Evaluation and Rehabilitation Program

1. GRADE 2+ ANKLE SPRAIN
IN COLLEGIATE ATHLETE
By Chelsey Toney
1

2. GRADE 2+ ANKLE SPRAIN
• Grade I
- Minimal tenderness and swelling
- Slight stretching and some damage to fibers of the ligament
• Grade II
- Tearing or popping sensation felt on the lateral aspect
- Painful palpation
- Positive anterior drawer and talar tilt test
• Grade III
- Complete tear of the affected ligament
- Tearing or popping sensation felt on lateral aspect, with diffuse
swelling over entire lateral aspect
- Positive anterior drawer and talar tilt test
(Anderson, Parr, Hall, 2009)
2

3. BONY/ SOFT TISSUE ANATOMY
3

4. SOAP NOTE
Date: 9/23/2013
SUBJECTIVE: Athlete limped/ hopped out of the game at WPI 9/21/2013 c/o
ankle pain in his L ankle. In the previous play he made contact with another
player and states he may have felt a pop in his ankle but is unsure of the MOI.
He said it was very painful to stand and walk on. Initial sideline evaluation was
inconclusive so ice was applied and it was re-evaluated at half time. At that
time he was placed in an air cast and crutches.
OBJECTIVE: Initially he was tender to palpate over “tom, dick, and very nervous
harry” running behind the medial malleoli but he was most tender over the
anterior ankle around the anterior tibiofibular ligament. Initial swelling was
over anterior ankle around the anterior tib-fib ligament as well but was not
severe. No noticeable ecchymosis at this time. MMT 5/5 for all motions except
4+/5 for resisted ankle dorsiflexion for pain. Anterior drawer test (-), Kleigers
test (-), Squeeze test (-), medial and lateral stress tests (-). ROM WNL but
painful going into ankle dorsiflexion.
Assessment: Potential sprain of anterior tibiofibular ligament, anterior
retinaculum tear, r/o fracture of lower leg, syndesmosis injury?
Plan: Air cast, and crutches NWB. RICE. Has an appointment to see infirmary
for second opinion and potential x-ray.
4

5. PROGRESS NOTES
9/24/2013 – Athlete was placed in a walking boot following visit to infirmary and an xray,
revealed small fx fragment at posterior malleolar tip
9/25/2013 – Reports feeling “really good, sore but not painful,” decreased swelling and
increased AROM & ecchymosis, treatment focused on swelling/ pain control & ROM return
using therex
9/26/2013 – Athlete reported haven taken a step back this day from a fall the night before
WB on injured foot, primary point of pain located at anterior ankle
10/1/2013 – Athlete saw Orthopedic specialist over the weekend who told him he had a
‘grade 2, possible grade 3 ankle sprain’. Instructed to stay in walking boot for 2 weeks.
Swelling has decreased but noticeable when compared bilaterally, pain decreased with
motion. Some pain at end ranges of motion and lacks strength. Estimated to be out of
walking boot on 10/5, rehab for ankle begins today
10/4/2013 – Athlete goes to training room for treatment and rehab daily, has show gains in
ROM, strength, and balance, and pain and swelling have gone down considerably,
progressed to stage 2 therapeutic exercises
10/10/2013 – Athlete shows gains in ankle strength, ROM, and proprioception. Stage 3
rehabilitation began on 10/9 , he stated all exercises feeling good except for heel raises,
during practice on 10/9 he ran around the track after being taped and stated it being mildly
sore
10/18/2013 – Slightly more swollen than normal creating some pain 10/15 but it was back
to normal the following day, dynamic rehab 10/17, participating in dynamic warm up w/o
pain, receiving ultrasound and heat for treatment
10/21/2013 - Athlete participated in non-contact practice in his helmet. Minimal pain with
some motions. Heated and taped prior to practice and ice bathed and stimmed following
practice
11/1/2013 - RTP 5

6. PATIENT X RAY
6

7. PATIENT X RAY
7

8. Orthopedic Evaluation
Radiology x-rays:
- Posterior mal fx. Avulsion mortise intact
Findings/Impression/Plan:
- L ankle fx (avulsion), sprain w/ instability
- Boot continue
- Taping for stability in several wks
8

9. INITIAL – 10 DAYS
9

10. 25 DAYS
10

11. REHABILITATION Stage 2
- early rehab
- ROM│Flexibility Exercises
- Balance│Proprioception Exercises
- Progressive Strength Exercises
• WWP 10 min – ROM/ ↓pain
• Heel Raises 2x8, 2x15, 3x12 – Strength/ balance
• ABC’s 3x – ROM/ strength
• Marble pick up – strength/ ROM
• Single Leg Ball Toss 2 x 10 – balance/ strength
• Heisman 30 sec – balance/ strength
11

12. REHABILIATION Stage 3
- late rehab
• SLS off step 2x10
• SL lunge on bosu ball 2x12
• BAPS board 2x10
• 4 way ankle 2x10
12

13. STAGE 4 ANKLE REHAB
Functional Rehab
• Agility Exercises
• Plyometric Exercises
• Sport specific skills and drills
13

14. REHABILIATION Stage 4
- functional rehab
• Bike
• Monster walk
• Mountain climber
• Dynamic
• - During practice on 10/9 he ran around the track
after being taped
• - 10/17 dynamic rehab with quick movements
(jumping, ladder drills, and cardio)
• - 10/21 participated in non-contact practice with
helmet
14

15. RESEARCH
According to Simon and Donahue
- Ankle taping or bracing creates an increased sense of
confidence, stability, and reassurance when performing a
dynamic-balance task
According to Basnett, Hanish, et al
- Available motion at the ankle, specifically dorsiflexion ROM
contributes to dynamic balance measures in individuals with
CAI
According to Bleakley, O’Connor, et al
- An accelerated exercise protocol during the first week after an
ankle sprain will improve ankle function
15

16. WORKS CITED
• Anderson, Marcia K., Parr, Gail P., Hall, Susan J. (2009). Foundations of Athletic Training Prevention,
Assessment, and Management. Pennsylvania: Lippincott Williams & Wilkins.
• Basnett, Curtis R., Hanish, Michael J., Wheeler, Todd J., Miriovsky, Daniel J., Danielson, Erin L., Barr, J.B., et
al. Ankle Dorsiflexion Range of Motion Influences Dynamic Balance In Individuals with Chronic Ankle
Instability. The International Journal of Sports Physical Therapy. 2013. 8. 2.
• Bleakley, Chris M., O’Connor, Sean R., Tully, Mark A., Rocke, Laurence G., MacAuley, Domhnall C., Bradbury,
Ian., et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled
trial. British Medical Journal. 2010. 340.
• Klykken, Lindsey W., Pietrosimone, Brian G., Kim, Kyung-Min, Ingersoll, Christopher D., Hertel, Jay. Motor-
Neuron Pool Excitability of the Lower Leg Muscles After Acute Lateral Ankle Sprain. Journal of Athletic
Training. 2011. 46. 3.
• Mattacola, Barl G., Dwyer, Maureen K. Rehabilitation of the Ankle After Acute Sprain or Chronic Instability.
NATA Journals. 2002. 37(4).
• Puls, Alecia, Gribble, Philip. A Comparison of Two Thera-Band Training Rehabilitation Protocols on Postural
control. Journal of Sport Rehabilitation. 2007. 16.
• Simon, Janet, Donahue, Matt. Effect of Ankle Taping or Bracing on Creating an Increased Sense of
Confidence, Stability, and Increased Sense of Confidence, Stability, and Reassurance When
Performing a Dynamic-Balance Task. Journal of Sports Rehabilitation. 2013. 22.
• Wahnert, Dirk, Gruneweller, Niklas, Evers, Julia, Sellmeier, Anna C., Raschke, Michael J., Ochman, Sabine.
An unusual cause of ankle pain: fracture of a talocalcaneal coalition as a differential diagnosis in an
acute ankle sprain: a case report and literature review. Biomed Central Musculoskeletal Disorders. 2013.
14. 111.
16