**5.1 Reduce pain and swelling**

### *5.1.1 Rest*

*Essentials in Hip and Ankle*

bility are markedly abnormal.

**3. Chronic ankle instability (CAI)**

instability or a combination of both [6].

and proximal tibiofibular joint [7, 8].

**5. Rehabilitation**

**4. Mechanical and functional instability**

three clinical grades of lateral ankle sprains [4–6].

ligaments. The most common mechanism of injury in lateral ankle sprains is when, in forced plantar flexion, inversion occurs with excessive ankle supination. In that position the ankle joint is the most unstable. In the course of the inversion, the body's center of gravity moves over the ankle leading to ankle sprains [2]. There are

Grade I—Mild. There is an incomplete tear of ATFL with little swelling and tenderness, minimal or no functional loss, and no mechanical joint instability.

Grade III—Severe. Complete tears of ATFL and CFL with marked swelling, hemorrhage, and tenderness. There is loss of function, and joint motion and insta-

some joint motion is lost, and joint instability is mild to moderate.

Grade II—Moderate. Complete tear of ATFL with or without an incomplete tear of CFL with moderate pain, swelling, and tenderness over the involved structures;

Athletes with chronic ankle instability give a history of two or three severe ankle sprains with the main complaint being intermittent giving out of the ankle. The athlete often complains of difficulty and apprehension on uneven surfaces. Even mild exacerbations lead to short-term dysfunction. It is characterized by residual ankle instability as a result of either mechanical ankle stability or functional ankle

Mechanical instability (MI) and functional instability (FI) are both due to recurrent lateral ankle sprains. Mechanical instability is defined as an increase in the accessory movements in the joint leading to hypermobility. Residual MI usually results from a tear or lengthening of one of the ligamentous structures supporting the joint and suggests a suboptimal healing process after injury. A lesser known phenomenon is hypomobility leading to ankle instability. Joint hypomobility can be intra-articular or extra-articular, giving rise to restricted range of motion at the ankle. Hypomobility occurs at the subtalar, talocrural joint, distal tibiofibular joint,

As the joint develops MI, proprioceptive changes occur, which result in alterations in defense mechanism to prevent injuries, thus leading to CAI. FI can result in balance deficits, joint position sense deficits, delayed peroneal muscle reaction time, altered common peroneal nerve function, strength deficits, a decreased range of motion (ROM), sinus tarsi syndrome, and anterolateral impingement syndrome.

Early mobilization of ankle sprains as compared with cast immobilization has been shown to be more comfortable as it results in less pain and provides for an earlier return to work. Cast immobilization does not improve healing compared with an active mobilization rehabilitation program and may have negative implications in relation to muscle wasting and stiffness. Functional treatment is considered

better in achieving more effective mobilization and an earlier return to daily activities. Lateral ankle sprains respond well to the conservative treatment which includes initially RICE—rest, ice, compression, and elevation—followed by early

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Rest is prescribed to avoid undue stress on the joint. It is required to reduce the metabolic demands on the injured tissue and thus avoid increased blood flow. It also helps in avoiding stress on the injured tissue that might disrupt the fragile fibrin bond, which is the first element of the repair process. Rest can be applied selectively to allow some general activity, but athletes must avoid stressful activities.

### *5.1.2 Ice*

Cryotherapy involves a nice bath with a temperature of 4°–10°C for 12–20 min, one to three times per day, and applying an ice pack to the injured area for 15–20 min, one to three times per day. Ice therapy should be started immediately after the injury and ice application initiated within day 0 or day 1. Both have shown better results and return to full activity as compared to when the ice was applied after 48 h. Ice application should provide deep penetration to gain full benefits. Also the ice should not be held immobile in one area or frostbites may occur.

Ice application causes vasoconstriction which decreases blood flow and therefore swelling to the injured area. The lowering of tissue temperature decreases the metabolism and the chemical actions of cells and thus lowers the oxygen and nutrient needs in the affected area. Decreased blood flow limits edema; there is less histamine release and therefore less capillary breakdown than would normally be present after injury. There is better lymphatic drainage from the injured area because of the lower pressure on the extravascular fluid (**Table 1**).

Hence, the rationale of minimum 15 min of cryotherapy per treatment.

#### *5.1.3 Compression and elevation*

Compression and elevation work better in combination with cryotherapy. Compression with an adhesive bandage and a foot elevation of more than 45° is the standard prescribed treatment for lateral ankle sprains. Compression can also be

