Ankle Ligament Injuries in The Lateral, Medial, and Syndesmosis: A Case Study

A Case Study presented to the

Faculty of the Physical Education Department

School of Education

Ateneo de Zamboanga University

In Partial Fulfillment of the Requirements

In PATHFIT FITNESS EXERCISES

By:

Norhaliza-norbi “Noah” A. Edding

Ateneo de Zamboanga University

December 2022
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TABLE OF CONTENTS

Title Page 1

Table of Contents 2

Abstract 4

Chapter I (Introduction) 5

Chapter II (Review of Related Literature)

• Section I: Anatomy of the Ankle 7

• Section II: Common Injuries 16

§ Causes

§ Symptoms

§ Risks

§ Complications

• Section III: Medical Diagnosis 24

• Section IV: Prevention 28

• Section V: Treatment 30

• Section VI: Exercise Forms 33

Chapter III (Significance of the Study) 38

Chapter IV (Results and Discussions)

• Section I: The Injury 39

• Section II: Therapy, Treatment and 43

Rehabilitation
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• Section III: The Exercise Form 47

Chapter V (Conclusion)

Summary of Findings 57

Concluding Statement 58

Summary of Statements 59

Bibliography 60
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ABSTRACT

Ankle injuries are common occurrences in movement-related activities performed

by active participants such as athletes, artistic, competitive, or otherwise. These individuals are

prone to sustaining injuries along the ligaments of the ankle when evidence of overuse or tears of

fibrous connective tissue is apparent. However, despite its notoriety, many are sometimes mistaken

about its severity. For example, athletes are often described as passionate and committed as well

as persistent, and while it benefits them in competition, they tend to underestimate injuries such as

sprains. They may hurry the recovery period by taking missteps, such as particular methods or

exercises that may or may not hinder the healing process, which guarantees unpredictable

outcomes like the escalation of the condition. Such is that this case study must aim to thoroughly

study how the anatomy reacts to exercise forms to find an efficient way to heal the place of injury,

prevent further damage or avoid acquiring the injury altogether. It is to discover if the ligament

may mend under a movement appropriate for its recovery or if a particular exercise may worsen

the specific part of the injured ligament. It is such that if any ligament of the ankle is left untreated

or poorly treated for its injury, it may risk developing recurrences or chronic instability due to pain.

Thus, this study intends to help people suffering from ankle injuries by providing coherent research

on which exercise regimen is suitable for efficient rehabilitation and avoiding the risks of

experimenting with movements and forms. Be that as it may, this study shall serve as an extended

instruction as one of many existing in remedying and preventing ankle ligament injuries.
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Chapter I

INTRODUCTION

Athletes most frequently sustain ankle ligament injuries, which account for 16–40% of all

sports-related injuries. Sports medicine continues to be interested in ankle sprains. Despite

improvements in diagnosis, treatment, and prevention brought about by research, recent

epidemiology studies have shown that lateral ankle sprains continue to be the most common sports

injury. Physically active people frequently suffer from ankle sprains, especially those who play

court and team sports. Reinjury is an issue for people who play high-risk sports like basketball. A

lateral ankle sprain was shown to be the most frequent of these injuries, accounting for 14% of all

sports-related orthopedic emergency visits. It should be emphasized that because 50% of people

who have an ankle sprain choose not to seek medical assistance, the overall prevalence of lateral

ankle sprains may be underestimated.

Successful recovery from a lateral ankle sprain depends on proper treatment of the athlete.

Through a thorough history and unbiased evaluation, the afflicted structures must be correctly

diagnosed and identified. An tailored evidence-based intervention plan can be created based on

this information to facilitate recovery while lowering the risk of reinjury. In order to manage lateral

ankle ligament sprains, this study will offer a current overview of the pathoanatomical

characteristics, differential diagnosis, objective assessment, management, and clinical course.

Annually, there are about 2 million acute ankle sprains. The incidence rate of acute ankle

sprains per 1000 person-years, according to data from visits to emergency rooms, is between 2 and

7. However, this number is probably significantly understated, given that many injured people do

not even seek medical attention.

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Acute ankle sprains are one of the most common musculoskeletal injuries, with a high

incidence among physically active individuals. Additionally, acute ankle sprains have a high

recurrence rate, which is associated with the development of CAI. Understanding the

epidemiology of these injuries is important for improving patients' musculoskeletal health and

reducing the burden of lower limb musculoskeletal conditions.

The purpose in studying the exercise form is to describe a functional rehabilitation program

that progresses from basic to advanced, while taking into account empirical data from the literature

and clinical practice. It is to outline rehabilitation concepts that are applicable to acute and chronic

injury of the ankle. It is also to provide evidence for current techniques used in the rehabilitation

of the ankle.
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Chapter II

REVIEW OF RELATED LITERATURE

SECTION I: Anatomy of the Ankle

Literature on the ankle ligaments is uncommon, even though said joints often sustain

injuries in sports and other activity-based events. As a result, a proper understanding of the

anatomy of ankle ligaments is essential for correct diagnosis and treatment, as ankle ligament

injury is the most frequent cause of acute ankle pain. The laxity of one of the ankle ligaments often

causes such results as chronic ankle discomfort, and there are three groups of ligaments divided

around the ankle depending on their anatomic position that are affected by many such pains: (a)

lateral ligaments, (b) deltoid ligament from the medial side, and the (c) tibiofibular syndesmosis

that connects the leg bone.

LATERAL COLLATERAL LIGAMENTS

The lateral ligaments bind the lateral malleolus to the bones below the ankle joint,

stabilizing the ankle and acting as a guide to control ankle mobility. They are in charge of providing

resistance to internal rotation stress and inversion. The anterior talofibular ligament, which joins

the talus to the fibula, is the most prone to injury of the three lateral ligaments because it is the

weakest. The talus and fibula are joined by the posterior talofibular ligament. The fibula is

inferiorly joined to the calcaneus by the calcaneofibular ligament.

a. Anterior talofibular ligament

The anterior talofibular ligament, which is also the most frequently

seen injury in emergency rooms, is the most frequently injured ligament in

the ankle (Boruta et al., 1990). This ligament is crucial in preventing

anterior talus displacement and plantar flexion of the ankle (van den
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Bekerom et al., 2008). The lateral malleolus' anterior edge is where the

anterior talofibular ligament begins. As measured along the fibula's axis, the

center is typically 10 mm away from the tip (Burks & Morgan, 1994). It

begins anteromedially and travels anterior to the joint surface where the

lateral malleolus is located on the talar body before inserting. In the neutral

position, the ligament is almost horizontal to the ankle; nevertheless, it

slopes upwards during dorsiflexion and downwards during plantar flexion.

The ligament is only strained and at risk of damage in the latter posture,

especially when the foot is inverted (Broström, 1966). The lower band of

the ligament remains relaxed during plantar flexion while the higher band

tightens. The inferior band tightens and the upper band becomes loosened

during dorsiflexion.

b. Calcaneofibular ligament

The anterior portion of the lateral malleolus is where the

calcaneofibular ligament begins, according to Golanó et al. (2010). Its

anatomical location is directly below the anterior talofibular ligament's

lower band. These ligaments frequently have fibers connecting them. The

ligament attaches to the posterior portion of the lateral calcaneal surface

while the ankle is in the neutral position, running obliquely downward and

backward. The peroneal tendons and sheaths barely superficially cross this

ligament, leaving just about 1 cm of the ligament exposed. This might cause

a concavity over the ligament. It is the only ligament connecting the

talocrural joint and subtalar joint, providing them with lateral stabilization.
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The insertion of this ligament and its axis of rotation permit the talocrural

joint to flex and extend. This ligament also allows subtalar movement due

to its bi-articular property.

The ligament is most commonly damaged during inversion injuries

to the ankle, and usually there is an associated injury to the anterior

talofibular ligament (ATFL). The CFL is rarely torn in isolation and only a

few case reports exist (Rigby et al., n.d.). According to Broström, solitary

calcaneofibular ligament ruptures are extremely uncommon and account for

20% of combined anterior talofibular and calcaneofibular ligament

ruptures. Unless there is a severe ankle dislocation, the posterior talofibular

ligament rarely sustains damage. Such is that Ruth investigated several

calcaneofibular ligament orientation variations. The calcaneofibular

ligament, which is always stiff throughout its full range of motion, turns

vertical during flexion and horizontal during extension. The angle created

by the ligament and the longitudinal axis of the fibula is significantly altered

by the talus's valgus or varus position. In the valgus position, the ligament

is relaxed, while in the varus position, it is stiff. This explains how an injury

could still occur without ankle dorsiflexion-plantar flexion.

c. Posterior talofibular ligament

When the lateral ligament complex is intact, the posterior talofibular

ligament simply serves as an adjunct to ankle stability. As it has no

independent stabilizing function in the intact ankle joint, a solitary rupture

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of this ligament is rare. It starts in the malleolar fossa on the medial side of

the lateral malleolus, according to Gollano et al., and continues almost

horizontally before entering in the posterolateral talus. The ligament is loose

in neutral ankle position and plantar flexion, but stiff in dorsiflexion. This

ligament has a multifascicular nature, which allows it to insert extensively.

Fibers, if any, insert in the lateral talar process or the os trigonum on the

talus's backside. The tube that houses the flexor hallucis longus tendon may

have been helped by a few fibers. Additionally, a collection of fibers joins

the posterior intermalleolar ligament (Paturet, 1951). Due to its role in the

posterior soft tissue impingement syndrome of the ankle, the posterior

intermalleolar ligament has been the focus of contemporary research

(Hamilton et al., 1996; Oh et al., 2006). Ballet dancers and soccer players

have traditionally been regarded as having posterior ankle impingement

syndrome (PAIS), which is a prevalent cause of posterior ankle pain (Russel

et al., 2010; Giannini et al., 2013; Roche et al., 2013; Nault et al., 2014).

Mechanical pinching of soft tissue or bone structures occurs during terminal

plantar flexion in the back of the ankle, which is the source of it (Russel et

al., 2010; Giannini et al., 2013; Roche et al., 2013; Nault et al., 2014; Kudas

et al., 2016). Its frequency of occurrence varies greatly, ranging from 19%

to 100% in radiological and anatomic studies (Milner & Soames, 1998; Oh

et al., 2006; Peace et al., 2004). A recurring finding is the intermalleolar

ligament (Golan et al., 2002). Since the posterior intermalleolar ligament

contracts during dorsiflexion and relaxes during plantar flexion, damage

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that causes the ankle to forcedly dorsiflex is likely to result in either this

ligament's injury or rupture, or osteochondral avulsion. It would relax

during plantar flexion and become more prone to becoming caught between

the tibia and the talus, resulting in impingement.

MEDIAL LIGAMENTS

The medial or deltoid ligament plays a crucial role in the formation of your ankle.

Several bones in your foot and ankle are joined and held together by it. This ligament aids in

preventing excessive foot or ankle inward rotation (Deltoid Ligament: Medial Ankle Ligament,

Deltoid Ligament Sprain, n.d.). Although there are many various anatomical explanations of the

MCL in the literature, most generally agree that it is made up of two layers—the superficial layer

and the deep layer—each of which serves a different purpose. The deep deltoid complex prevents

lateral talar translation away from the medial malleolus and opposes posterior talar translation

(Sridharan & Dodd, 2019).The MCL is a multifascicular ligament that originates from the medial

malleolus and inserts in the talus, calcaneus, and navicular bone, much like the posterior talofibular

ligament (Hintermann & Golanó, 2014). Similar to how the peroneal tendon sheath is connected

to the calcaneofibular ligament on the lateral side, the posterior tibial muscle's tendon sheath covers

the middle and posterior portions of the deltoid ligament. The initial hypothesis put forward by

Milner and Soames is the one that describes the MCL in the most widely recognized manner. The

deep posterior tibiotalar ligament, tibionavicular ligament, and tibiospring ligament are the three

bands or components of the MCL that are always present; the other three may or may not be present

(superficial posterior tibiotalar ligament, tibiocalcaneal ligament, and deep anterior tibiotalar

ligament).

SYNDESMOSIS LIGAMENTS
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These ligaments connect the distal epiphyses of the tibia and fibula, according to Golano

et al. The distal tibia and fibula form a fork-shaped dome that forms the talocrural joint, and the

talar trochlea is encompassed by this mortise. The surface contours of the cartilagenous portions

of the ankle joint are not consistent. The talar dome has a concave contour in the frontal plane. The

tibial and fibular facets' planes are not parallel. The cartilage-covered surfaces of the trochlea have

slightly curved sides and are wider anteriorly than posteriorly. The tibial facet is concave, whereas

the fibular facet has a convex shape. Through modest upward and medial rotation movements of

the fibula during severe dorsiflexion (maximum width) and by inverse movements during plantar

flexion, the tibia-fibula as a whole is able to adjust to the variable width of the upper articular

surface of the talus (minimum width).

The syndesmotic ligament complex prevents the distal tibia and fibula from moving apart

by resisting stresses in the axial, rotational, and translational directions (Lin et al., 2006; Golano

et al., 2010; Ebraheim et al., 2006). The anterior or anteroinferior tibiofibular ligament, the

posterior or posteroinferior tibiofibular ligament, and the interosseous tibiofibular ligament are the

three ligaments in charge. The interosseous membrane's inferior segment also aids in stabilizing

the tibiofibular syndesmosis. The tibiofibular synovial recess of the ankle joint corresponds to the

residual anterior surface of this ligament distal to its insertion location, and at the posterior surface,

there is a small cluster of adipose tissue known as the fatty synovial fringe. During ankle

movements, the synovial fringe descends or ascends, retreating in plantar flexion toward the ankle

joint and rising in dorsiflexion to place itself between the tibia and fibula. Anterolateral soft tissue

impingement, or more particularly, syndesmotic impingement, a condition known as a cause of

chronic pain after ankle injury, has been linked to this structure.
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a. Anterior or anteroinferior tibiofibular ligament

The ligament's fibers travel distally and laterally to the insertion point in the

anterior border of the lateral malleolus from where they originate in the

anterior tubercle of the tibia (5 mm on average above the articular surface)

(van den Bekerom & Raven, 2007). Because of the ligament's division into

many fascicles, the peroneal artery might branch from the rupture. At its

beginning, the ligament's furthest-reaching fibers could be mistaken for

those of the anterior talofibular ligament (Akseki et al., 1999; Basset et al.,

1990; Sarraffian, 1993). It works to avoid excessive fibular displacement

and external talar rotation by holding the tibia and fibula firmly together.

The Volkmann fragment serves as the origin of the posterior-inferior

tibiofibular ligament, which joins to the posterior lateral malleolus (Chase

et al., n.d.). For the lower extremities and the ankle to function dynamically,

the syndesmosis' stability is essential. The tibia and fibula make up the

osseous portion of the distal tibiofibular syndesmosis, and the inferior

transverse ligament, anterior inferior tibiofibular ligament, posterior

inferior tibiofibular ligament, and interosseus ligament are the four

connecting ligaments (Hermans et al., 2010). The tibiofibular syndesmosis'

distal ligaments' main job is to keep the fibula from moving out of the

groove in the tibia (laterally, anteriorly, or posteriorly) (Barham & Clarke,

2008). The pathologic external rotational forces that seek to laterally or

externally rotate the talus and displace and push the fibula away from the

tibia are resisted by the ankle syndesmosis. The anterior tibiofibular

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ligament stops the fibula from moving out of control to a great extent and

also stops the talus from rotating externally (Tibiofibular Diastasis, n.d.).

When the foot and ankle point forward (plantarflexion) and slightly inward

(inversion), the ligament is harmed (Ligament Reconstruction Atfl Repair -

Ankle - Surgery - What We Treat - Physio.co.uk, n.d.). The ATFL ligament

is stretched during this motion, making it more prone to damage.

b. Posterior or posteroinferior tibiofibular ligament

It is well known that the posterior talofibular ligament (PTFL) offers

support against ankle joint inversion. The superficial and deep components,

which work independently to produce this ligament, are its primary building

blocks. The superficial component starts at the lateral malleolus's posterior

edge and travels proximally and medially before inserting in the tibial

tubercle at the back of the leg. Similar to the anterior tibiofibular ligament,

this component. The superficial portion is typically referred to as the

posterior or posteroinferior tibiofibular ligament. The deep component has

a cone-shaped beginning in the malleolar fossa's proximal region and inserts

into the tibia's posterior edge. The fibers may extend to the medial

malleolus; it inserts exactly posterior to the cartilaginous layer of the

inferior tibial articular surface. This part, also referred to as the transverse

ligament, creates a genuine labrum that stabilizes the talocrural joint and

prevents posterior talar translation (Sarraffian, 1993). According to Li

(2019), this ligament also prevents excessive movement of the fibula and

external rotation of the talus in addition to anchoring the fibula tightly to

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the tibia. The posterior tibiofibular ligament runs more horizontally to the

posterior portion of the fibula than the anterior ligament and is smaller than

its anterior cousin (Li, 2019). When the joint is in dorsiflexion, the broader

portion fills the mortise anteriorly more completely and there is the most

contact possible (Norkus & Floyd, 2001). Additionally, a complete

dislocation of the talus is the only circumstance in which the posterior

talofibular ligament (PTFL) is affected (Molis, 2021).

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SECTION II: Common Injuries

Inversion of the foot is the most frequent mechanism of injury to the ankle ligaments. The

anterior talofibular ligament is the first or only ligament to be injured with this mode of damage.

The posterior talofibular ligaments and the calcaneofibular ligament are also involved in a total

rupture. The deltoid ligaments will be damaged by an injury involving eversion, whereas the

syndesmotic ligaments may be hurt by a trauma involving hyperdorsiflexion. The most prevalent

injury seen in the emergency room is an ankle sprain (Boruta et al., 1990). Up to 40% of those

with a history of ankle ligament injuries have persistent symptoms that interfere with daily

activities (Gerber et al., 1998; Verhagen et al., 1995). Understanding the basic mechanism of

injury, diagnosis, and treatment of these ankle sprains are all based on having a solid understanding

of the anatomy of the ankle ligaments. An ankle sprain frequently comes before ankle soft tissue

impingement disorders. A specific ligament or multiple ligaments may be affected, depending on

the mechanism of injury (van Dijk, 1994). Following an ankle sprain, injury to the anterior

talofibular ligament is the most frequent. The calcaneofibular ligament is injured in about 20% of

patients, albeit it occurs most frequently as an isolated injury (Brostrom, 1966). The capsule, lateral

or medial collateral ligaments, or tibiofibular ligaments may be harmed by an inversion sprain.

Anteroinferior border of the tibia, the posterior intermalleolar ligament, and the osteochondral

region of the neck of the talus may all sustain damage as a result of the additional effect of plantar

or dorsiflexion on the injury mechanism. Although an inversion sprain can also cause a damage to

these structures, the medial capsular and ligamentous elements are more intimately linked to the

process of foot eversion. The rotating portion of the subtalar joint, to which the capsule and the

MCL are vulnerable, is likely to have a greater impact on medial damage.

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The following are a list of common injuries unique to each ligament complex:

1. Lateral Collateral Ligament Complex

a) Anterior talofibular ligament

With or without plantar flexion, anterior talofibular ligament injuries frequently

accompany ankle inversion problems. The anterior talofibular ligament (ATFL), the

weakest ligament in the lateral collateral complex of the ankle, is often the site of about

two-thirds of ankle sprains (Baba, 2022).

b) Calcanefibular ligament

A lateral ankle sprain frequently involves both an anterior talofibular ligament

damage and a calcaneofibular ligament injury; they are infrequently encountered alone.

These wounds may consist of both ligament rips and avulsion fractures (Knipe, 2022).

c) Posterior talofibular ligament

The only other time the posterior talofibular ligament (PTFL) is hurt is when the

talus completely dislocates (Molis, 2021).

2. Medial Ligament, also known as the Deltoid Ligament

Only around 15% of ankle sprains involve the deltoid or medial ligament. The majority of

deltoid ligament injuries are brought on by a direct blow to the ankle. The most frequent reason

for a deltoid ligament sprain is an ankle fracture, or shattered bone on the outside of the ankle

(Deltoid Ligament: Medial Ankle Ligament, Deltoid Ligament Sprain, n.d.).

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3. Syndesmotic Ligament Complex

According to Pietrangelo (2019), syndesmotic ankle sprain, also known as a "high ankle

sprain," is an injury to one or more of the ligaments that make up the distal tibiofibular

syndesmosis. In contrast to the more frequent lateral ankle sprain, the high ankle sprain causes

pain more closely to the ankle joint and is more frequently associated with significant

morbidity. High-energy forces and abrupt twisting movements can cause syndesmosis injuries.

This may be particularly common in sports where cleats are worn because they might keep the

foot planted while forcing the ankle to twist outward. A hit to the outside of the ankle is another

possibility in sports. The anterior inferior tibiofibular ligament of the syndesmosis is the area

of the rotation that is first affected. The posterior tibiofibular ligament will be injured if external

rotation is allowed to persist (Norkus & Floyd, 2001b).

a. Causes

Ankle ligament injuries can result from a variety of activities, especially for those

who often use their ankle joints in sports or even just working out. As a general rule, stretch

your muscles out properly before engaging in any strenuous exercise that could shock your

tendons and tissue. Because of this, rolling or twisting your ankle inward is the most typical

way to tear an ankle ligament. It may occur if one is moving quickly in a different direction

or walking or sprinting on uneven terrain. People typically sprain their ankles when it’s

forced to move it from its natural position, which can cause one or more of the ligaments

in the ankle to stretch, partially tear, or totally tear. These scenarios include falls that cause

the ankle to twist, uncomfortable foot landings following jumps, and rotating. For athletes,

it typically occurs in sports like trail running, basketball, tennis, football, and soccer that
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frequently call for jumping or cutting motions. However, the severity of ankle ligament

injuries can vary, making it challenging to correctly evaluate an injury to the ankle. Ankle

ligament tears are the most severe type of ankle sprains because they are the most likely to

turn into tears (Ankle Ligament Tear, 2017). High-energy ankle injuries, such as

dislocations, falls, severe sports injuries, and automobile accidents, usually result in these.

Along with ankle fractures, these conditions could also occur. For the study of injury

prevention, understanding the injury mechanism is crucial (Bahr & Krosshaug, 2005;

Krosshaug et al., 2005). Ankle inversion, internal foot twisting, plantarflexion, and

adducting and inverting of the subtalar joint are all symptoms of an ankle supination strain

(Safran et al., 1999; Vitale & Fallat, 1988). Additionally, the lower leg can occasionally

rotate externally with respect to the ankle joint (Hertel, 2002). The majority of ankle

sprains, according to Stormont and colleagues, are thought to happen during systematic

loading and unloading, rather than when the ankle is fully loaded because of articular

restrictions. The anterior talofibular ligament is frequently injured when the foot is in

plantarflexion, while the calcaneofibular ligament is frequently injured when the foot is in

dorsiflexion (Bennett, 1994). In soccer, player contact caused the majority of ankle sprains,

but goalkeepers often suffered them in non-contact scenarios (Woods et al., 2003). In a

recent study to analyze the ankle supination sprain injury with video, Andersen and

colleagues found two main mechanisms: (1) the opponent's impact on the medial aspect of

the leg just before or at foot strike, which caused a laterally directed force to cause the

player to land with the ankle in a vulnerable inverted position; and (2) forced plantar flexion

when the injured player struck the opponent's foot while attempting to shoot or clear the

ball. Since the anterior talofibular ligament frequently experienced greater strain and strain
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rate values than the other ligaments at the lateral ankle, the majority of these processes

ultimately resulted in its rupture (Self et al., 2000).

b. Symptoms

The most prevalent sign of an ankle ligament injury is pain, which is also frequently

accompanied by edema and bruising. Sometimes the patient may experience joint stiffness

and have trouble walking. The degree of the injury and the amount of the ligament damage

determine the symptoms of an ankle ligament injury (Ankle Ligament Injury Sydney |

Ankle Sprain Treatment Campbelltown, n.d.). Bruising, a loose feeling in the ankle, pain

on the sides or front of the ankle, a popping or snapping sound, swelling around the ankle

joint, difficulty bearing weight on the ankle or foot, and weakness in the ankle joint are all

signs that one of the ankle's ligaments has been injured. While the signs of a shattered bone

are similar to those of a severe sprain. When a significant ligament injury occurs, you may

feel a pop or maybe hear a noise. An immediate medical evaluation is necessary for ankle

injuries with this level of severity.

c. Risks

Risk factors were frequently divided into extrinsic and intrinsic categories (Lysens

et al., 1984). Intrinsic risk factors originate from within the body, and extrinsic risk factors

arise from the environment. Anatomic foot type, foot size, generalized joint laxity,

anatomic alignment, ankle-joint laxity, and range of motion of the ankle-foot complex are

among the intrinsic risk factors for sprains of the lateral ankle ligaments that have been

studied through prospective studies. Other risk factors include muscle strength, muscle

reaction time, and postural sway. A thorough analysis of the 20 or so prospective studies'
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findings on the risk factors for ankle injuries in sports was conducted in 1997 by Barker,

Beynon, and Renstrom. Although there were significant differences between the included

studies regarding extrinsic factors, they generally concluded that prescribing orthoses—

rather than high-top shoes—could help reduce the incidence of ankle sprain injuries in

players with a history of sprains. Although the player positions in basketball and soccer did

not differ, increased exercise intensity in soccer increased the chance of injury. A history

of ankle sprains, wide feet, greater ankle eversion to inversion strength, plantarflexion

strength and ratio between dorsiflexion and plantarflexion strength, and limb dominance

were all listed as intrinsic characteristics that could enhance the likelihood of ankle sprain

injuries. It was determined that the kind of foot, signs of ankle instability, and a high degree

of overall joint laxity were not risk factors. Gender, overall joint laxity, and foot type were

not risk factors for ankle sprain injury, according to Beynon, Murphy, and Alosa's 2002

analysis of the available evidence. In 2007, Morrison and Kaminski proposed a connection

between the incidence of lateral ankle sprain injuries and the cavovarus deformity, greater

foot width, and increased calcaneal eversion range of motion. Significant inconsistencies,

however, were discovered regarding the existence of risk variables for ankle sprain injuries,

including height, weight, limb dominance, ankle joint laxity, anatomical alignment, muscle

strength, muscle reaction time, and postural sway.

According to some recent research, athletes who don't stretch before training, have

a history of ankle sprains, wear shoes with air cells in the heel, and have a history of ankle

sprains are 4.9, 4.3, and 2.6 times more likely to suffer an ankle sprain injury (McKay et

al., 2001). Obesity and poor single-leg balance increased the risk of sprain injury by 2.4

and 3.9 times, respectively (Trojian & McKeag, 2006; Tyler et al., 2006). Additional risk
 22

factors have been identified as having a posteriorly positioned fibula, using artificial turf

for soccer, and having a reduced range of ankle dorsiflexion (de Noronha et al., 2006;

Orchard & Powell, 2003; Eren et al., 2003). In relation to ankle sprain injuries, Willems

and colleagues looked into certain dynamic risk variables during walking in 2005. They

revealed that a laterally located center of plantar pressure was discovered at initial contact

during the stance phase for participants who were at risk of suffering an inversion sprain.

The intrinsic risk factors for both males and females' inversion ankle sprains were also

revealed by the same research team. Significant risk variables for men included slower

running speed, decreased cardiorespiratory endurance, decreased balance, decreased

dorsiflexion muscle strength, decreased dorsiflexion range of motion, poorer coordination,

and quicker reaction of the tibialis anterior and gastrocnemius muscles. The main risk

variables for females were weaker coordination of postural control, a larger extension range

of motion at the first metatarsophalangeal joint, and a less precise passive joint inversion

position perception. We must keep in mind that these risk variables only partially correlate

with ankle ligament sprain injuries. They might not be the aetiology or primary cause of

an ankle ligament strain.

d. Complications

Many people ignore this ailment because they believe it will go away on its own

because of how frequent and common it is (Knipe, 2022). This is a severe error because it

can lead to several issues and make the "sprain" much worse than it has to be. These issues

arise when the damage is more likely to be serious and when an appropriate diagnosis is

not received or not allowing the ankle the necessary time to heal and starting activities too

soon or if he same ankle has been sprained numerous times. Torn ligaments may randomly
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fuse together and generate fragile, rigid scar tissue if left to heal on their own. If left

untreated, a sprained ankle can develop into a dangerous chronic instability. A person's

range of motion may be severely compromised, which may make it challenging to walk

for an extended period of time. The following consequences may result from improper

ankle sprain treatment, participating in activities too soon after spraining the ankle, or

spraining the ankle repeatedly: chronic ankle discomfort. chronic instability of the ankle

joint. joint arthritis in the ankle. Untreated strains can make it harder for a person to stand

and walk later in life and raise their chance of developing new strains. An ankle joint that

is continuously unstable might result from untreated sprains. This condition raises your

risk of getting illnesses like arthritis in your ankle, degenerative changes in the ankle joint,

and chronic inflammation. Untreated sprains can also give you the impression that your

ankle is always going to give up. This instability raises your chance of re-injuring your

ankle. Failure to receive appropriate treatment for ankle fractures can result in serious and

disabling sequelae, such as a high risk of infection, arthritis, and walking impairment due

to foot abnormalities (How to Keep a Sprained Ankle From Becoming a Chronic

Instability: Urgently Ortho: Orthopaedic Urgent Care, Sports Medicine & Wellness

Clinics, n.d.). However, almost all isolated low ankle sprains can be cured without surgery

as long as the injury is handled properly. If the ligament is properly immobilized and

rehabbed, even a total tear will recover without surgery.

 24

SECTION III: Medical Diagnosis

Every acute ankle sprain injury should have a solid differential diagnosis system since

primary care providers frequently misdiagnose multiple ankle issues as straightforward ankle

sprains (LeBlanc, 2004). While Harmon presented a systematic approach that consists of five steps

to avoid missing potentially serious injuries, Lynam presented a protocol for the nurse to assess

acute foot and ankle sprain at the emergency room. These steps are: (1) palpation of bony

structures, (2) palpation of ligamentous structures, (3) assessment of range of motion of the ankle,

(4) testing of ankle muscles, and (5) special tests. First and foremost, the detection of fracture

injuries was crucial because these patients typically need to be admitted to hospitals for urgent

surgical procedures (Mak et al., 1985). The Ottawa Ankle Rules, which had a nearly 100%

sensitivity and could be used to considerably reduce the routine use of radiography, were often

used to diagnose ankle fracture injuries (Uys & Rijke, 2002; Stiell, 1996; DiGiovanni et al., 2004;

Childs, 1999; Papacostas et al., 2001; Leddy et al., 1998). Second, feeling the ligamentous tissues

revealed which ligament is most likely injured. This can also be done, particularly in voluntary

dorsiflexion and plantaflexion, in conjunction with the range of motion test. The doctor might

check the ankle muscles while doing the range of motion test.

To accurately determine whether the issue is a ligamentous injury, specialized diagnostic

tests should be carried out once a fracture has been ruled out. The anterior drawer test and the talar

tilt test were the two commonly used tests to evaluate the anterior talofibular ligament's integrity

and may help in determining the severity of the ligament tear (Bennett, 1994; Bahr et al., 1997).

The eversion stress test was frequently used to evaluate the medial ligament, namely the deltoid

ligament at the medial aspect of the ankle (Hintermann et al., 2006). The external rotation test and
 25

the squeeze test could be used to test this (Penna & Coetzee, 2006). These particular tests,

including the stress radiography test, are occasionally carried out in conjunction with radiography

(Uys & Rijke, 2002). Sonography, magnetic resonance imaging, arthrography, three-dimensional

computed tomography, bone scintography, and arthroscopic diagnostics were some of the

additional tools and methods used to aid in the diagnosis (Campbell, 2006; Childs, 1999; Milz et

al., 1998; Nakasa et al., 2006; Philbin et al., 2004; van Dijk et al., 1998).

In addition to ligament damage, a tendon rupture could be the issue. The Thompson test

(Morelli & James, 2004), which involved squeezing the patient's calf while flexing their knee,

could be used to determine whether the Achilles tendon rupture at the back ankle. The Achilles

tendon was at least partially intact if the foot moved during the plantar flexion maneuver. To

establish the diagnosis, tendonscopy or surgical exploration may occasionally be necessary for

peroneal tendon rupture since it was less responsive to physical examination techniques like the

subluxation test and stress radiography assessment (Scholten & van Dijk, 2006; Minoyama et al.,

2002; Verheyen et al., 2002).

There are many different grading scales for acute ankle ligament sprain injuries (Mann et

al., 2002). The Anatomic System, which assigns an injury one of three classes based on the severity

of the ligament damage, and the American Medical Association Standard Nomenclature System,

which takes the severity of the ligament damage into account (Clanton, 1999). There were also

various three-grade systems that ranked the severity of the injury in relation to the accompanying

injuries to the nearby structures as well as the combined clinical presentation of the anatomical

damage and the severity of the injury (Jackson et al., 1974; Hamilton, 1982; Crichton et al., 1992).

To grade an ankle injury in accordance with the pathology—damage to the ligamentous structure
 26

and clinically apparent instability—Davis and Trevino introduced a staging system with four

grades and some subgrades. A workable system for outpatient clinical usage was developed by

Mann and colleagues. It was predicated on three things: discomfort, edema, and immobility. Each

item received a score between 0 and 3, and the final grade was calculated as follows: Grade I: 1-3

points, Grade II: 4-6 points, and Grade III: 7-9 points.

Here are the following grading descriptions:

• Grade 1: A slight sprain is a first-degree damage to an ankle ligament. It denotes an

overstretched or barely torn ligament. You'll feel some discomfort, some swelling, and

perhaps some bruising if you have an ankle strain of grade 1. However, you will still be

able to flex and rotate the ankle and bear weight on the affected leg.

• Grade 2: An ankle sprain in the second degree results in a mild (partial) ligament tear.

Bruising, swelling, and some pain are among the symptoms. You may experience some

difficulty placing weight on the leg if the injury is grade 2. You can also find it difficult to

rotate or bend your ankle.

• Grade 3: A complete tear or rupture of an ankle ligament is a third-degree injury. You will

have extreme bruising, swelling, and discomfort with this level of injuries. The affected

limb will be immobile, and you won't be able to flex or rotate the ankle.

In order to evaluate ankle injuries, Kaikkonen, Kannus, and Jarvinen developed a performance

test protocol with a scoring scale that included three subjective assessment questions, two clinical

measurements of the ankle, two muscle strength tests, one test of ankle functional stability, and

one test of balance. The procedure was useful for clinical evaluation of ankle sprain injuries since

the overall score associated well with the isokinetic strength test of the ankle, the subjective
 27

judgment of recovery, and also the subjective function assessment. In order to evaluate the

discomfort, instability, weight bearing, edema, and gait pattern, de Bie and colleagues developed

an ankle functional scoring system that totaled up to a score of 100. Clanton created a different

system that was tied to the requested therapy regimens. The system has two basic categories that

classified the injured ankle as either stable or unstable. It was proposed that the stable group get

symptomatic therapy for pain alleviation. Another subcategory for the unstable category divided

the patients into older patients, non-athletes, and young, active athletes. Functional treatment was

advised for individuals who weren't athletes and those who were elderly. For the young, active

athlete group, there was a further layer to separate the patients into those with subtalar instability,

positive tibio-talar stress radiograph results, and negative stress radiograph findings. It was advised

that people with confirmed tibio-talar instability think about having the ligament complex

surgically repaired.
 28

SECTION IV: Prevention

Given that sports are where most ankle ligament injuries occur, it is advised to exercise

greater caution when participating in activity-based events. The first study team to attempt to

prevent ankle sprain injuries was Garrick and Requa (1973). They claimed that during the course

of a year-long trial, 2,562 basketball players had a decrease in the frequency of ankle sprain injuries

when wearing high-top shoes with prophylactic ankle tape. A "sequence of injury prevention" was

put up by van Mechelen, Hlobil, and Kemper (1992) in 1987 to explain how studies on sports

injuries came to be combined into the study framework. The first phase involved determining the

scope of the sports injury issue using epidemiology studies. The aetiology and mechanism of

injuries were determined in the second step, and preventive measures were created and introduced

in the third. Finally, a rerun of the first epidemiological study was done to evaluate the efficiency

of the preventive strategies (step one). Since then, multiple research have been carried out to

compare various methods of preventing ankle sprain injuries. Prophylactic devices, functional

training, skill training, changing the laws of the game, and education could all be considered

strategies (Abernethy & Bleakley, 2007).

Most attempts at prophylactic devices focused on tape, bracing, and orthoses. The way both

devices worked similarly was that they wrapped around the ankle joint from the foot portion to the

shank part. Some studies claimed that these devices offered mechanical assistance to counteract

the ankle inversion moment, while others claimed that they enhanced proprioception and joint

position awareness, maintaining the correct anatomical position throughout landing (Eils &

Rosenbaum, 2003; Firer, 1990; Hume & Gerrard, 1998; Ottaviani et al., 1995; Robbins et al., 1995;

Thonnard et al., 1996; Ubell et al., 2003). Numerous studies have documented the effectiveness of
 29

these devices in lowering the rate of ankle sprain injuries (Surve, 1994; Pedowitz et al., 2008;

Sitler et al., 1994; Verhagen et al., 2000). Less is known about the function of shoes in preventing

ankle sprains (Verhagen et al., 2000). Robbins, Waked, and Rappel (1995) contended that current

athletic footwear degraded proprioception, while Barrett and Bilisko (1995) claimed that high-top

shoes restricted excessive range of motion, decreased external stress, and boosted proprioception

of the ankle joint. A low-top shoe with a laced ankle stabilizer is useful in decreasing ankle sprain

injury, according to Rovere and colleagues (1988).

The majority of functional training protocols included stability and postural control

exercises (Tropp et al., 1995). For example, in stability training, a wobble balance board or an

ankle disk were frequently used, and their effects were demonstrated in numerous studies (Junge

& Dvorak, 2004; Sheth et al., 1997; Mohammadi, 2007; Verhagen et al., 2004). Some research

groups also recommended technique training. Stasinopoulos (2004), for example, developed a

technical training program for volleyball players on take off and landing technique during attack

and two man blocks that was effective in reducing ankle sprain occurrence. The players were

instructed to take a quick, long final approach step and to jump straight to avoid falling on the

center line beneath the net or on other players' feet. In order to prevent the most prevalent injury

mechanism, which was to land poorly, Scase and colleagues (2006) developed a program to teach

a group of junior elite Australian football players safe landing, falling, rolling, and recovery

abilities. The program was found to be effective in lowering the frequency of ankle sprain injuries,

particularly those associated to landing.

The game's rules have a big part to play in the occurrence of injuries. In a one-year

prospective study on the Norwegian professional football league, Andersen, Engebretsen, and
 30

Bahr (2004) found that less than one-third of the injuries witnessed on film were deemed to be

foul. They came to the conclusion that perhaps the game rules needed to be improved in order to

safeguard players from risky behavior. According to Reeser and colleagues (2001), the majority

of ankle sprain injuries in volleyball occur when the players collide close to the net. They therefore

advocated changing the rule to make any centerline touch within the conflict zone between the

attacker and blocker a fault. In rugby, it was thought that injuries were related to the speed of the

game and the power of physical contact and tackles. In a one-year prospective analysis, Gabbett

(2005) revealed that the injury rate was much lower when the game's limited interchange rule was

implemented. It was hypothesized that because of player weariness brought on by the limited

interchange rule, the match speed and impact forces were decreased. The importance of education

for athletes cannot be understated. Hume and Steele (2000) found that just 5.1% of participants in

a three-day netball tournament in New South Wales, Australia, in 1995 wore high-cut shoes despite

being urged to do so prior to the event. Furthermore, despite being instructed to seek emergency

medical attention when hurt, 54.7% of participants ended the game without doing so. They argued

that heeding the recommendations of sports medicine experts and researching the efficacy of

various injury prevention measures were both crucial for injury prevention and promoting safety

in sports (Timpka et al., 2006).

SECTION V: Treatment

Exercise and bracing have been suggested with greater levels of evidence and should be

included in the rehabilitation process among other therapies for the management of acute ankle

sprains. A well-rounded exercise regimen should include workouts for flexibility, strength,

neuromuscular control, proprioception, and sport-specific movements. Application of an

 31

algorithmic strategy based on evidence and considering individual characteristics is beneficial and

need to be advised. Both this part and the "Exercise Forms" must have all the information.

Firstly, an accurate diagnosis is the first step in any treatment for a torn ankle ligament.

This often include a physical examination to assess range of motion, stability, and weight-bearing

capacity as well as to evaluate the injury's history. An MRI or an ultrasound scan may be utilized

to detect ligament or other soft tissue damage, and an x-ray may also be necessary to check for a

fracture. Depending on the severity of the injury, different treatments are available. Physiotherapy

is an excellent way to treat a partial ankle ligament damage. Exercises will be taught to you to

strengthen the muscles in and around your ankle. This will increase stability and aid in avoiding

further injuries. However, a complete tear will require three weeks of immobilization in an Aircast

boot. Targeted massage can promote blood flow to speed up the healing process, reduce fluid

retention, and lessen scar tissue thickening.

Surgery is typically only advised if the ligament tear has damaged other ankle components,

has resulted in long-term instability, or has increased your chance of developing other conditions

like arthritis. Ligament tears can be treated surgically by being stitched back together, being

reattached to the bone, or being replaced with a graft (a tendon from another part of your body or

from a donor). The majority of ankle ligament surgeries are performed by a small incision

(arthroscopically).

There is evidence that non-steroidal anti-inflammatory medications and functional support

are used after ankle sprains. Weak evidence suggests that using manual treatment may have

beneficial short-term outcomes. Electro-physical agents are not advised because they don't seem

to improve results. Exercise may help manage chronic ankle instability and decrease the likelihood
 32

of recurrent ankle sprains. An early introduction of activity following surgical stabilization of an

ankle fracture, either via early weight-bearing or exercise during the immobilization phase, may

improve outcomes. However, using an orthosis or brace to allow for exercise during the period of

immobility may also result in a higher rate of adverse events, indicating that this treatment regimen

needs to be used with caution. A gradual exercise program should be the main focus of treatment

for an ankle fracture following the period of immobility.

Ankle sprain treatment is typically conservative and consists of symptom control during

the acute phase and afterwards a period of rehabilitation. The main repercussion of an ankle sprain,

persistent ankle instability, is frequently treated by the therapist. The treatment of ankle sprain has

been the subject of several systematic reviews and randomized controlled trials in recent years,

which are taken into consideration here. It should be emphasized that, unless otherwise specified,

all research in the section on acute ankle sprains use a non-specific selection of ankle sprains.

For the majority of ankle sprains, functional support is preferred to immobility. Functional

support uses an adjustable and detachable immobility device, therefore the treatment plan

frequently includes exercise. Significant differences in favor of functional support, which includes

a brace, elastic bandage, tape, softcast, or wrap over immobility, were discovered in a meta-

analysis (Lin et al., 2010). Increased participation in sports, quicker return to work, less persistent

swelling, and wider range of motion were all differences in favor of functional support. However,

neither Kerkhoffs et al. nor a later analysis by Jones et al. (2007) discovered a distinction between

immobilization and functional support in terms of the rate of instability, either objectively or

subjectively, or recurrent sprain.

 33

SECTION VI: Exercise Forms

The use of exercise therapy as the primary component of the treatment regimen is

supported by growing data (Kerkhoffs et al., 2012; van der Wees et al., 2006; Bleakley et al., 2010;

van Rijn et al., 2010; van Os et al., 2005). Exercise therapy programs have been shown to be

effective, especially when started right away after an acute ankle sprain (Vuurberg et al., 2018;

van Rijn et al., 2009 & 2010). These initiatives can lessen functional ankle instability and the

frequency of recurrent injuries (van der Wees et al., 2006; Zech et al., 2009; Bleakley et al., 2008;

Postle et al., 2012). Additionally, they could speed up recovery and increase self-reported function

after an acute ankle sprain (Doherty et al., 2017; van Rijn et al., 2010; Zech et al., 2009; Postel et

al., 2012).

Exercise is advised at home and under supervision. However, supervised exercise may be

more beneficial than self-directed exercises in terms of enhancing ankle strength and

proprioception and enabling quicker return to work and athletics (van Rijn et al., 2010; van Os et

al., 2005; Feger et al., 2015; Kerkhoffs et al., 2012). Though other papers dispute these

encouraging findings, they contend that adding supervised exercise therapy may not make the

usual program any more efficient (van der Wees et al., 2006; van Rijn et al., 2007; Hing et al.,

2011; Punt et al., 2016). Therefore, it is still unclear whether or not exercise therapy should be

supervised, and more research is required (Vuuerberg et al., 2018).

Comprehensive and progressive exercise therapy should include ROM, flexibility (stretching),

resistance (strengthening), neuromuscular and proprioceptive exercises, and eventually athletic

functional strength training (Vuuerberg et al., 2018; Kaminski et al., 2013; Kerkhoffs et al., 2002;

Beynnon et al., 2006; Bleakley et al., 2010; Docherty et al., 1998; McKeon & Hertel, 2008; Wester
 34

et al., 1996; Holme et al., 1999; Bellows & Wong, 2018). However, there is disagreement over the

best exercise volume and content in this area (Bleakley et al., 2019).

1. ROM exercises

Once pain allows, early ROM exercises should be performed (Kerkhoffs et al., 2003). Injuries

of grades I and II can typically be treated with such a program right away, while those of grades

III may need to be delayed (Welck et al., 2015). Individuals should start weight-bearing and ROM

therapy as soon as the discomfort permits (Tiemstra, 2012; Kerkhoffs et al., 2003). However,

during the initial phases of rehabilitation, it is preferable to limit inversion and eversion. Exercises

for inversion and eversion should be added after the soreness over the ligament is reduced. Athletes

are advised to perform these workouts carefully, pain-free, and with lots of repetitions (Prentice,

2015). Prior to beginning functional rehabilitation, ROM should be reestablished (Osborne &

Rizzo, 2003).

2. Stretching exercises

Starting with non-weight-bearing dorsiflexion stretches and open-chain ankle motions for all

planes, these exercises should advance to standing calf stretches and generalized ankle stretching

in the closed chain (Osborne & Rizzo, 2003; Reider et al., 2014). It is best to start extending the

heel chord firmly as soon as possible. Tight heel cord is thought to function like a bowstring and

increase the risk of ankle sprains (McCluskey et al., 1976).

3. Strengthening exercises
 35

The athlete begins this phase with isometric exercises in the frontal and sagittal planes against

an immovable object after regaining normal range of motion. The athlete next advances to isotonic

resistive exercises for dorsiflexion, plantar flexion, inversion, and eversion as pain is tolerated

utilizing weights, elastic bands, or manual resistance by the therapist. It is advised to begin with

isotonic activities that do not put the ligaments at risk, such as dorsiflexion and plantar flexion, in

the early stages. Prentice (2015) states that strengthening activities can be started in all planes of

motion as the ligaments continue to recover and ROM returns to normal, utilizing pain as the

primary cue. These mix exercises that shorten muscles and those that extend muscles (Tiemstra,

2012; Wolfe et al., 2001). It is advised to start with low resistance and lots of repetitions (two to

four sets of 10 repetitions). It is crucial to strengthen the peroneal muscles since decreased eversion

strength has been linked to chronic instability and recurrent injury (Welck et al., 2015). Using an

angle board or steps while raising both bilateral standing toes through their complete range of

motion could also be beneficial (Reider et al., 2014). Exercises that isolate the required motions at

the talocrural joint through proprioceptive neuromuscular facilitation (PNF) may also be helpful.

Include exercises that target the proximal muscles of the hip and trunk as the athlete advances

through the program. Low hip strength has been linked to an increased risk of lateral ankle sprains,

research has indicated (McHugh et al., 2006). Athletes with an acute ankle sprain should take into

consideration combining hip and trunk workouts in the rehabilitation process because it may be

helpful in lowering the rate of re-injury (McGovern & Martin, 2016).

4. Neuromuscular and proprioceptive exercises

To regain balance and postural control, the next stage of therapy entails neuromuscular and

proprioceptive training (Wester et al., 1996; Hupperets et al., 2009). It has been shown that
 36

following an ankle sprain, neuromuscular activation patterns change, which may be a factor in

unfavorable outcomes such functional instability, aberrant gait patterns, and a higher recurrence

risk (Punt et al., 2015). As a result, these activities may enhance functional outcome measures,

lower subjective instability, and lower the likelihood of recurrence (Postle et al., 2012; van der

Wees et al., 2006; Zech et al., 2009; Calatayud et al., 2014). Early neuromuscular training in the

first week following injury results in higher activity levels without negative effects like increased

pain, edema, or the frequency of re-injury (Bleakleyet al., 2008). As a result, early neuromuscular

re-training is advised as a crucial component of the rehabilitation program for athletes who have

sustained an ankle sprain[33,38,126] (Postle et al., 2012; McGover & Martin, 2016; Chen et al.,

2019). This kind of training ought to be done all the way through the recovery process (Kaminski

et al., 2013; McKeon et al., 2008; Wester et al., 1996; Holme et al., 1999; Bellows & Wong, 2018).

When performing exercises on a foam surface, wedge board, Bosu, or DynaDisc while seated,

neuromuscular (sensorimotor) workouts may be initiated with intrinsic foot motion (toe extension

with ankle plantar flexion/toe flexion with ankle dorsiflexion) (Wester et al., 1996; Hupperets et

al., 2009; Tropp et al., 1985). The athlete should start out by moving in the sagittal direction with

a wedge board. The board may be rotated in a coronal direction when discomfort subsides. Full

ROM workouts can be performed while seated on a Biomechanical Ankle Platform System

(BAPS) board when the athlete can complete these motions without any difficulty (Prentice, 2015;

Reider et al., 2014).

Standing balancing exercises should be started once seated activities can be completed without

difficulty. Without a board, they can be started while standing on one leg. After that, the patient

balances themselves on the unstable surface of a wedge board in either the coronal or sagittal
 37

orientation using both hands and the damaged foot. Next, while standing on the wedge board, hand

support may be dropped. The BAPS board uses the same sequence after that (Prentice, 2015). With

the inclusion of a sport-specific perturbation, the exercise may become more difficult for athletes

(depending on the individual sport; chest pass/overhead pass, volleyball passing, hand fighting for

football/wrestling). The last stages should involve unilateral jumps to unstable surfaces (foam pad)

and full-speed planned movement drills such as ladder or cone (Reider et al., 2014).

Sport-specific training is part of the rehabilitation process' final stage. Plyometric training with

jumping moves may be used with a volleyball player, and running and cutting drills may be used

with a soccer player (Mattacola & Dwyer, 2002). Early on in a sport-specific training regimen, the

use of a brace or tape may be needed (Welck et al., 2015).

5. Sport-specific exercises

It seems prudent, based on the evidence currently available, that sport-specific training be

included in the rehabilitation program of athletes with acute ankle sprains, even though there isn't

any evidence to support stronger results of sports-specific training compared to neuromuscular

training with regard to reducing the chance of re-injury (McGovern & Martin, 2016; Martin et al.,

2013). This stage of the training program requires knowledgeable trainers or therapists with tools

and settings that replicate the actual sporting environment. To enable the treating physician to

make a decision about return to play, the rehabilitation team must effectively assess mastery of

sport-specific skills (Richie & Izadi, 2015).

 38

Chapter III

SIGNIFICANCE OF THE STUDY

First and foremost, this study endeavors to gather evidence to support the effectiveness of

an exercise routine above existing practices that aid in treating and preventing ankle ligament

injuries. Such would also act as additional knowledge in ankle ligament research and bring light

to its current popularity in the medical field. The infamy came from the fact that there is little

research found concerning the subject, such as the chances of inaccuracies in diagnoses and the

misuse of exercise that either worsens the injury or damages it completely. The talk of ankle

injuries is seemingly unimportant even as a sports-related problem, and most underestimate the

severity of a sprain. Such that this study aims to remedy the lapses in judgement and aid in

campaigning to share knowledge of the proper way to use ankle ligaments and avoid the chances

of worse wounds that risk chronic ankle pain and ankle instability. Ankle stability is integral to

normal motion and to minimizing the risk of ankle sprain during participation in sport activities.

The ability of the dynamic and static stabilizers of the ankle joint to maintain their structural

integrity is a major component of the normal gait cycle.

 39

Chapter IV

DISCUSSIONS AND RESULTS

SECTION I: The Injury

According to Halabchi and Hassabi's research, acute ankle sprains are the most frequent

lower limb injury in athletes. It is particularly prevalent in soccer, American football, and

basketball. The lateral ligaments, especially the anterior talofibular ligament, are the most

commonly injured. Despite its great frequency, a large percentage of patients have ongoing

residual symptoms and recurrent injuries. Exercise and bracing have been suggested with greater

levels of evidence and should be included in the rehabilitation process among other therapies for

the management of acute ankle sprains. A well-rounded exercise regimen should include workouts

for flexibility, strength, neuromuscular control, proprioception, and sport-specific movements.

Application of an algorithmic strategy based on evidence and taking into account individual

characteristics is beneficial and need to be advised.

One of the most frequent musculoskeletal ailments is acute ankle injury (Polzer et al.,

2012). The most frequent lower limb injury in people who are physically active is an ankle sprain

(Boruta et al., 1990; Gribble et al., 2016). In Western nations, roughly one ankle sprain happens

every 10,000 people every day. In the United States and the United Kingdom, over two million

ankle sprains are treated each year in emergency rooms (Ruth, 1961; Doherty et al., 2017). The

incidence in sports is significantly higher, making up 16% to 40% of all occurrences of sport-

related trauma (Polzer et al., 2012; Aslan et al., 2014; Balduini et al., 1987). Basketball (41.1%),

American football (9.3%), and soccer (7.9%) have the greatest incidence rates of all sports-related

ankle sprains and traumatic injuries, accounting for nearly half of all ankle sprains (Watermann et
 40

al., 2010; Doherty et al., 2017-2019; McKay et al., 2001). Ankle sprains are more common in

females, kids, and athletes that participate in indoor and court sports, according to Doherty et al.

(2014).

The lateral ligaments are involved in around 85% of ankle sprains. An isolated anterior

talofibular ligament (ATFL) injury occurs in around 65% of cases, whereas combined ATFL and

calcaneofibular ligament injuries occur in 20% of instances. The posterior talofibular ligament

rarely sustains injuries (Ferran & Maffulli, 2006). The remaining 15% are caused by medial and

syndesmotic ankle sprains (Doherty, et al., 2014). A syndesmotic ankle sprain, also referred to as

a "high ankle sprain," is an injury to one or more of the ligaments that make up the distal

tibiofibular junction (Vuurberg et al., 2018). The long-term prognosis of an acute ankle sprain is

not favorable despite its overwhelming occurrence, and a large percentage of patients endure

ongoing residual symptoms and injury recurrence (Doherty et al., 2017; Smith & Reischl, 1986;

van Rijn et al., 2008). Additionally, it is common for ankle sprain-related injuries such tendinous

and osteochondral injuries and midfoot fractures to go undiagnosed (Debieux, 2020). Thus, there

is a significant socioeconomic burden associated with treating lateral ankle sprains and its

aftereffects due to direct and indirect financial and societal expenses (Vuurberg et al., 2018;

Verhagen et al., 2000; Gribble et al., 2016).

Ankle ligament injuries are most usually brought on by the foot turning inward, as was

indicated in the part of relevant literature. People frequently injure their ankles by forcing it to

move out of its normal posture. This may cause one or more ankle ligaments to sprain, partially

tear, or totally tear. It frequently occurs for athletes in sports like trail running, basketball, football,

and tennis. The ligaments can occasionally tear small pieces of bone away. After the acute injury
 41

phase has passed, the ankle may become unstable if the ligaments are completely torn. The bones

and cartilage, the smooth lining of the joint, may be harmed over time as a result of this instability.

Athletic trainers and sports medicine specialists can give an athlete the right instructions

and feedback to assist lower the risk of injury in order to prevent such injuries. Ankle sprains can

be avoided with the help of flexibility, strength, and proper balance. Standing with your feet apart

and on your toes, ideally near the edge of the step, will help to strengthen your ankles. In addition,

balance must be taken into account. Strengthening the body's core is the simplest approach to

achieve this. When it comes to lowering the risk of an ankle injury, hip and core strength are

equally crucial. These are also recognized as workouts for preventing ankle sprains for this specific

reason. Additionally, flexibility needs to be developed, and yoga is one of the workouts that can

help. Consider taping and bracing the ankles if there has been a history of ankle injury. In fact, the

chance of an ankle injury can be significantly reduced with a properly adjusted ankle sprain

preventive brace. It's crucial to seek professional advice if someone has a history of ankle issues.

Although the process of treating an ankle sprain is not difficult, it does require some extra time

and attention. It is not a good idea to take on too much before you know how to workout properly.

Getting the right footwear is one of the many crucial things to do in order to protect the

ankles. It will take work and knowledge on your part to prevent ankle sprains. The patient's need

for appropriate footwear also relies on the type of athlete they are. It will take work and knowledge

on your part to prevent ankle sprains. Additionally, it relies on the patient's level of athletic ability.

For the ankles, choosing a route with more level terrain is crucial. The ankles could become injured

with only one wrong step. Running on unlevel ground or jogging uphill more frequently might

gradually harm the ankles and feet. The issue is that because it happens so gradually, some people
 42

fail to recognize it or perhaps think it's nothing to worry about. However, the buildup of damage

is a significant issue. People are aware of this injury, but they frequently vastly underestimate how

serious it is. An ankle sprain can be moderate to severe and is a very common injury. Your ankle's

supporting structures could become stretched, sustain microscopic tears, or be completely pulled

out of the bone, which could result in arthritis and long-term instability. Untreated strains might

make it harder for you to stand and walk later on and raise your chance of contracting new ones.

An ankle joint that is continuously unstable might result from untreated sprains. Your risk of

acquiring disorders like ankle joint degeneration is increased by this condition. According to

statistics, ankle injuries are the most frequent type of injury, but half of that group chooses not to

seek medical care because they don't realize how serious an ankle injury may be.

People who suffer this kind of injury but do not adequately care for it or seek medical help

when symptoms appear will eventually have chronic pain and cases of ankle instability. Sprains

are a regular occurrence, but they can also be a tear or a hairline fracture, which is worrisome

because these sprains may be entirely different things and result in worse conditions for the

affected ankle, including arthritis or persistent discomfort.

 43

SECTION II: Therapy, Treatment, and Rehabilitation

Ankle injury rehabilitation needs to be planned and customized. The goals of the acute

phase should be to reduce inflammation, regain complete range of motion, and build up strength.

Exercises for improving balance should be added once a pain-free range of motion and weight

bearing have been restored in order to restore normal neuromuscular control. The goal of advanced

rehabilitation should be recovering normal function. This includes workouts designed especially

for activities that will be done while playing sports. Although it's crucial to have a basic plan in

place for the rehabilitation of ankle injuries, physicians must keep in mind that everyone reacts

differently to exercises. Each program must therefore be altered to meet the demands of the person.

Sports-specific exercises and activities that test the healing tendons, ligaments, bones, and

muscle fibers without overtaxing them are necessary for the rehabilitation of athletic injuries.

Returning an athlete to the same or higher level of competition as before the injury is the aim of

rehabilitation. Normal tissue size, flexibility, muscular strength, power, and endurance must be

considered during rehabilitation. Frequent application of external pressure, use of modalities like

cryotherapy, and an active range of motion are required to control edema and effusion (ROM).

The success of future function and athletic performance is frequently determined by the efficiency

of the rehabilitation program following an injury or surgery (Andrews et al., 1998). The

development of a rehabilitation strategy requires a thorough understanding of the body's reaction

to damage. Ligamentous and soft tissue injuries cause metabolic alterations that resemble those

that are seen after an accident (Andriacchi et al., 1987). Pain is caused by blood and tissue damage

that follow an injury. The inflammatory reaction begins after the initial injury, followed by the

proliferative phase and the maturation phase (Martinez-Hernandez & Amenta, 1990).
 44

Before beginning functional rehabilitation, range of motion must be reclaimed using the

treatment-related literature as a guide. Regardless of the ability to bear weight, Achilles tendon

stretching should begin within 48 to 72 hours following damage due to the tissue's propensity to

contract after trauma. The patient is prepared to go on to the strengthening phase of rehabilitation

once ROM has been reached and discomfort and swelling have been managed. Faster healing and

prevention of reinjury require the strengthening of weakening muscles (Surve et al., 1994).

Because inadequate strength in this muscle group has been linked to CAI and repeated injury,

exercises should concentrate on conditioning the peroneal muscles (Hartsell & Spaulding, 1999).

All exercises should be carried out bilaterally and should focus on all ankle muscles. When

exercising bilaterally, we would anticipate significant strength gains in both limbs, however when

training only one limb, the cross-over effect may only be 1.5% to 3.5%. (Uh et al., 2000).

Beginning with isometric workouts performed in all four directions of ankle movement against an

immovable object, strengthening moves on to dynamic resistive exercises employing ankle

weights, surgical tubing, or resistance bands.

Proprioceptive training is started as soon as the patient can bear their full weight without

experiencing any pain in order to regain their balance and postural control. In conjunction with a

series of progressive drills, the use of various equipment created expressly for this stage of

rehabilitation has successfully helped patients regain high functional levels (Mattacola & Lloyd,

1997; Bahr et al., 1997). The wobble board, which consists of a small discoid platform coupled to

a hemispheric base, is the most basic tool for proprioceptive training (Hintermann, 1999). The

patient is told to place one foot on the wobble board and change weight in order to make the disc's

edge follow a continuous circular route. By having the patient use various sized hemispheres and

by changing the visual input, these activities can be advanced. The athlete can also be evaluated
 45

in a variety of visual and support environments. The athlete needs to develop consistent motor

patterns despite inconsistent feedback as somatosensory and visual cues are disrupted. Moving

from a position of non-weight bearing to weight bearing, bilateral stance to unilateral stance, eyes

open to closed, firm surface to soft surface, uneven surface, or moving surface is a common

transition when completing balance exercises. The wide range of surfaces and environmental

factors provides the physician with plenty of opportunities to present novel difficulties throughout

the rehabilitation process. For instance, using water's natural resistance created by turbines creates

a risky yet forgiving environment. If there is time, the trainer can manually shift the ankle and foot

into different positions before asking the athlete to actively and passively mimic joint angles. All

areas of the body acquire sensory information, which is then transmitted via afferent pathways to

the central nervous system. The body responds to disturbances in different ways (feed-forward

versus feedback reaction). Therefore, it's crucial to protect both cognitive and unconscious

awareness of functional joint stability. In slow, moderately quick, or even quick jobs,

proprioception is helpful for preventing damage; nevertheless, it might not be sufficient for forces

that put the neuromuscular system under the most strain (Ashton-Miller et al., 2001). Lack of

variation in pace and intensity during proprioception and balance training is a common error.

Improvements in joint position awareness, postural stability, and threshold to detect motion can be

measured using a variety of techniques (Riemann, 2002; Konradsen, 2002).

The patient may advance to a routine of 50% walking and 50% jogging after the patient's

ability to walk for greater distances is no longer constrained by pain. Jogging eventually gives way

to running, reverse running, and pattern running using the same criteria. Documentation

demonstrating the athlete can do sport-specific exercises without pain and at a level consistent

with his or her pre-injury status constitutes the final stage of the rehabilitation process. Even though
 46

they take a lot of time, these exercises are the last step in the rehabilitation of the ankle joint, and

completing the program is crucial for the restoration of ankle stability. In other words, practitioners

must design movements and workouts that gradually test the wounded athlete's neuromuscular

coordination.
 47

SECTION III: The Exercise Form

Numerous researches have looked at how different training plans affect the traits of CAI

and the signs of acute ankle sprains. A wide range of exercises and programs are highlighted in

the available literature on the rehabilitation of ankle injuries and CAI ankle instability. A sort of

balance board has been successfully used by several specialists to enhance strength and balance

tests in people with acute injury and CAI (Gauffin et al., 1988; Hoffman & Payne, 1995; Matsusaka

et al., 2001; Osborne et al., 2001; Tropp et al., 1984–1988; Wester et al., 1996). Others have

discovered that including a variety of activities for coordination training results in appreciable

gains in measures of strength and proprioception (Bernier & Perrin, 1998; Holme et al., 1999;

Blackburn et al., 2000). And still others have discovered that strength training can aid to improve

both ankle strength and proprioception (Docherty et al., 1998; Kern-Steiner et al., 1999; Blackburn

et al., 2000). While numerous researchers have demonstrated the potential benefits of strength and

balance training, conclusive outcome studies that detail the variety of interventions, their

combinations, and the quantity of exercise required to restore athletes to full function are still

absent. The results of such research are crucial as proof of management efficacy.

The prescribed exercise program or regimen in this case study consists of a number of

different activities that have been grouped together based on how long has passed since the

patient's injury. Numerous studies show these exercises' efficacy in promoting or hastening the

healing process, and physical therapists have examined and approved them. Using the suggested

framework for fitness routines, this program will be provided below. The practice will be followed

by a list of its impacts and relevance based on the data. The Mattacola and Dwyer study,

"Rehabilitation of the Ankle After Acute Sprain or Chronic Instability," served as the basis for this

program.
 48

EARLY FUNCTIONAL REHABILITATION:

MOVEMENT
EXERCISES COUNT SIGNFICANCE FOCUS
EXECUTION
Enables the
tendons,
Clinician ligaments and
15-30s, 10
applies light muscles around
Stretching repititions, 3-
pressure to the ankle to
5x/day
facilitate stretch accommodate
for the duration
of the routine
Maintain
Loosens the
Achilles tendon, Use towel to extremity in a
15-30s, 10 heel cord and
stretch, non- pull foot toward non-gravity
repititions, 3- increases
weight bearing face position with
5x/day mobility
compression
Stand with heel
Achilles tendon,
on the floor and
stretch, weight 15- Strengthen
bend at the
bearing 30s, 3-5x/day ankle joints
knees
Move the ankle
in multiple
planes of
Can be
motion by This helps the
Alphabet 2-3 times per hr 4- performed with
drawing the ankle move in
exercises 5x/day heat or cold
alphabet in all directions
therapy
lowarcase and
uppercase
motions
(1) While
sitting, put your
Enhances
feet together flat
stability; keeps
on the floor.
the affected
Press your
Resistance can area's position.
injured foot
be provided by This exercises
inward against
Hold for about 6 an immovable can help
Strength training your other foot.
seconds, and object (e.g. wall because muscles
(Isometric) (2) Then place
relax. Repeat 8 to or floor) or the often tighten
the heel of your
12 times. contralateral without
other foot on
foot movement to
top of the
help stabilize
injured one.
joints and
Push down with
body’s core
the top heel
while trying to
 49

push up with
your injured
foot.
Strengthens the
muscles in the
ankle, leg, and
Strengthening foot that support
Push foot
Hold muscle can be plantar flexion
downward
Plantar flexion contraction for 5- accomplished in will keep the
(away from the
10s a pain-free range foot flexible,
head)
of motion protect your
ankle, and
prevent future
injuries
Pull foot
upward (toward Allows for the
5-10 repititions the head); push tibia (shin) to
Dorsiflexion
per direction, 3- foot inward move forward
Inversion
5x/day (toward the relative to the
midline of the foot.
body
Push foot
outward (away
Strengthens the
Hold for about 6 from the
muscles of the
seconds, and midline of the
Eversion ankle which
relax; Repeat 8 to body) against a
contribute to
12 times; 3-5x/day wall or a piece
ankle stability
of furniture that
doesn't move
(1) Using a
resistance band
around your
forefoot, hold
the ends of the
band with your
Resistance can
hand and gently
Hold for about 6 be provided by
push your ankle
Strength training seconds, and the contraletral Improves joint
down as far as
(Isotonic) relax. Repeat 8 to foot, rubber position sense
you can and
12 times tubing, weights,
then back to the
or the clinician
starting
position. (2) Tie
the resistance
bands around a
fixed object and
wrap the ends
 50

around your
forefoot. Start
with your foot
pointing down
and pull your
ankle up as far
as you can.
Return to the
starting position
and cycle your
ankle 10 times.
(3) Tie the
bands around an
object to the
outer side of
your ankle. Start
with the foot
relaxed and then
move your
ankle down and
in. Return to the
relaxed position
and repeat 10
times. (4) Tie
the ends of the
bands around an
object to the
inside of your
ankle and hold
your foot
relaxed. Bring
your foot up and
out and then
back to the
resting position.
Strengthens the
muscles in the
ankle, leg, and
Strengthening foot that support
Push foot
Hold muscle can be plantar flexion
downward
Plantar flexion contraction for 5- accomplished in will keep the
(away from the
10s a pain-free range foot flexible,
head)
of motion protect your
ankle, and
prevent future
injuries
 51

Pull foot
upward (toward
5-10 repititions the head); push
Dorsiflexion
per direction, 3- foot inward Allows for the
Inversion
5x/day (toward the tibia (shin) to
midline of the move forward
body relative to the
foot.
Push foot
outward (away
Strengthens the
Hold for about 6 from the
muscles of the
seconds, and midline of the
Eversion ankle which
relax; Repeat 8 to body) against a
contribute to
12 times; 3-5x/day wall or a piece
ankle stability
of furniture that
doesn't move
(a) Place foot on
a towel. Curl
Strengthening
toes, moving the
can be
2 sets of 10 towel toward Increases toe
Toe curls and accomplished
repititions, 3- the body. (b) strength and
marble pick-ups throughout the
5x/day Use toes to pick flexibility
day at work or at
up marbles or
home
other small
objects.
Strengthens the
leg and foot
muscles and is
therefore good
for flat feet and
fallen arches.
Encourages
Strengthening
Lift the body by venous return in
can be
raising up on the legs.
Toe accomplished
the toes. Walk Walking on the
raises, heel 3 sets of 10 using the body
forward and heels stretches
walks, toe walks repititions as resistance in a
backward on the the calf muscles
weight-bearing
toes and heels. and strengthens
position
the foot
extensors.
Walking on the
toes strengthens
the calf muscles
and stretches
the frequently
 52

shortened toe
extensors.

Range of motion must be recovered before functional rehabilitation may begin. Regardless

of the ability to bear weight, Achilles tendon stretching should begin within 48 to 72 hours

following damage due to the tissue's propensity to contract after trauma. The patient is prepared to

go on to the strengthening phase of rehabilitation once ROM has been reached and discomfort and

swelling have been managed. In order to recover quickly and avoid reinjury, it is crucial to

strengthen weakening muscles. Exercises should concentrate on strengthening the peroneal

muscles because CAI and repeated injury have been linked to this group's weakness. All exercises

should be carried out bilaterally and should focus on all ankle muscles. Bilateral training would

result in significant strength gains in both extremities, but exercising only one leg would have a

cross-over effect of about 1.5% to 3.5%. Beginning with isometric workouts performed in all four

directions of ankle movement against an immovable object, strengthening moves on to dynamic

resistive exercises employing ankle weights, surgical tubing, or resistance bands.

Many workout programs' strength exercises would be more successful if they included

manual resistance that was assisted by a trainer. Athletes frequently execute hundreds of

repetitions using different grades of exercise tubing, although the targeted muscles virtually ever

become exhausted. In each cardinal plane, it is advised that manual resistance be used for 3 to 5

seconds for 10 to 12 repetitions. The physician can ensure that the targeted musculature is being

maximally loaded in a pain-free arc by adjusting the length of time that a maximal contraction is

maintained. Athletes are asked to exert their maximum resistance to randomly induced

perturbations during advanced exercises.

 53

INTERMEDIATE FUNCTIONAL REHABILITATION:

MOVEMENT
EXERCISES COUNT SIGNFICANCE FOCUS
EXECUTION
Rotate board in
clockwise and
counter- Exercises can be
clockwise performed with
Circular wobble 5-10 repetitions, directions eyes open or
board 2-3x/day nonweight- closed and with
bearing and or without
weight-breaing resistance
for bilateral and
unilateral stance
Walk in normal
or heel-to-toe Exercises can be
fashion over performed with
Walking in 20-50 ft (6.10-
various surfaces eyes open or
different 15.24 m), 5-
(e.g., hard floor, closed and with
surfaces 10x/day
uneven carpet, or without
different foam resistance
pads)
Clinician
provides
degrees of Velocity and
Manual
resistance and resistance can be
proprioceptive
5-20 repetitions, random varied to
neuromuscular
1-2x/day perturbation as stimulate
facilitation
athletes moves sensory
exercises
the foot through feedback
function
patterns

ADVANCED FUNCTIONAL REHABILITATION:

MOVEMENT
EXERCISES COUNT SIGNFICANCE FOCUS
EXECUTION
Athlete balances
Increase
on wobble board
difficulty by
with rubber-
Wobble-board 5-10 repetitions, varying surfaces
tubing
exercises 1-2x/day and alternating
resistance or
eyes open and
after light
eyes closed
perturbation
 54

from the
clinician
Athlete Increase
performs difficulty by
Functional functional performing
exercise on activities on skills on
5-20 repetitions,
different variable unstable
1-2x/day
surfaces and surfaces (e.g. surfaces and
with resistance trampoline, with varied
foam, in water velocity of
with resistance) movement
50% walking
and 50%
Increase
jogging in
Increase distance intensity and
straight
Walk-jog by 1/8-mile (.2- incorporate
direction,
km) increments activity-specific
forward,
training
backward, and
pattern running
50% jogging
and 50%
Increase
running in
Increase distance intensity and
straight
Jog-run by 1/8-mile (.2- incorporate
direction,
km) increments activity-specific
forward,
training
backward, and
pattern running

Proprioceptive training is started as soon as the patient can bear their full weight without

experiencing any pain in order to regain their balance and postural control. In conjunction with a

series of progressive drills, a number of devices that have been created especially for this stage of

rehabilitation have successfully helped patients regain high functional levels. The wobble board,

which consists of a small discoid platform coupled to a hemispheric base, is the most basic tool

for proprioceptive training. The patient is told to place one foot on the wobble board and change

weight in order to make the disc's edge follow a continuous circular route. By having the patient

use various sized hemispheres and by changing the visual input, these activities can be advanced.

The athlete can also be evaluated in a variety of visual and support environments. The athlete needs
 55

to develop consistent motor patterns despite inconsistent feedback as somatosensory and visual

cues are disrupted. Moving from a position of non-weight bearing to weight bearing, bilateral

stance to unilateral stance, eyes open to closed, firm surface to soft surface, uneven surface, or

moving surface is a common transition when completing balance exercises. The wide range of

surfaces and environmental factors provides the physician with plenty of opportunities to present

novel difficulties throughout the rehabilitation process. For instance, using water's natural

resistance created by turbines creates a risky yet forgiving environment. If there is time, the trainer

can manually shift the ankle and foot into different positions before asking the athlete to actively

and passively mimic joint angles. All areas of the body acquire sensory information, which is then

transmitted via afferent pathways to the central nervous system. The body responds to disturbances

in different ways (feed-forward versus feedback reaction). Therefore, it's crucial to protect both

cognitive and unconscious awareness of functional joint stability. In slow, moderately quick, or

even quick jobs, proprioception is helpful for preventing damage; nevertheless, it might not be

sufficient for forces that put the neuromuscular system under the most strain. Lack of variation in

pace and intensity during proprioception and balance training is a common error. Improvements

in joint position awareness, postural stability, and threshold to motion detection can be measured

using a variety of techniques.

Ankle injury rehabilitation needs to be planned and customized. The goals of the acute

phase should be to reduce inflammation, regain complete range of motion, and build up strength.

Exercises for improving balance should be added once a pain-free range of motion and weight

bearing have been restored in order to restore normal neuromuscular control. The goal of advanced

rehabilitation should be recovering normal function. This includes workouts designed especially

for activities that will be done while playing sports. Although it's crucial to have a basic plan in
 56

place for the rehabilitation of ankle injuries, physicians must keep in mind that everyone reacts

differently to exercises. Each program must therefore be altered to meet the demands of the person.
 57

Chapter V

CONCLUSION

SECTION I: Summary of Findings

There are around 2 million acute ankle sprains each year. Acute ankle sprains occur

between 2 and 7 times per 1000 person-years, according on statistics from visits to emergency

rooms. However, considering how many injured people choose not to even seek medical

assistance, this number is likely greatly underestimated. One of the most frequent musculoskeletal

ailments is an acute ankle sprain, which frequently affects physically active people. Acute ankle

sprains also have a high rate of recurrence, which is linked to the emergence of CAI. Ankle

ligament injuries, which make up 16–40% of all sports-related injuries, are the most common type

suffered by athletes. Ankle sprains remain a topic of interest in sports medicine. Despite advances

in research-driven diagnosis, treatment, and prevention, recent epidemiological studies have

revealed that lateral ankle sprains remain the most frequent sports injury. Ankle sprains are a

common problem for physically active persons, particularly for those who participate in court and

team sports. A lateral ankle sprain requires careful care if the athlete is to recover entirely. The

exercise form is being investigated to characterize a functional rehabilitation program that

progresses from basic to advance while taking into account empirical evidence from the literature

and clinical experience. Ankle injury rehabilitation needs to be planned and customized. Each

program must therefore be altered to meet the demands of the person.

 58

SECTION II: Concluding Statement

Prior to starting the paper, I had little to no knowledge of the advantages of physical

therapy. However, I learned during my study for this post that people with specific orthopedic

problems or those who are healing from orthopedic accidents or operations often benefit from

physical therapy. I learned from this essay how important biomechanics is to everyday life. It is

mind-boggling to think about how various body parts, such muscles, tendons, and ligaments, must

cooperate to carry out a movement. I became aware of how many of the movements we do on a

daily basis could result in permanent handicap as a result of the material I gathered for this study.

It is easy for us to take for granted the things that enable regular movement until they become

injured since our bodies are continuously being pushed to their limits without our even being aware

of it. This made me consider my own body mechanics, see my shortcomings, and understand and

learn how I might better myself.

 59

SECTION III: Summary of Statements

According to this study, routines, rituals, and dances help us become conscious of how

crucial it is to take care of our body. We assume that the muscles, tendons, and ligaments that hold

our body together are the reason we can move the way we do. People underestimate the severity

of an ankle injury because of misconceptions about specific portions of our bodies, such as the

ankle. The ability to walk could be at jeopardy from a single ruptured muscle or ligament, and this

subject made sure we understood how crucial it is to understand our bodies and take care of them.

Therefore, in cases of injury, this study has given me ample knowledge on how to better care for

my ankle if I sustained damage in any of my ligaments and how to improve its condition as well

as prevent recurring sprains and tears.

 60

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