"Can I play yet?"
I treat a lot of high school athletes. Besides “Do I have to”, the second most common question from them is, yup you guessed it, “When can I play”. I don’t necessarily dislike this question; it makes me assess, and evaluate, and it keeps me on top of my game. However, one group in particular seems to utter these words more often than others; patients with ankle sprains.
Inversion sprains, or lateral ankle sprains are the most common type of ankle sprain, with the ATFL
being the most involved structure. Some other tissues often involved include the deltoid ligament
and the peroneals
. Once tissue integrity is assessed, and it is determined that the patient is appropriate for rehab, a likely course of stabilization, strengthening, proprioception/balance, and stretching exercises will be prescribed for the ankle and possibly the hip, along with appropriate modalities such as GameReady
Once swelling and pain decrease, proprioception is likely to improve greatly, leading to improved balance, most likely around the 2-4 week mark. At this point, I will usually begin hearing that familiar song of “When can I play”. Even at 4-6 weeks post-injury, tissue healing is probably not complete and care must be taken during all exercises, especially dynamic balance, to prevent reinjury.
At this point I don’t really care how long this demographic can stand on one leg compared to the other, mostly because they will hardly do this during their day, and especially during a sport. I am still having trouble thinking of a sport where one must balance for more than a few seconds on one leg without moving. Therefore, in my ankle sprain programs, dynamic stability and balance are MORE crucial than static balance. Single leg stance should still be evaluated to assess balance strategies such as ankle vs. hip vs. stepping, but this is only a minor piece to the puzzle (especially in this demographic).
For me, initial (static) balance activities are advanced to dynamic ones once single leg balance with front to back and side to side kicks are able to be held 80% of the uninvolved leg’s time (up to one minute), and balance strategies are the same side to side. Beginning dynamic stability/balance activities include single leg balance while performing simple skills required of the athlete’s sport, heel-to-toe walking, and skater walks. Moderate exercises include double leg hops front to back and side to side with stuck landings, walking lunges, and side shuffles. Finally, high level exercises include plyo’s, running, and assessment of sport skills such as decelerating, cutting, pivoting, landing, and bounding.
The overall goal before I answer “yes” to “when can I play” is having both sides be equally strong while performing the above sport skills. If proprioception is impaired in the ankle, then everything above in the kinetic chain is at risk (especially the ACL); therefore, just because an athlete feels “fine” it is still important to use caution when working with patients with ankle sprains.
**On a side note: The first injury that sent me to PT was an inversion sprain (while landing on a friends foot), which I feel my PT did not take “seriously”. She sent me back long before I was ready. Coincidently, I ended up back in PT 3 weeks later after re-spraining the same ankle while laterally shuffling, and without stepping on someone’s foot.**