Common Foe

November 30, 2017
By David Gable

David Gable, MS, LAT, ATC, is Associate Athletics Director for Sports Medicine and Head Athletic Trainer for Football at Texas Christian University. He can be reached at: d.gable@tcu.edu.

Injuries are part of sport. Unfortunate, but true. It is why we as athletic trainers have jobs. For some reason, injuries tend to come in cycles. Some years, you have an unusual number of shoulder injuries. The next year, it may be knee or back injuries. Ankle injuries are very common in sport, but the high ankle sprain appears to be coming more prevalent than the “textbook” lateral sprain. Fortunately, we are becoming more accustomed to dealing with these high ankle sprains, so more options are available to treat them appropriately.

To start, imaging is important in determining what type of sprain you are dealing with. We try to limit our imaging as much as possible, but if you know exactly what you are facing, it makes your treatment and rehab plans more efficient. X-ray is great for ruling out fractures and even determining if there is an instability in the joint through stress and weight-bearing views. MRI will help identify more specifically what ligaments, tendons, or other soft tissue may be involved. Often, you will find multiple ligament disruptions with a high ankle sprain, which will help define the proper course of treatment.

The tight rope surgical procedure, which basically entails anchoring the distal ends of the tibia and fibula together using a “cord” and “buttons,” has shown to be very effective in returning athletes to sport in a safe, timely manner following unstable high ankle injuries.

Once diagnosed, determining the best treatment plan is crucial for a timely return from a high ankle sprain. Surgical intervention is obviously more invasive than conventional methods but may ultimately allow the athlete to return to sport more quickly than rehabilitation alone. Our philosophy on surgery is we can’t make the ankle any better than the one the athlete was born with, so we do not pursue surgical options unless necessary. However, the tight rope surgical procedure, which basically entails anchoring the distal ends of the tibia and fibula together using a “cord” and “buttons,” has shown to be very effective in returning athletes to sport in a safe, timely manner following unstable high ankle injuries.

Following a tight rope procedure, early range of motion—particularly plantar and dorsiflexion—is encouraged with caution. Athletes will normally only remain in a walking boot for protection for about one week before transitioning to a rigid ankle brace that minimizes inversion and eversion. Early management of pain and swelling through traditional modalities is crucial in allowing early active exercise.

Isometrics and partial weight-bearing activities are initiated within seven to 10 days. It is important not to neglect the quad, hamstrings, and core while focusing on the lower leg and ankle. We begin incorporating proprioceptive exercises, shuttle exercises, and resistive bands between days seven and 10, as well. Pain and/or swelling should be your guide to progression.

Once the wounds have healed appropriately around day 10, you can begin work in the pool or, if you have access to one, the Alter G anti-gravity treadmill. Approximately 50 percent weight bearing is a good starting point, but, again, let the athlete be your guide.

Over the course of weeks two to four, rehab exercises can be progressed as tolerated. Around week two, the athlete is allowed to ambulate without the use of the rigid ankle brace. However, we still encourage its use if we feel they may be exposed to “risky” environments around a lot of people who are unaware of their injury. Increasing conditioning and bodyweight load can progress as tolerated during this time, as well.

By the end of week four, the athlete is performing functional drills on the court or field at the surgeon’s discretion and the athlete’s tolerance. Return to sport-specific activity and competition can also follow these guidelines and can vary from athlete to athlete.

Management of the high ankle sprain was once thought to be a long-term process with variable outcomes, but thanks to advancement in surgical techniques and a more aggressive approach to rehab, it is now a very manageable injury. Gaining the athlete’s trust and building their confidence through successful outcomes in each phase of rehab are critical in this process. Always challenge your athlete in rehab, and, hopefully, they will challenge you in return, which will ultimately make you a better clinician.

Image by Whoisjohngalt

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