domingo, 6 de fevereiro de 2011

Sprain Ankle - Part II

Physical Examination

In the sprain, on stretching the sprained ligament, the increased tension gives rise to acute pain, since this structure is partially torn and its inflamed nerve endings are exquisitely sensitive. In the rupture, on stretching the ruptured ligament, there is increased mobility but little pain, since the ligament is completely divided and there is therefore no tension.  With a rupture no amount of immobilization is likely to secure healing and it will be necessary to consider surgical repair in order to reconstitute the completely torn ligament and to secure a sound result (McMurray, T.B., Orth, M.C. (2008). Nevertheless, after the surgery physical therapy is still need to eliminate the pain, accelerate healing and restitute the complete range of motion of the ankle.
Mild or “Grade I” ankle sprains involve tearing of the ligament fibers and minimal swelling. There is usually no joint instability. These ankle sprains occur when a person rolls his ankle and notices pain. These milder ankle sprains are treated with ice, a small ankle brace and early weight-bearing. Many times the athlete can return to action in a week or two. Moderate, or “Grade II” ankle sprains are characterized by immediate pain, swelling, bruising, and tenderness over the involved ligaments. These injuries usually result in some loss of joint motion: Although some ligament fibers may be torn, the overall stability of the joint is intact, with only a minimum amount of looseness within the ankle joint. These injuries are usually treated with an ankle brace, followed by physical therapy and rehabilitation. Severe or “Grade III” ankle injuries are complete tears of the ankle ligaments and usually involve instability of the ankle, marked swelling and pain. The patients usually can’t walk, require crutches, ankle braces, casts, and in certain instances surgery is requires to repair the torn ligaments (Lucie, R.S., 1998).
The reflex reaction of the muscles, especially the peroneal muscles, is the first response in the dynamic defense mechanism when an ankle is inverted. This response can be attributed to the combined input of many receptors in the ankle joint complex, primarily the tendon-muscles mechanoreceptors (Jordan et al, 2006), which rapidly transmit information to the central nervous system (CNS) about the position of the ankle. When that information reaches the CNS, information is transmitted to the muscles of the ankle to be activated, protecting the ankle, not letting the joint reach movements that would sprain the ankle. When an ankle trauma occurs, this reflex reaction is also injured and the nerves may be damaged, leading to slower nerve conduction velocity. This is the reason why repetitive sprains occur more rapidly when an initial sprain is not rehabilitated properly.


Management of acute ankle sprain typically involves rest, ice, compression, elevation, and physical therapy. Physical therapy treatment is crucial, because an untreated ankle sprain may lead to chronic ankle instability, a condition marked by persistent discomfort and a “give away” of the ankle, with the chance of developing weakness in the leg. Also, impairments in ankle range of motion and joint mobility can additionally predispose patients to other lower extremity injuries including plantar fasciitis, Achilles tendinopathy, fracture, chronic ankle instability, and patellar femoral pain syndrome. Physical therapy treatment involves mobilization and manual therapy to improve the ROM of the ankle, deep tissue massage to enable the new replaced collagen to align with the stresses and forces applied at the ankle (Mattacola, C.G., Dwyer, M.K., 2002) and diminish its laxity, sensoriomotor exercises to improve the reflex reaction of the muscles and the neuromuscular re-education, thus improving the balance, and strengthening exercises.
McKay et al (2001) reported that 55% of the individuals who sprain their ankles do not seek treatment from a health care professional and concluded that this may be why the ligaments of the ankle do not heal properly. There is good evidence that a combined approach of early mobilization, manual therapy, and neuromuscular re-education is effective in restoring the range of motion of the ankle (ROM), returning to work quicker than patients who only received early mobilization. Bleakley (2008) and van der Wees (2006) reported that manual therapy can significantly improve short-term symptoms and neuromuscular reeducation training does decrease the chance of re-injury. Specifically, Green et al 2001, found that the addition of joint mobilization lead to full restoration of ROM in fewer sessions than patients who did not receive joint mobilization. Verhagen et al, 2004, shown that ankle injury prevention exercises are effective in reducing the incidence of ankle injuries. He reported a significant reduction in the ankle sprain risk, and its recurrence, for volleyball players when balance boardtraining was used as a normal part of the daily warm-up. Gauffin et al observed that eight weeks of ankle disk training resulted in improved bilateral postural control in soccer players with a history of ankle sprains.
A severely sprained ankle is often a multiple lesion, and each component should be carefully diagnosed. The sprained ankle may be a complex matter and should be considered in that light. It should not be regarded as a lesion of minor importance (McMurray, T.B., Orth, M.C. (2008).

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