Introduction
The patient, a 20-year-old female ballet dancer, presented with pain in the lateral ankle, particularly in the anterior lateral malleolus and on the calcaneus, and swelling. Patient was examined immediately after the injury occurred. Upon examination, there were positive tests for both the talar tilt test and the anterior drawer test; greater than 10˚ and 8mm respectively compared to the uninjured ankle. Weight bearing on the injured limb was not possible for more than two steps; the patient experience great pain and described the sensation of her ankle “buckling.” A history was taken; the patient described rolling her ankle after landing on a colleague’s foot, and stated that she has had a lateral ankle sprain (Grade I) in the past. Patient was referred for radiographic (x-ray) imaging to rule out fractures and other ankle injuries.
Patient was finally diagnosed with a Grade III ATF & CF ankle sprain. After radiographic and arthroscopic imaging was completed, it was determined that the rupture had occurred at the attachment point on the fibula for both ligaments9; an avulsion fracture was not found. Initial treatment performed on the patient consisted of the R.I.C.E. (Rest, Ice, Compression, and Elevation) method. Patient was wrapped with the foot in as much of a dorsiflexed position as could be tolerated, with u-shaped foam orthotics around both malleoli to help with compression and stability.
Patient was informed of her options regarding surgical and non-surgical treatments. In general surgical intervention in Grade III lateral ankles sprains is not recommend. This is because the end results of this injury are great regardless of which type of treatment is received, and that if instability is still found after functional treatment, surgery can be performed to fix the problem with equitable results to initially having had the surgery. There have been some studies that have indicated a decreased time of return to pre-injury activity levels with a combination of the surgical method and functional treatment. However, in the end the decision is made by the patient. After much discussion, it was decided that surgical repair of the ankle was the best option for this patient. The orthopedic surgeon reattached the ligaments to bone using the “anterior advancement method for rupture at bone attachment.”9 He prescribed immobilization for two weeks in a functional walking orthosis with a hinged ankle, a non-steroidal anti-inflammatory drug (NSAID) as needed for pain management.9
The patient’s rehabilitation is set to begin the second day after surgery. The rehabilitative process will take approximately 5-6 weeks, depending on the patient’s progress. It should be noted that it will take much longer for ligaments to completely heal. There will be four main phases. The first phase will be the post-operative phase; in this phase the main goal is to decrease joint effusion and pain, while increasing the amount of pain free range of motion (ROM) in the sagittal plane. During this phase as well as all other phases, the patient will be encouraged to walk as normally as possible with as much weight bearing as can be tolerated. It will also be very important for the patient to perform exercises that will help maintain her cardiovascular endurance and strength. The second phase will focus on gaining joint stability and begins at the two week mark, with the removal of the orthotic. The goals of this phase are to achieve full ROM in all planes of movement, as well as pain free weight bearing. Proprioception exercises and mild manual muscle resistance exercises will also be introduced in this phase. Techniques from the previous phase maybe used as needed. Phase three will focus on strengthening the joint. Phase four will focus on preparing the patient for a return to ballet.

Phase 1: Post-Operative (begins 2 days after surgery)

A. Goals: 1. Pain free and increased ROM 2. Decreased Swelling & Pain 3. Cardiovascular endurance and strength maintenance B. Therapy
1a. Continuous Passive Motion (CPM)
This exercise is carried out utilizing a CPM machine. The machine will passively move the patient’s foot through the pain free arc of their ROM in the sagittal plane (dorsiflexion and plantar flexion), at a controlled speed. This exercise will be used whenever the patient is not engaged in another activity, for at least 8 hours a day. The initial settings will be determined by the amount of pain free range of motion the patient has. The patient will be reassessed each day, and, if they are progressing well, the amount of movement will be increased a few degrees as tolerated.
1b. Passive Range of Motion (PROM): Towel Stretch
To perform this exercise, the patient should be long sitting with her feet off the table. A towel will be wrapped around the forefoot and the foot will be passively dorsiflexed. When stretch is completed the foot should return to the starting position. This exercise will initially be performed for 3 sets of 10 seconds, 3 times a day, 3 times a week. The length of the stretch will increase to as much as 30 seconds as long as the motion remains pain free.
1c. Wall Slides
Patient is lying supine on a table facing the wall. The patient slowly slide one of their feet up the wall, and back down to their starting position, then repeat with the other foot. This exercise will be performed 3 times a week for 5 minutes, as tolerated. Patient will progressively increase time as their pain declines.
2a. CPM
2b. RICE
2c. NSAIDs
Should be taken as prescribed by their physician, therapist does not provide.
2d. Electrical Stimulation
Electrodes are placed above and below the joint.
3. Upper Body Exercise: Hand Bike
The patient should perform this activity 6 days per week, for 30-45 minutes at an intensity of 60-90% of the predicted max heart rate (this can be found utilizing Karvonen Formula). In this case, the patient should be exercising at an intensity of 144-186 (Target Heart Rate, THR). C. Theory
1a./2a. CPM has many purposes. It prevents the loss of ROM because by keeping the joint in constant motion which prevents scar tissue from forming, and from muscle contractures (that result from a muscle being immobilized in a shortened position). The motion also increases the blood flow to the area, and a greater exchange of synovial fluid, which brings more nutrients and oxygen to the joint, this also in turn decreases joint effusion. The theory behind this being that as the joint moves, swelling is reduced (through constant motion) and perception of pain is decreased (via the Gate control mechanism), the patient will be able to achieve and greater pain-free range of motion.
1b.

D. Criteria for Advancement
Patient must have pain free ROM but not complete ROM in the sagittal plane, and no active joint effusion. E. Evaluation of Progress
Patient’s ROM (both pain free and active) will be measured using goniometry and bilateral comparison. At this time, only dorsiflexion and plantar flexion will be assessed. Joint effusion will be measured by girth measurements and bilateral comparison. Patient’s pain level will also be measured using the Comparative Pain Scale (1 being no pain and 10 being the worst pain).
Phase 2: Joint Stability (begins when the criteria for advancement have been met from previous phase, approximately week 2) A. Goals 1. Full ROM 2. Pain free weight bearing 3. Cardiovascular endurance and strength maintenance B. Therapy
1a. CPM (all planes of motion)
1b. Towel Stretch
1c. Spelling out the Alphabet
1d. Drawing circles with toes
1f. Manual Muscle resistance
2a. Incline board
2b. Proprioception exercises

C. Theory D. Criteria for Advancement E. Evaluation of Progress

Phase 3: Joint Strengthening

A. Goals B. Therapy C. Theory D. Criteria for Advancement E. Evaluation of Progress

Phase 4: Functional

A. Goals B. Therapy C. Theory D. Criteria for Advancement E. Evaluation of Progress

Conclusion

The patient’s prognosis is great. She should