Immediate Care of Ankle Injuries

7/28/2019 Immediate Care of Ankle Injuries

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000-0000/79/0001-0046$02.00/0THE JOURNALF ORTHOPAEDICND SPORTS HYSICALHERAPYCopyrightO The Orthopaedic and Sports Medicine Sections of the American Physical Therapy Association

Immediate Care of Ankle InjuriesLYNN WALLACE,* MS, PT, ATC; KAREN KNORTZ,t MS, PT, ATC; PERRY ESTERSON, MS, PT, ATC

Physical therapists have an excellent back-ground to deal with immediate care of injuries,although they traditionally have not been in-volved with this aspect of patient care. The oc-currence of ankle injuries in sports is high6 42%of high school athletes had previous anklesprains) and the effects immediate. Appropriateattention and acute care by a physical therapistcan reduce the period of disability considerably.The following are immediate care "concepts"for the physical therapist to consider.EVALUATION

The immediate temptation upon seeking anathlete who has just suffered an "obvious" anklesprain is to ice, compress, and elevate it. How-ever, a quick but thorough evaluation is essen-tial. This examination can be completed in 60-90 seconds with the extremity elevated. Theexamination should consist of a series of rule-outs with areas of possible pathology markedand a good data base established.= A thoroughhistory can be obtained after the ankle has beeniced, compressed, and elevated.

IMMEDIATE CAREElevation is a modality which is always avail-

able. High elevation (i.e., having an athlete lie onthe floor with his leg upon the table or having ateammate hold his leg in the air) is very effective.Prolonged high elevation can become extremelyuncomfortable and is usually restricted to 10-1 5minutes.

Compression in the form of wet and preferablycold elastic wraps should be applied. Wrapsshould be preimmersed in a bucket of water, andpreferably stored in a freezer. The wrap shouldstart at the base of the toes and gradually de-

* Rainbow Sports Medicine Center, Case Western ReserveUniversity. Cleveland. OH.t University of Nebraska. Athletic Department. Lincoln. Ne.5 Western Reserve Therapists. Inc., Chesterland. Oh.

creasemally.

Coldin pressure as the wrap is applied proxi-is best applied by means of crushed ice

in a plastic or English ice bag with a little waterin it. This can be secured to the ankle with tapeor a second elastic wrap. Cold should be appliedfor up to ' hour and then removed. Prolongedcooling can lead to the Hunting Reaction4 whichmay defeat the purpose of icing.

DRESSINGS-COMPRESSION WRAPSOpen-Faced Gibney (Open-faced BasketWeave) with Elastic Wrap

This dressing (Fig. 1) is used with the ambu-latory patient whose edema is expected to in-crease. The elasticity of the elastic wrap andopening in the front of the taping can accom-modate this swelling yet the adhesive tape pro-vides support that the elastic wrap cannot. Thedisadvantage to this wrap is that its applicationrequires skill, and that it needs to be replacedevery 2 or 3 days.Orthoplast Splint

This splint (Fig. 2) provides maximum supportof the ankle as almost no inversion or eversionis possible. This is used when a patient must beambulatory o r is returning to a high risk activity.Despite its bulky "look" it is quite comfortable ifmolded properly and function is not restricted.The splint is secured to the ankle by an elasticwrap, and may be taken off and reapplied by thepatient. In some situations the cost of orthoplastmaterial is simply prohibitive, and in most cases,one needs to consider the indications carefully.Rubber or Felt "Horseshoe"

The horseshoe is kept in place by either anelastic wrap or open Gibney (open basketweave) taping (Fig. 3) or both. The pressure ofthe horseshoe controls bleeding and edema andforces any exudate present to other areas thusspeeding absorption.


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Summer 19 79 IMMEDIATE CARE OF ANKLE INJURIES 47

Fig. 1


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48 WALLACE, KNORTZ AND ESTERSON Vol. 1 , No. 1 .

Cotton Cast

Fig. 3.

HOME INSTRUCTIONSA cotton cast (Schantz or Watson-Jones

dressing) (Fig. 4) consists of alternate layers ofelastic wraps and cotton (surgical) wadding. Thisdressing provides a maximum combination ofpressure and immobilization. The disadvantagesare that it cannot easily be removed or loosenedby the patient and then reapplied and is uncom-fortable in warm weather.Elastic Wrap

An ordinary elastic wrap properly applied pro-vides adequate pressure over the joint but pro-vides no support. It is convenient for the patientto correctly reapply this wrap.ASSlSTlVE DEVICES

If the athlete has even a slight limp, crutchesand a nonweight bearing status are indicated. Apartial weight bearing gait should not be used asthe athlete will soon change it to full weightbearing. A thorough explanation of how non-weight bearing allows the traumatized joint to"settle down" is indicated. A cane usually hasno place in the treatment program.

Equally as important as any first-aid technique,is a complete set of home instructions that theathlete understands. The following are somesuggestions of the Do's and Don'ts:

Do-1) elevate your ankle (the athlete mustbe told what elevation is, otherwise, he mayspend the entire evening sitting in a chair withhis/her foot on a phone book); 2) ice the ankle(generally 20 minutes on and 30 minutes off); 3)keep the wrap on (if you must remove or loosenit, reapply starting at the base of the toes andloosening pressure as you move up); 4 ) use thecrutches and keep all weight off the ankle; 5)elevate the end of your bed (using bricks, books,etc.); and 6) see us tomorrow.

Don't-1) keep your ankle in a dependentposition; 2) use any kind of heat (hot baths,showers, soaks, heating pad, etc.); 3) take even1 step without your crutches; and 5) get excitedif it hurts more tonight.THE NEXT DAY

"Cook Book" treatment programs are of novalue; however, certain considerations are inorder on the 2nd day. Reevaluation to add to


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Summer 1979 IMMEDIATE CARE OF ANKLE INJURIES 49

Fig. 4.

Fig. 5 .


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50 WALLACE, KNO RTZ AND ESTERSON Vol. 1, No. 1 .and clarify the data base is essential. Treatmentmust be directed towards reducing swellingwhich will increase the pain-free range of motionand decrease the pain. Icing the ankle in anelevated position or ice immersion with the anklewrapped in sponge rubber and elastic wraps(this pressure helps to overcome the effects ofgravity (Fig. 5)) seems to work well. Strengthand flexibility maintenance programs for otherbody areas also should be initiated.OTHER TREATMENT CONSIDERATIONS

Cyriax'.' suggests the use of cross-frictionmassage early in the treatment program to pre-vent the formation of intra-ligamental adhesionsand adhesions between ligament and bone.How long to use cold?

The therapist should continue to use cold untilno further gains in the treatment program arenoted. Heat applied to the ankle joint too earlyrisks the chances of increasing edema and thusprolonging recovery.When to get off the crutches?

The athlete should remain on the crutches untilhe/she can walk without a limp. He/she shouldbe prepared to get off the crutches by goingfrom a nonweight bearing gait to partial weightbearing with a heel to toe gait. Tape, cloth wrap,

or orthoplast splint should be used to preventinadvertent respraining of the ankle.Exercise

Should be initiated early in the treatment pro-gram to increase circulation, metabolism, reab-sorption of fluid exudate, etc. Strength must beregained before returning to activity. An anklestrength maintenance program should be contin-ued throughout the athlete's career.Complete Rehabilitation

The old athletic axiom "once a sprain, alwaysa sprain" need not be true. If the ankle is com-pletely rehabilitated the chances of him/her re-spraining the ankle are no greater than b e f ~ r e . ~Athletes and coaches must be made to under-stand that ankle taping and wrapping are notgood substitutes for ankle rehabilitation.REFERENCES:

1. Cyriax J: Textbook of Orthopaedic Medicine. Vol 1. Chapt 25.London, Bailliere Tindall. 1975

2. Cyriax J: Textbook of Orthopaedic Medicine. Vol 2.Chapt 2 and4. London. Bailliere Tindall. 19 77

3. Jackson DW: Treatment of Ankle Sprains. Am Coll Sports MedNews 9: 1974

4. Krusen F, et al: Handbook of Physical Medicine and Rehabilita-tion. Second Edition. Philadelphia.WB Saunders Co., 1971

5. Wallace LA: Assessment of Ankle Injuries. Newsletter of SportsMedic ine Section of APTA. 2: 1976

6. Wallace LA: Unpublished High School Screening Data, 1975-1976

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Immediate Care of Ankle Injuries