The Influence of Therapeutic Exercise after Ankle Sprain on the Incidence of Subsequent Knee, Hip, and Lumbar Spine Injury
Foster KS, Greenlee TA, Fraser JJ, Young JL, Rhon DI. Medicine & Science in Sports & Exercise. 2022 August. doi: 10.1249/MSS.0000000000003035.
https://pubmed.ncbi.nlm.nih.gov/36084225/
Take-Home Message
Performing therapeutic exercise after an ankle sprain reduces the chance of a knee, hip, or lumbar spine injury over the subsequent year.
Background
Ankle sprains are the most common injury, especially among active individuals. However, not everyone receives care, which can contribute to chronic ankle instability and impairments in lower extremity movement, including instability and reduced sensorimotor function. These impairments may increase someone’s risk of subsequent injury in other joints in the lower extremity. However, we have little evidence to support or refute this hypothesis.
Study Goal
The authors evaluated the rate of secondary injury following an ankle sprain and if therapeutic exercises after an ankle sprain reduced the risk of future injury to the knee, hip, and lumbar spine.
Methods
The authors conducted a retrospective cohort study within the Military Health System. They used diagnostic and billing codes to identify individuals who sought care for an ankle sprain between 2010 and 2011, whether or not they received therapeutic exercise within 90 days of injury, and whether or not they suffered a subsequent injury in the knee, hip, or lumbar spine within a year of the ankle injury.
Results
Twenty percent of individuals (6,848) were diagnosed with a proximal joint injury. Most of these were knee and lumbar spine injuries. Only 28% of all individuals received therapeutic exercises for their initial ankle sprain. Individuals that received therapeutic exercises were ~13%, ~18%, and ~32% less likely than their peers without exercises to have a knee, lumbar spine, or hip injury at any point during the year after an ankle sprain.
Viewpoints
Individuals may sustain a secondary injury after an initial ankle sprain because of decrements in mobility, strength, and muscle activation. Only 8% of total costs for ankle sprains go to physical therapy, yet those who do not seek care are more likely to report reduced function and develop chronic ankle instability. Ankle sprains are often perceived as minor injuries, which may explain the lack of care-seeking or referral for therapeutic exercise. However, physical rehabilitation after an injury can improve ankle range of motion, pain, gait, balance, and stability, so it stands to reason that it would have a positive impact on risk of future injury. It would have been helpful to know who made the initial diagnosis and how their background/training influenced referral to therapeutic exercise.
Clinical Implications
We must be more proactive about educating healthcare professionals about the need to refer people after an ankle sprain to physical rehabilitation. They need to recognize that this is not a minor injury and that one in five individuals will suffer an injury to the knee, hip, or lumbar spine within a year after an initial ankle sprain, which is already the most common sports injury.
Questions for Discussion
Have you encountered any patient perceptions of ankle sprains being minor, and if so, how have you explained the problem to them? Conversely, how would you change the way you explain ankle sprains to patients, even if they appear to be minor?
Related Posts
- Nothing to Fear but Fear Itself in Those with Chronic Ankle Instability
- Ankle Sprains are being Over-Medicated and Under-Rehabilitated
- Chronic Ankle Instability Starts Earlier Than We Thought
Written by Jennifer Xu
Reviewed by Jeffrey Driban
I have experienced, firsthand, the ‘lighthearted’ mentality that surrounds an ankle sprain. Having been an avid basketball player throughout my entire life, my ankles are no stranger to the grade I and the grade II lateral ankle sprain. Unfortunately, I cannot say that I have completed any sort of rehabilitation that included therapeutic exercises in response to one of the many incidents of an ankle sprain. Throughout the years, I have developed functional ankle instability in both ankles. Every so often when I’m playing basketball or just being active in general, I feel my ankles “give out” a little bit. Thankfully, I haven’t suffered a substantial injury from this instability, but it serves as a constant reminder about my recklessly carefree response to the subsequent ankle sprains I’ve suffered.
Having begun my professional career in the athlete training field as a student just a few months ago, I have learned a great deal about the importance of the rehab process. This article highlighted a real-life application about the importance of proper rehabilitation and how it not only can prevent re-injury of the same structure(s), but how it may also serve a role in preventing injury throughout the body. Moving forward, the main point I would like to get across to all my future patients/athletes is that any injury, no matter how minor it may appear, will recover better if you give proper rehabilitation for that injury the appropriate attention and care. Rehabilitation can prevent injury recurrence, which should hopefully be enough to convince them that participation would be worthwhile. Further, I will emphasize to my patients/athletes that the body is one whole unit and when one part of that unit doesn’t function properly (like it would post-injury), the entire unit suffers. If something affects the foot, it likely will affect the ankle, and that will likely affect the knee, and so on and so forth. If they aren’t convinced enough at this point, then hopefully the thought of rehabilitation programs preventing other concurrent injuries/pathologies from developing elsewhere in the body makes them understand the importance of rehab. Since athletic trainers serve as advocates for their athletes’ health, stressing the vital importance of a rehabilitation program to those athletes is an essential part of our job.
I haven’t personally experienced an ankle sprain, but I have worked in several settings where this has been a common injury sustained in sports. There have been several soccer players as well as basketball players that I have seen wear ankle braces to help provide better support after an ankle sprain. On the other hand, some athletes have been seen to wear tape as a precaution or even as support following an ankle sprain. These are just some interventions used for ankle sprains, the main one athletes tend to avoid is rehabilitation. Rehabilitation is huge after an injury because it helps strengthen the injured limb and help improve range of motion as well.
In class, our stress has been on how important and influential rehabilitation can be for athletes both as prevention and following injuries. Rehabilitation is important in building strength to help prevent further injury or a secondary injury. Within this article, it studied how ankle injuries can lead to further injuries of different body parts. Our teacher has stressed the importance of how the feet are the base as well as the most important part of how the rest of the body works. If there is weakness in the ankles, it can cause a whole chain of problems for the rest of the body. The instability and impairments that come with ankle sprains stress how important rehabilitation can be for athlete’s to complete in order to get back full function in their sport. It would be interesting to further investigate what causes athletes to not receive rehabilitation and see if there is a reason they choose not to. The perception that ankle sprains are not a big deal could be part of the reason why some athletes don’t believe in rehabilitation or thinking they don’t need it. People should believe in and push for rehabilitation following injuries to help prevent secondary injuries. Athletic trainers need to stress the importance of rehabilitation and how crucial it can be with recovery.
When talking to peers about ankle sprains, rehabilitation and treatment is often brushed off in their list of concerns. Many people I’ve encountered will continue to walk on their injured ankle because they need to continue their activities of daily living, but don’t understand the long term effect that it could have, because they think more of the immediate consequences to their life than any future consequences. I think the way that ankle sprains are talked about in daily life is also indicative of a lowered sense of urgency to treat, as people will simply reference their ankle sprains as a “little tweak” and do little to help it feel better. It seems to be a common sentiment that if it isn’t too painful to remove people from activity (walking in most cases) then they don’t need to do anything except treat the most pressing symptoms of pain, usually with NSAIDs.
I think that it is so important to highlight the importance of strengthening the entire kinetic chain when injuries occur, as it is often overlooked in low grade injuries by patients. Many patients think that since ankle sprains occur so often, they are similar to that of a cut or a scrape that will eventually resolve on its own. Being able to reference literature that indicates there are long term effects to a minor ankle sprain can be the difference when educating these patients. As a student, treatment and rehabilitation are highlighted to be extremely important when it comes to predicting the functionality of a structure when it is no longer injured. It is important to treat every injury, no matter how minor, with the same care and detail to ensure the patient’s best outcomes. Being able to educate athletes prior to injury about the importance of treatment and rehabilitation will be something that can save the athlete a lot of time and energy in the long run and ensure that they are able to play for their career and also still engage in their lives actively when they are no longer active athletes.
I have had experience with an athlete who thinks an ankle sprain is a light-hearted injury. It was when I was shadowing my athletic trainer. It was at the high school level and the athlete was a football player. My athletic trainer noticed the athlete was limping and when to question him. He brushed the AT off and said he was fine. The next day he came into the training room and his ankle was swollen. This idea of ankle sprain is a mild injury without the proper rehabilitation can cause functional ankle instability and can be detrimental. to how the injury heals like this athlete’s case here.
Ankle sprains are a common injury that occurs when the ligaments that support the ankle are stretched or torn. While some ankle sprains may be minor and can be treated at home with rest, ice, and over-the-counter pain medication, others can be more severe and may require medical attention. It is important for patients to be evaluated by a healthcare provider to determine the extent of the injury and receive appropriate treatment.
If a patient believes that their ankle sprain is minor, it may be helpful to explain the potential complications that can occur if the injury is not properly treated. These can include chronic pain, instability of the ankle, and an increased risk of future sprains. Emphasizing the importance of proper treatment and rehabilitation can help to ensure that the injury heals properly and the patient can return to their normal activities without further problems.
I have experienced a patient ignoring the severity of an ankle sprain firsthand. When I was shadowing my athletic trainer a football athlete had a noticeable limp and my athletic trainer noticed. But when they confronted the athlete the athlete brushed off the severity of it and did not allow the AT to evaluate them. The athlete then came into the training room the next day with swelling in the ankle and an even more aggressive limp.
An ankle sprain is a very common injury in sports while some sprains may be minor and heal on their own with proper care, others can be more severe and require medical attention and improper care of an ankle sprain can lead to functional ankle instability. It’s important for patients to understand the potential seriousness of an ankle sprain, even if it appears to be minor so that they can receive proper treatment and avoid complications.
To explain the potential seriousness of an ankle sprain to a patient, I would emphasize the importance of seeking an evaluation of the injury, even if the injury seems minor. I would also explain the potential risks and complications of untreated or improperly treated sprains, such as chronic pain, instability, and increased risk of future injuries. By seeking attention to the injury patients can ensure they receive the appropriate treatment and avoid these complications.
I have personally experienced the downplaying of a sprained ankle when I was playing basketball in middle school and high school. In playing basketball for several years I sustained a number of ankle sprains. Since we did not have an athletic trainer in my town, I went to a doctor who took an x-ray and stuck me in a boot for 6 weeks. I did a couple weeks of physical therapy for Achilles tendonitis, but never fully rehabilitated my sprained ankle. This lead to severe ankle instability and several more ankle sprains as I continued to play basketball. I constantly complained about ankle pain, feeling like it was going to give out, and chronic swelling. This was brushed off as issues from chronic ankle sprains and I was told it was no big deal and symptoms like this are common for somebody playing basketball and spraining their ankle. Fast forward several years and I was told my ankle symptoms were due to a very serious tumor condition that was overlooked because it was viewed as a “not very serious” ankle sprain. While my long-term consequences were not the same as the ones discussed in the article, I still am paying the price for an an ankle sprain being viewed as the only issue possible in the ankle of a young athlete.
In addition to my personal experience with ankle sprains being underplayed, I have also encountered many athletes who have sprained their ankle. In high school, this issue was very much addressed as tape it up and maybe sit out a game before going back in. As I progressed to working in the NCAA setting, I was able to see ankle sprains be addressed in a more serious manner. In working with a Division I football team, I was able to see many ankle sprains and the different ways each athlete handled them. I worked with several athletes who saw ankle sprains as no big deal. In these situations, I was able to be apart of conversations with the athletes and the ATC to educate the athletes on the consequences of not performing proper rehabilitation for an ankle sprain. These conversations helped the athlete to see the importance of completing the rehab program and they were motivated to get back on the field the “right way.”
While I previously have educated athletes on the long-term consequences that are ankle-specific, I have not mentioned the other issues such as lumbar spine, hip, and knee injuries discussed in this article. In the future, I would like to have statistics of these secondary injuries so that the athlete can get a full picture. This would help them to understand that an ankle sprain can negatively affect more than just your ankle if it is not treated properly.