Chronic Ankle Pain and Instability Secondary to an Ankle Sprain

BACKGROUND AND PURPOSE:

Ankle sprains are a common diagnosis throughout the United States, with about 2 million reported each year.1 The most common cause of ankle sprains is athletic injury at 49.3%, followed by falling from stairs (26.6%) and ground level stumbles (6.7%).1 Of those reported, lateral ankle sprains are the most common type of ankle sprain.2 Anterior talofibular ligament (ATFL) laxity is common following a lateral ankle sprain and anterior displacement of the talus has been shown to occur in many people.3 Chronic ankle pain and instability is common after an initial sprain with 5-33% of patients continuing to report pain after 1 year and re-sprains occurring in up to 34% of people.

4 In patients presenting with chronic ankle instability an anterior shift of the fibula has been found to occur.5 Research has shown that chronic ankle instability is a multidimensional impairment that requires a comprehensive approach to treatment.6 In addition to exercises, talocrural joint mobilizations have been shown to improve ROM, function, and dynamic postural control in patients with chronic ankle instability.7 The purpose of this case report is to describe the physical therapy treatment and outcomes of a patient presenting with chronic ankle pain and instability, secondary to a lateral ankle sprain following a motor vehicle accident.

CASE DESCRIPTION:

The patient described in this case report is a 32-year-old Caucasian female who works as a collegiate soccer coach. On April 29, 2018 the patient was the passenger in a vehicle when the driver lost control of the car and connected with the median on the passenger side. Following the accident, the patient was diagnosed with a right lateral ankle sprain and malleolus fracture. She was placed in a walking boot for two weeks but did not receive any additional interventions. The patient presented to physical therapy on July 18, 2018 with reports of persistent stiffness and pain in the right ankle. The patient's family and medical history were unremarkable, although she reported a history of ankle sprains in both ankles. A systems review was found to be unremarkable apart from the musculoskeletal system, which revealed impairments to right lower extremity joint structure, range of motion (ROM), and strength. An anterior drawer test was performed on the right ankle and although it showed no obvious laxity, the test yielded positive results due to pain. This result indicated that although the right ATFL was still intact, there may have been some pathology present.8,9 A posterior drawer test was also performed which revealed negative results for a posterior talofibular ligament (PTFL) tear.

Active ROM measurements were collected, in which the patient had decreased right plantar flexion at 50° and dorsiflexion at 10°. Pain was reported on the lateral ankle at end range of dorsiflexion and inversion. Manual muscle testing (MMT) revealed limitations to the patient's right ankle, with 4/5 strength in inversion and -4/5 strength in eversion. The patient also reported pain on the lateral aspect of the right ankle during both inversion and dorsiflexion MMT. All other lower extremity measurements were WNL (5/5). The Lower Extremity Functional Scale (LEFS) was administered, totaling a score of 62/80. This score indicated that the patient was at 77.5% of her maximum level of function. She also reported a pain rating of 5/10 on the visual analog scale (VAS).

Evaluation revealed impairments to strength, ROM and iADL's, as the patient was unable to perform yard work without increased pain. Additionally, the patient was limited in her ability to perform all necessary work duties as a collegiate soccer coach. She was unable to pass a soccer ball, run, plant or cut on her right foot or stand for prolonged periods of time without increased discomfort in her right ankle. The patient was also limited in her community and leisure activities, such as paddle boarding and maintaining a daily exercise routine. The patient followed a 4-week rehabilitation program that included 2 visits per week for 60 minutes per visit. Interventions focused on strengthening, stretching, talocrural joint mobilizations, Mulligan mobilizations, balance training, agility training and modalities.

OUTCOMES:

Following 8 physical therapy visits, the patient had improved right ankle ROM, with dorsiflexion WNL when compared to the left side, plantar flexion at 60° and no pain reported. The patient's right ankle strength had also returned to WNL with a score of 5/5 in all planes of motion during MMT. When performed a second time the anterior and posterior drawer tests of the right ankle were both negative. The patient's pain symptoms had decreased to a 1/10 on the VAS. When the LEFS was administered at discharge the patient had improved to a score of 73/80, indicating she was now at 91% of her maximal lower extremity function. Although she was still unable to participate fully, the patient also reported improvements in work related activity performance. The patient no longer had impairments to her iADL's at discharge and was able to return to paddle boarding and exercising with limited reports of discomfort.

DISCUSSION:

As expected, the patient demonstrated improvements in dorsiflexion and overall ankle ROM following the use of mobilizations with and without movement.3,7 The inclusion of strength training to the patient's program also lead to substantial improvements in her ankle strength.10 Although this patient's dynamic balance was not specifically measured, she was able to make progressions in her balance exercises quickly and stated that she felt "more stable" towards the end of her care. These findings are consistent with literature reporting that a combination of strength training, proprioceptive and balance training exercises leads to improvements in dynamic balance and self-reported functional mobility.6,11 Although she made great progress, the patient did not reach full recovery in right ankle ROM and self-reported function prior to discharge. This limitation was likely attributed to her required discharge date of August 8, 2018 and some missed appointments throughout the plan of care. Overall, this patient would benefit from a continued home exercise program that included strengthening, balance exercises and agility training.

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