AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Ankle sprains are the most common sports injuries encountered today. These injuries occur frequently. Complications associated with prolonged ankle pain, a high recurrence rate, and chronic ankle laxity underline the importance of careful diagnosis and treatment of ankle sprains.¹

Related Medscape topics:
Mechanical Laxity in the Functionally Unstable Ankle
Therapeutic ultrasound for acute ankle sprains

Related eMedicine topics:
Ankle Sprain- Physical Medicine and Rehabilitation
Ankle Sprain- Sports Medicine

History of the Procedure

In the spring of 1862 at the Royal College of Surgeons, John Hilton gave a series of lectures in which he described performing anatomic studies on an ankle sprain in order to increase his knowledge of the condition.² Since its development, radiography has been used to study ankle sprains. Radiography is still the first-line investigation of ankle sprains, second only to the classic clinical history and physical examination, since radiographs make it possible to distinguish between ligamentous and bony injuries around the ankle. Currently, magnetic resonance imaging (MRI) allows cartilage and ligament injuries to be diagnosed in ankle injuries.

Problem

Ankle sprains result from force around the ankle that exceeds the tensile limits of the supportive ligaments of the ankle mortice but is less than that which would break the ankle bones. The ankle joint is the site of concentrated forces because it is the dynamic link between the leg above and the foot planted on the earth below. The large muscle masses of the lower extremity and the momentum of the body’s weight are concentrated on the ankle, connected to the foot, which may be firmly planted on the ground. These factors make ankle sprains the second most frequently encountered outpatient orthopedic condition in many orthopedic clinics (after chronic back pain).

Frequency

Most ankle sprains are probably self-treated and are never reported to a health care provider; therefore, many ankle sprains are not documented. Sprained ankles have been estimated to constitute approximately 15% of all sports-related injuries (see the Rothman Institute site). More than 23,000 people per day, including athletes and nonathletes, require medical care for ankle sprains in the United States.³ Stated another way, incident cases have been estimated at 1 per 10,000 persons per day.³

Etiology

Mechanical forces exceeding the tensile limits of the ankle joint capsule and supportive ligaments cause ankle sprains. There are a number of contributing factors, which can be classified as predisposing and provocative factors:

• Predisposing factors can include poor muscle tone or proprioceptive sense and shortened and/or contracted joint capsule or tendons from a lack of conditioning. Inadequate training or experience with a physical activity being performed can also predispose to injury.
• Provocative factors include accidents and other unforeseen circumstances that result in mechanical stresses that exceed the tensile limits of the ankle joint capsule and ligaments. Obesity can contribute to sprains by increasing kinetic energy to the point that it exceeds joint-design stress limits.

Pathophysiology

Type A collagen tissue constitutes the bulk of the capsule and supporting ligaments of the ankle joint. The fiber density and orientation are arranged dynamically according to the average mechanical stress experienced by the joint. Within limits, the greater the excursion of the joint capsule and ligaments, the less likely sprains are to occur; with increased motion, the muscles absorb the mechanical force energy, without exceeding the tensile limits of either the joint capsule or the ligaments.

The strongest ankle capsule-ligament complex is the deltoid ligament, which has 2 parts: the superficial component and the deep component. The superficial component runs the farthest from the medial malleoli to the medial aspect of the calcaneus, posteriorly. It also attaches to the sustentaculum tali of the talus in the center portion; anteriorly, it joins the spring ligament attaching to the tuberosity of the navicular. The deep component of the deltoid ligament is short and attaches to the neck, body, and posterior portion of the talus. The greatest mechanical forces across the ankle joint are directed medially in the normal external rotation of the foot in walking and running. This is reflected in the strength and thickness of the deltoid ligament. The medial malleolus usually fractures before the deltoid ligament fails mechanically.

The anterior and posterior capsular ankle ligaments are relatively thin compared to the medial and lateral ankle ligaments. The lateral ankle ligaments are the anterior talofibular ligament, the fibulocalcaneal ligament, and the posterior talofibular ligament. Their attachments and positions are designated by their names.

The ankle joint is a hinged synovial joint with primarily up-and-down movement (plantarflexion and dorsiflexion). The other joints around the ankle are responsible for other movements, giving the ankle a total range of motion comparable to that of a ball and socket. The combined movement in the dorsiflexion and plantarflexion directions is greater than 100°; bone-on-bone abutment beyond this range protects the anterior and posterior ankle capsular ligaments from injury. Ankle spurs may occur at any of the bony ligament attachments. On lateral radiographs, it is not uncommon to see an anterior spur at the neck of the talus, where the anterior ankle capsule attaches. This is caused by ossification of the hematoma organization associated with anterior ligament sprains.

The lateral ligament of the ankle joint commonly experiences ankle sprains. The lateral ankle ligament has 3 divisions that run from the lateral malleoli to the surrounding bones. The anterior talofibular ligament is most often injured; this ligament runs from the front of the lateral malleoli to the anterolateral aspect of the talus. The foot is not designed to withstand inversion strains because that is not the position in which it normally functions. When the ankle is stressed in this position, ankle sprain of the anterior talofibular ligament commonly results.

The middle portion of the lateral ankle ligament is called the fibulocalcaneal ligament. It is cordlike and is thicker and stronger than the anterior talofibular ligament. The fibulocalcaneal ligament runs from the tip of the lateral malleolus to the lateral aspect of the calcaneus directly below the fibula. The posterior portion of the lateral ankle ligament is the strongest of the 3 portions of the lateral ankle ligaments and is called the posterior talofibular ligament. It runs almost horizontally from the fossa in the inner aspect of the tip of the lateral malleolus to the posterior tubercle of the talus.

A fifth ankle ligament is rarely sprained because of its great strength. It is a strong syndesmotic ligament with a deep portion between the bones and superficial, anterior, and posterior portions. This distal tibiofibular ligament holds the distal tibia and fibular bones together at the ankle joint and maintains the integrity of the ankle mortice. It takes a great amount of force to strain this ligament, which normally does not have much excursion. A tear of this ligament requires surgical treatment. Severe posttraumatic arthritis of the tibiotalar joint (ankle) can quickly result if the tear of the distal tibiofibular ligament syndesmosis remains unrecognized and untreated. Tear of this syndesmotic ligament is usually a part of an ankle fracture that needs to be specifically treated. This is not generally true of the other ankle ligaments.

Clinical

A history, a physical examination, and radiographs are the only investigations typically indicated in an ankle sprain. Many osteochondral lesions heal with standard ankle sprain care.^{4, 5, 6, 7}

The history of an ankle sprain is usually of an inversion-type twist of the foot followed by pain and swelling. An individual with an ankle sprain can almost always walk on the foot carefully with pain. The ability to walk on the foot usually excludes a fracture and indicates that a sprain has been experienced in an individual with normal local sensation and cerebral function. A person with a third-degree ankle sprain often reports a history of an audible snap followed by pain and swelling.

The physical examination confirms the diagnosis made on the basis of patient history and differentiates an ankle sprain from a fracture. A sprain is usually well defined by pain over the ligament that is sprained. Ankle motion is painful, and the ankle appears to be in the normal anatomic position. The skin is usually intact with local swelling and bruising in third-degree ankle sprains. A finding of a positive anterior drawer sign in the injured ankle is evidence of an anterior talofibular ankle ligament rupture. The degree of swelling or ecchymosis is proportional to the likelihood of fracture.

The drawer sign is best elicited with 2 hands, with the patient sitting so that the weight of the foot distracts the ankle joint to its normal degree. With 1 hand cupped over the heel and the other hand providing counter pressure over the front of the tibia at the level of the ankle, carefully assess the degree of movement. Repeat these steps for the other ankle, and compare results. In a person with lax joints, several millimeters of bilateral movement  is a negative ankle drawer sign finding. A positive ankle drawer sign finding is a difference of movements in a relaxed patient between the injured side and the uninjured side, with the injured side having more movement than the uninjured.

Women often have more tibial varus than men because the pelvis is wider in females. When this increased tibia varus is associated with an increased calcaneal eversion range of motion, these women are at a greater risk for ankle ligament trauma. Men with an increased talar tilt are at a greater risk for an ankle sprain.⁸

A radiograph is the study of choice to determine if the ankle or foot is fractured.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The indications for surgery are limited in patients with sprained ankles. One of the few absolute indications for surgery is a distal talofibular ligament third-degree sprain that causes widening of the ankle mortice (please see the Staging section under Workup). To restore the ankle mortice, the distal tibiofibular articulation must be screwed together. The usual postoperative course entails avoiding weightbearing for 6 weeks, followed by removal of the screw, and then continuing external immobilization while allowing weightbearing for an additional 6 weeks. This program serves to avoid breakage of the syndesmotic screw and the associated difficulties that may present.

An isolated complete medial ankle sprain with a palpable defect and demonstrable clinical instability is an indication for surgery, particularly if the deltoid ligament is caught in the medial ankle joint. This allows for removal of the ligament from the joint and repair of the ligament.

Evans reported the outcome of 100 randomly selected patients with isolated lateral ligament sprains 2 years after injury. Patients were divided into 2 groups, each with 30 individuals with anterior ligament sprains only and 20 individuals with both anterior and middle ligament ruptures. One group of 50 patients was treated surgically, and the other group was treated with cast immobilization. This study demonstrated no functional or symptomatic advantage for those who were treated surgically. The nonsurgically treated group returned to work earlier and had less morbidity than the surgically treated group of patients.⁹

Staples reported that young, active, athletic patients with tears of both anterior talofibular ligaments and calcaneofibular ligaments are best treated surgically. He reported on a group of young athletic patients with only 58% satisfactory results after immobilization, and he subsequently reported on a similar group of patients who had 88.9% satisfactory results with surgical repair.^{10, 11}

The average age of the young, athletic patients that Staples reported on was 19.7 years. In the group of patients who underwent surgery, the average hospital stay was 7.6 days. Six of the 27 patients who underwent surgery had complications (22.2%). Marginal necrosis of the skin at the wound edge and hypesthesia of the 4th and 5th toes and adjacent forepart of the foot were the only reported complications. In select young patients with high athletic demands who have both anterior talofibular and fibulocalcaneal complete ruptures, surgical repair may be the treatment of choice. In Staples' discussion, the group who underwent surgery had more careful postoperative supervision than the group who underwent immoblilzation treatment alone. Five out of 8 (62.5%) of the patients with double lateral ligament complete rupture, demonstrated by arthrograms, who had refused surgical treatment were completely asymptomatic at 1 or more years after injury.¹¹

The cause of continued symptoms after ankle sprain, regardless of the method of treatment, is incompletely understood. Equal supervision of the postinjury course may tend to lessen the difference in outcomes between the surgical and conservative treatment protocols. Newer methods of bracing, such as a controlled ankle motion (CAM) walker and air cast type braces, protect well while allowing mobility and may provide better outcomes than rigid casting. Further research is needed to determine the best treatment for complete double ligament lateral ankle sprains.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

See Pathophysiology.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Currently, it is generally accepted that for most patients, operative repair of third-degree anterior talofibular ligament tears and medial ankle ligament tears does not contribute to an improved outcome. Early active treatment with good follow-up care obviates the necessity for late reconstruction of lateral ankle ligaments for chronic symptomatic instability. See Pathophysiology for the details of the anatomic considerations that make surgery unnecessary (except in cases of distal tibiofibular syndesmosis, as discussed in Indications).

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• No laboratory studies are indicated for isolated ankle sprains.

Imaging Studies

• Radiography
• • Plain radiographs may be clinically indicated to diagnose a fracture of the ankle or foot.
  • Ankle stress radiographs contribute little to the management of acute ankle sprains because surgical treatment of the acute sprain is rarely indicated. Abnormal swelling or clinical ankle instability in an acute sprain may be documented with bilateral stress radiographs of the ankle.
• MRI
• • MRI is not indicated unless unusual features are present, such as extensive swelling, ecchymosis, or pain, that suggest an osteochondral lesion not observed on plain radiographs.
  • Initially, conservative ankle sprain treatment is indicated, even if MRI scans demonstrate bone bruising or actual articular cartilage damage.
• Arthrogram
• • Ankle arthrograms may be useful for determining capsular damage and the number of ankle ligaments damaged; however, arthrography is only indicated if surgery is needed, and the criteria for surgery to repair double lateral ligament complete tears are still under debate. Staples found that arthrograms provided the most preoperative information.^{10, 11}
  • Ankle arthrograms are not indicated in every patient considered for surgical treatment. Marked clinical instability in a young individual with great physical demands being considered for surgery requires an ankle arthrogram.

Staging

• Ankle sprains are classified into the following 3 grades:
• • Grade 1 is a symptomatic stretch within the tensile limit but without failure of the ligament fibers (tear).
  • Grade 2 exceeds the limits of tensile strength, with failure of part of the ligament fibers.
  • Grade 3 is complete failure of the ligament fibers.
• Ankle sprains are primarily staged or graded clinically. The degree of swelling and ecchymosis and the clinical stability of the ankle determine whether the ankle ligaments are stretched without significant tear (grade 1), partially torn (grade 2), or completely torn (grade 3). Arthrograms, stress radiographs, and MRI scans add little to the management of the ordinary ankle sprain. In order to have any significance, stress radiographs should be performed on both ankles.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical therapy

Most ankle sprains heal spontaneously with immediate application of ice locally, elevation for the first 24 hours after injury, the use of an ankle support as long as symptoms persist, and avoidance of activity that causes pain. Many immobilization devices are comfortable and conform to the ankle with air cushion pads (eg, air cast). Immobilization that allows movement until healing has taken place (3-6 weeks) is the criterion standard for ankle sprain treatment because the collagen fibers heal the fastest and orientate along the lines of force where protected movement occurs. Early movement also helps in decreasing swelling and the danger of fibrosis that normally develops in chronic swelling.^{12, 13, 14, 15, 16}

For acute third-degree ankle sprains, cast immobilization is indicated for 3 weeks, followed by a walking boot or other ankle immobilization device, after the immediate swelling has subsided. Immediate icing and elevation are used to decrease the swelling and reduce the danger of long-term postswelling fibrosis.

Surgical therapy

The 2 indications for surgical treatment of acute ankle sprains that are generally agreed upon are (1) a deltoid sprain with the deltoid ligament caught intra-articularly with widening of the medial ankle mortice and (2) an inferior tibiofibular syndesmosis sprain causing real or potential widening of the ankle mortice. Acute grade 3 tears of the interior tibiofibular ligament can have a normal radiographic appearance in patients not bearing weight; this is the standard of care in acute ankle sprains because of the discomfort associated with bearing weight. Thus, keep in mind that normal radiographic findings do not rule out the need for surgery.^{12, 13, 14}

Pain and swelling localized over the inferior tibiofibular syndesmosis should alert the clinician to tears in the syndesmosis complex that may be best treated with surgical fixation. There is still controversy concerning the surgical treatment of complete anterior talofibular and fibulocalcaneal tears (double ligament tears) and for the rare cases in which all 3 lateral ankle ligaments are torn. In a young patient with athletic requirements, surgical repair of severe lateral ankle sprains is sometimes indicated.

Treatment of distal tibiofibular syndesmosis sprains consists of screw placement across the syndesmosis that remains in place for 6 weeks and is removed before weightbearing is allowed so as to avoid screw breakage.

Surgical repair of the lateral ligaments is still debated. Exposure must be carefully made so as to avoid the sural nerve posteriorly and the lateral branch of the superficial peroneal nerve anteriorly. Nonabsorbable flexible suture is preferred for suturing the tendons and the capsule. The peroneal tendon sheaths are opened and the tendons retracted to access and repair the calcaneus fibular ligament. The peroneal tendon sheaths should be repaired along with the joint capsule. Careful skin handling and meticulous repair are indicated, as the skin is thin and fragile over the lateral ankle, even in young athletes.

Intraoperative details

Open reduction of a deltoid ligament caught in the medial ankle is performed through a curved incision below the medial malleolus. For greater exposure, some surgeons prefer a vertical incision. (The physician should use his or her best judgment when choosing the type of incision that will result in the least skin problems and the best healing). Release the caught ligament, and either suture the ligament together or suture it to bone with a trocar needle using a nonabsorbable pliant suture. A standard postoperative course should be followed, including splinting in the same manner as for conservative treatment of ankle sprains.

Postoperative details

Acute sprains that do not heal and become painless should alert the clinician to possible complications, such as a loose body, posttraumatic arthritis, or an occult fracture. An MRI could be helpful in defining a mechanical cause of continued symptoms that could be corrected surgically.

Follow-up

Follow-up care is very important because ankle sprains tend to recur and progress to ankle instability if neglected. The goals of follow-up care are 3-fold:

• First, the range of motion must be completely restored. This is most important to help prevent a recurrence of an ankle sprain. The desired range of motion is 10-15° of dorsiflexion of the ankle with the knee extended and a full 90° of plantarflexion. Stretching exercises, particularly for the tendo Achillis and for both muscles that attach to the tendo Achillis, are needed.

  Home exercises after appropriate physiotherapy instruction are important.

• Muscle strengthening after immobilization for any length of time is the second goal. Muscle strength can be targeted specifically, with a physical therapist, or simply, with self-directed walking exercises; ideally, the individual should walk 2 miles a day for 5 days a week for life. Daily walking exercise affords many health benefits besides increased ankle strength and fewer recurrences of ankle sprains. Thera-Band exercises for all muscle groups around the ankle can be self-directed after instruction from a physical therapist or other office staff personnel. Exercising specific muscle groups lacks the synergistic effect obtained from activities such as walking or using a proprioceptive board as described below.
• The third goal is to restore, facilitate, or develop proprioception in the ankle joint. Proprioception is facilitated or developed with physiotherapy instruction and help, if necessary. A half-inch to three-quarter–inch thick piece of plywood, measuring as long and as wide as the foot, can be made and used economically at home for 6 weeks of self-directed exercises by a compliant and motivated patient. This proprioceptive board also helps with the stretching and strengthening exercises.

  Half of a 3-4 inch diameter plastic or wooden ball is fixed to the center of 1 surface of the board. This device affords 2 levels of range of motion. The patient steps on it with the half of a ball down on the floor to perform 10 sets of ankle motion in plantarflexion and dorsiflexion. Then the foot is placed on the wood cross-wise, and side-to-side motions are performed 10 times. These sets of exercises are performed once or twice daily with the patient’s attention directed to what the foot is doing in order to facilitate the cerebellar-foot neural connections.

  When these exercises are performed easily (after approximately 3 weeks), the range of motion is increased and the device is used in the opposite fashion; the plantarflexion and dorsiflexion motions can be performed with the foot sideways on the proprioceptive board, and the side-to-side movements can be performed with the foot on the board such that it fits the foot. Care must be taken with these exercises to avoid causing another ankle sprain, which is what the proprioceptive exercises are designed to prevent.

Following the criteria for the patient’s return to sports activities is important. When the athlete can run without a limp or hesitation or pain, the patient can be approved to return to sports. Figure-of-8 measurement around the ankle and midfoot, compared to the contralateral side, can be used to accurately measure swelling. The lack or presence of ankle swelling has been reported to poorly correlate with functioning; therefore, running without pain or limping is the preferred criteria for returning to sports (that is, assuming that the patient has regained proprioception, muscle strength around the ankle, and a full range of motion or has reached a plateau for several weeks with range of motion, particularly for postoperative patients, and is pain free with a clinically stable ankle). Meeting all of these criteria is necessary to minimize the recurrence rate for repeat ankle sprains and to minimize chronic symptoms following a severe ankle sprain.

Protective strapping and the use of an ankle support or high-topped footwear are strategies that may help reduce the ankle sprain recurrence rate. There is no substitute for a full range of motion, ankle strength, and proprioception in decreasing the recurrence rate for ankle sprains.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The major complications of ankle sprains are recurrence and prolonged pain and ankle instability. These complications are best avoided with rigorous early treatment with adequate immobilization. A rare complication is complex reflex pain syndrome (sympathetic dystrophy). Unrecognized osteochondral injuries are more common in patients with ankle fractures than in those with ankle sprains because higher forces result in fractures rather than in sprains.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The prognosis for isolated and adequately treated ankle sprains is excellent. The prognosis for a patient with ankle sprains and other traumatic injuries is related to the prognosis for the other injuries.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Dreams of a future instant cure for ankle sprains and controversies about the best method of achieving the fastest and most pain-free cure are always present.

Controversies exist about the best management for ankle sprains. No objective evidence indicates which symptomatic complaints are most likely best addressed nonmechanically. Surgery is almost always a poor treatment choice for a nonmechanical problem.

Many new surgical techniques are being used and discussed for the management of chronic ankle sprains (ie, chronic ankle instability). Arthroscopic techniques have obvious advantages and have stood the test of time for knee and shoulder joints. Arthroscopy is being used more often for the ankle joint, with perhaps less advantage than that seen in the knee or shoulder, proportional to less covering and tighter tolerances in the ankle.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  A 3-inch diameter solid rubber ball has been cut in half and each half has been glued to a different half-inch plywood board 5 inches wide and 1 foot long. The size of the board is cut to the size of the patient's foot. This is a proprioceptive board used for rehabilitation exercises after immobilization for treatment of ankle sprains. Both halves of the ball are pictured on 2 proprioceptive boards. Only 1 board is used for each patient. The plywood board is covered with carpet or cloth to give it an aesthetically pleasing finish. The carpet covering has no effect on the board's function other than cosmetic; this may possibly aid in exercise compliance.
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Media type:  Photo

Media file 2:  The proprioceptive board exercises are of 2 levels of difficulty depending on which way the board is aligned relative to the foot. Pictured is the minimal level of range of motion of dorsiflexion and plantarflexion. This is the foot and board alignment to use at first. Exercises are done bearing weight as tolerated and by looking at the foot as it is exercised to aid in proprioceptive reinforcement. The usual protocol calls for 10 minutes of exercises, 10 movements each in dorsiflexion, plantarflexion, varus and valgus. For minimal-level varus and valgus movement, the alignment of the board relative to the foot must be rotated 90° so that the side-to-side movement in varus and valgus is a minimal range position initially. These exercises are performed once a day at a minimum for 3-6 weeks of rehabilitation. Patients should hold on to something to steady themselves as necessary while performing the exercises.
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Media type:  Photo

Media file 3:  This photo shows the maximum range of motion in varus. This is the second level of difficulty exercises that may be performed when the first level, with limited range of motion, is fully mastered and performed for a week or 2 with no difficulty. The maximum range of motion in dorsiflexion and plantarflexion is achieved with the foot aligned 90° from what is shown, so that the heel and the toes hang over the sides of the board, allowing for maximum range of motion. The advantages of using such a proprioceptive board as shown are that the board can be made to size to accommodate feet of different sizes and it is easily made using low-cost, readily available materials. These exercises achieve 3 goals: range of motion with stretching of healing ligaments, muscle strengthening, and proprioceptive training. Diligent performance of postsprain rehabilitation exercises is 1 of the keys to complete resolution of postinjury symptoms.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

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Article Last Updated: Feb 4, 2008