Learning Through Experience: Treating My First Grade 3 Ankle Sprain

One of the most memorable cases I treated as a physical therapist was a pivotal experience for me, both professionally and personally. This case was significant because it served as my introduction to the complexities of the ankle joint and marked the beginning of my journey in patient care.

Like many new graduates, I faced a steep learning curve when I started working with patients. One of my biggest challenges was managing the nervousness that came with the responsibility of providing care. I constantly questioned myself: "Is this technique right?" or "Is this treatment plan effective?" The weight of knowing that a patient’s recovery relied on my decisions felt overwhelming at times. This particular case, which I’ll call "Ahmed" for privacy, encapsulated these challenges perfectly.

Ahmed, a 28-year-old man, came to me with a Grade 3 ankle sprain. He had sustained the injury after making a misstep while hurrying down the stairs to his car. He described hearing a "click" followed by intense pain that made walking almost impossible. Fortunately, a hospital near his home provided an initial diagnosis, and he was referred to physical therapy.

At the time, I found the ankle joint to be particularly intimidating. Its intricate biomechanics and complex anatomy were challenging for me to fully grasp. When Ahmed’s case was assigned to me, I felt a mix of excitement and apprehension. My initial focus was on reducing the swelling in his ankle, as it was severe. I decided to hold off on introducing any exercises until we managed the inflammation.

For the first two weeks, my treatment was centered around swelling reduction. Once the swelling had subsided, I transitioned to a structured treatment protocol tailored to Ahmed’s needs. In my next post, I’ll dive deeper into the specific protocols I used and share insights from this rewarding case.

The first protocol

The first protocol relied more on organizing and reducing any risk of problems that might happen during the treatment. this the protocol I used the most but it's not the only one.

Treatment Plan for Grade 3 Ankle Sprain

1. Initial Phase (0-2 weeks) - Acute Management

Goals:

• Reduce pain and swelling
• Protect the injured ligament
• Prevent further injury

Treatment:

• RICE Protocol: Rest, Ice, Compression, Elevation Rest: Limit weight-bearing activities. Use crutches if necessary. Ice: Apply ice packs to the ankle for 15-20 minutes every 2-3 hours. Compression: Use an elastic bandage or compression wrap to control swelling. Elevation: Keep the ankle elevated above heart level to reduce swelling.
• Bracing or Splinting: Use an ankle brace or splint to stabilize the joint and allow healing.
• Pain Management: Over-the-counter NSAIDs (e.g., ibuprofen) for pain relief and to reduce inflammation.

2. Subacute Phase (2-6 weeks) - Early Rehabilitation

Goals:

• Restore range of motion (ROM)
• Begin strengthening exercises
• Improve proprioception and balance

Treatment:

• Range of Motion Exercises: Ankle Circles: Perform gentle circular motions with the foot. Alphabet Exercise: Use the big toe to write the alphabet in the air. Towel Stretch: Sit with the leg extended, loop a towel around the ball of the foot, and gently pull towards the body.
• Strengthening Exercises: Isometric Contractions: Press the foot against a wall or immovable object in different directions (e.g., dorsiflexion, plantarflexion). Theraband Exercises: Use resistance bands to perform controlled ankle movements (e.g., dorsiflexion, plantarflexion, inversion, eversion).
• Proprioception and Balance: Single-Leg Stance: Stand on the injured leg while maintaining balance. Progress to closing eyes or standing on an unstable surface (e.g., foam pad). Balance Board: Use a wobble board to challenge and improve balance.

3. Strengthening Phase (6-12 weeks) - Progressive Rehabilitation

Goals:

• Improve muscular strength and endurance
• Enhance dynamic balance and proprioception
• Begin functional activities

Treatment:

• Advanced Strengthening Exercises: Calf Raises: Stand on the edge of a step and perform heel raises. Resisted Ankle Movements: Increase resistance on theraband exercises. Step-ups and Step-downs: Use a small step to perform controlled step-ups and step-downs.
• Balance and Proprioception Training: Single-Leg Squats: Perform squats on the injured leg. Dynamic Balance Activities: Use balance boards or BOSU balls for more challenging exercises.
• Functional Activities: Agility Drills: Incorporate gentle agility drills like side shuffles, carioca steps, and figure-eight running. Plyometric Exercises: Begin with low-impact plyometrics like mini-hops and progress to higher-impact activities.

4. Return to Activity Phase (12+ weeks) - Advanced Rehabilitation and Maintenance

Goals:

• Restore full function and strength
• Prepare for return to sports or physical activities
• Prevent recurrence of injury

Treatment:

• Sport-Specific Drills: Implement drills and exercises that mimic the movements and demands of the patient's sport or activity.
• Advanced Plyometrics: Include exercises like box jumps, single-leg hops, and bounding.
• Continued Strength and Conditioning: Maintain a regimen of strength and balance exercises to support ankle stability.
• Gradual Return to Sport: Gradually reintroduce the patient to their sport, starting with low-intensity and progressing to full participation.

Monitoring and Follow-up

• Regular follow-up appointments to monitor progress and adjust the treatment plan as necessary.
• Objective measurements such as ROM, strength testing, and balance assessments to track improvement.
• Educate the patient on proper warm-up techniques, use of supportive footwear, and ongoing preventive exercises to reduce the risk of re-injury.

Additional Considerations

• Manual Therapy: Include mobilization techniques such as joint mobilizations and soft tissue massage to improve ROM and reduce scar tissue.
• Patient Education: Educate the patient on the importance of compliance with the rehabilitation program, proper technique for exercises, and strategies for injury prevention.
• Nutrition and Hydration: Advise on a balanced diet and adequate hydration to support the healing process.

The Second protocol

The second protocol is from a popular file and it's one of the best when it comes to the most well known problems in physiotherapy. You can access the link here

Conclusion

After more than 20 sessions, Ahmed fully recovered. His range of motion returned to normal, and his ability to perform exercises improved dramatically. Witnessing his progress from start to finish was incredibly rewarding. This case holds special significance for me as it was one of the very first I had the opportunity to treat.