed rather than a clock or calendar. It is not uncommon for an athlete to return to play about three months after this type of devastating injury, but it may be longer.
It is important to understand that the athlete will continue to heal physiologically for up to a year to 18 months after a serious injury like this, and will likely experience bouts of soreness and/or swelling throughout this period of time. Treatment will be dictated by symptoms, but should not inhibit the player’s return or continued play.
It is also imperative to understand that the athlete’s ankle will always be a little “loose.” Ligaments are elastic tissue in nature, and like a rubber band, once they are over-stretched or torn, they will never return completely to their pre-stretched consistency. But again, this should not inhibit the athlete’s participation in his chosen activity. As long as he continues with his strength and balance activities, he should be able to return to top playing form.