In any sport, injuries occur. This is going to happen no matter what is done in the off season and pre-season to prepare for the regular season. This is no different for soccer.
Over the past 25 years I have noticed a distinct disconnect with clinical clearance in relationship to return to play.
Let me take you through a through a step by step plan with an ankle sprain from initial injury to rehab in a clinic setting to clearance on the field. Please keep in mind this a general overview.
A laterally sprained ankle occurs when one or more of the ligaments on the outer side of your ankle are torn. If a sprain is not treated properly, you can have long-term problems.
Typically the ankle rolls either inward (inversion sprain-most common type of sprain) or outward (eversion sprain). Inversion sprains cause pain along the outer side of the ankle.
The foot is usually in a position of pointing down (plantar flexion) and turned in (inversion). Weight on the foot in this position causes tension within the ligaments.
Too much or a sudden force with the foot in this position will to lead an inversion ankle sprain. In soccer we see this when a player stops to change direction and the foot gets caught in rut or landing on another player’s foot after attempting a header.
Basic Classification of Ligament Sprains
When this happens, one, two or three of the lateral ligaments will or tear. Actually it is micro treating. Let say for example there a 1000 fibres that make up a ligament.
If you have a mild sprain or grade 1 sprain let’s say 250 of those fibres tear in half.
If you have moderate sprain then 500 fibres are torn.
A grade three or severe sprain would be more than 500 fibres tearing.
A complete tear would mean that all the fibres are torn.
In the process of the ligaments being stretched and torn there is a loss of balance sensors located in the ligaments. These help the body know its place in space in at an unconscious level.
Immediate Treatment
P. I.E.R.
Pressure – reduces the swelling in the area and gives support.
Ice- slows down the inflammatory process.
Elevation – helps reduce swelling and gets blood flowing to the heart (increase venous return).
Rest or Restricted Activity – prevents unwanted movement at the ankle.
Next step is to go for therapy /clinical rehab.
Clinical Rehabilitation 4 Phases
Phase 1 Assessment
At the clinic the initial assessment entails a case history, postural assessment, gait assessment and functional testing of the ankle joint.
The case history includes but is not limited to the following questions: What is your chief complaint? Can you point to the area of pain? Can you tell me what makes it worse? What makes it better? Have you seen a doctor? Have you injured it before? What have you done for it since you injured it? How long ago did this happen?
Next if possible the therapist will have walk or have you stand. Following this the therapist will test your range of motion. He /she will see if you can move the foot up or down and side to side. They will then test your strength and possibly do a few more tests.
Once the assessment is complete your therapist will create a rehabilitation program for you that should include flexibility, strength for the ankle joint, balance / proprioception and return to play movements.
Phase 2 Protection Phase
Initial treatment may include modalities like ultrasound, laser and PIER to help with swelling, muscle setting exercises and pain free active range of motion exercises like moving the ankle up (dorsiflexion) and to the outside (eversion). These need to be done in a clinic setting with a home program to do away from the clinic when not being treated.
In this phase the focus is to decrease, remove swelling and maintain the current range of motion at the ankle.
Phase 3 Controlled Motion Phase
In this phase the goal is to regain normal range of motion, flexibility and the introduction to weight bearing and balance exercises.
Stretching the calf muscle and actively moving the ankle in all directions.
At this point if the ankle is supported the athlete may get on stationary bike and do 30-45 minutes of work to maintain a basic level of fitness.
Phase 4 Return to Function Phase
In this phase the goal is to integrate total body strength and power exercises such as lunges, squats, single and double hops / jumps in different directions and agility exercises that mimic the movements on the sports field such as stop starts and change of direction.
This phase also includes appropriate interval training to regain pre-sport fitness levels. Ideally this should be ground based; however this may be done a bike.
At this point the athlete may be braced or taped depending on the severity of the injury.
It is in this phase that the athlete may return to the field to do isolated agility drills, stop starts and change of direction.
Field Clearance – 2-3 Phases
Now that the athlete has gone through the four phases of clinical rehabilitation they need to be active and start training on the field. Some players my go straight to phase 2.
Phase 1 – This may happen at the same time as phase 4 in the clinic.
- FIFA 11 WARM UP – If they cannot do the FIFA 11 warm up then they do not proceed to the next step.
- Walking through and around cones without the ball first to see if there is any tenderness any or limping.
- Next dribbling through and around cones with a ball without any tenderness or limping
Phase 2 – U12 and Younger Must Occur on the Field
- Must be able to jog then sprint 20 yards five time
- Jump land sprint 5 yards to the left 3 times
- Jump land sprint 5 yards to the right 3 times
- Change of direction with acceleration – Left 5 times – with and without the ball
- Change of direction with acceleration – Right 5 times – with and without the ball
- Neutral or full contact practice depending on the results of the testing.
There must not be any pain, soreness or change IN RUNNING MECHANICS (IE-LIMPING) in order to proceed to be cleared to play. Players need to able to play full out without any issues before returning to games.
Phase 2 – U13 to u15 Players Must Occur on the Field
- FIFA 11 WARM UP – If they cannot do the FIFA 11 warm up then they do not proceed to step 2
- 20 minute jog 75% Effort
- Jump land sprint 5 yards to the left 3 times
- Jump land sprint 5 yards to the right 3 times
- Change of direction with acceleration – Left 3 times
- Change of direction with acceleration – Right 3 times
- Practice as a neutral player
There must not be any pain, soreness or change IN RUNNING MECHANICS (IE-LIMPING) in order to proceed to the next step.
Phase 2 – U16 and up Players Must Occur on the Field
- FIfa 11 WARM UP – If they cannot do the FIFA 11 warm up then they do not proceed to step
- 20 minute jog 75% Max heart rate
- Jump land sprint 5 yards to the left 3 times
- Jump land sprint 5 yards to the right 3 times
- Change of direction with acceleration – Left 3 times
- Change of direction with acceleration – Right 3 times
- Practice as a neutral player
There must not be any pain, soreness or change IN RUNNING MECHANICS (IE-LIMPING) in order to proceed to the next step.
Phase 3 – U13 to u15 Players Must Occur on the Field
- FIFA 11 WARM UP – If they cannot do the FIFA 11 warm up then they do not proceed to step
- Five minutes jog 75% target heart rate,
- 15 minutes of internals box routine – 20 seconds on -40 seconds off sprint forward 15 yards, side to side 15 yard lead with the right foot , Backwards 15 yards, side to side 15 yards lead with the left foot
- Jump – land- sprint 5 yards to the left 3 times
- Jump- land- sprint 5 yards to the right 3 times
- Change of direction with acceleration – Left 3 times
- Change of direction with acceleration – Right 3 times
- Full contact practice.
Going through this return to play field requirements gives the player the confidence that they are ready to return to compete in a game.
Phase 3 – U16 and up Players Must Occur on the Field
- FIFA 11 WARM UP – If they cannot do the FIFA 11 warm up then they do not proceed to step
- 10 minute of internals box routine – 30 seconds on -40 seconds off sprint forward 15 yards, side to side 15 yard lead with the right foot , Backwards 15 yards, side to side 15 yards lead with the left foot
- Jump land sprint 5 yards to the left 3 times
- Jump land sprint 5 yards to the right 3 times
- Change of direction with acceleration – Left 3 times
- Change of direction with acceleration – Right 3 times
- Full contact practice.
There must not be any pain, soreness or change IN RUNNING MECHANICS (IE-LIMPING) in order to be cleared to play..
The Disconnect
The two most common things I see are that parents and players do not want to go for therapy and if they do, they do not want test themselves on the field before going straight into full practice or game.
Disconnect 1 – No Therapy
This disconnect occurs after the initial injury.
One of the most common comments I hear is “there’s only a bit of swelling and he /she can walk on it. We’ll rest for a week then return.”
There are couple of problems with this. First since they are going to rest it there will be a lot of scar tissue formed. Scar tissue carries a lot of pain sensitive fibres and is not as strong as the original ligament. The ankle is now less stable than before.
Next the ankle also lost some “balance sensors”. This means the ankle will be slower to react to any change of direction or sudden stop and go action. This makes it more likely that the player will turn or roll the ankle again and this time with more damage!
Disconnect 2 – Skip The Field Work
The next disconnect occurs when athlete returns from the clinic without participating in any field work and expects to go straight into full practice.
In many cases the player has gone to therapy given modalities like ultrasound and laser with a few exercises and are sent on their merry way. Unfortunately for them there has been no retraining of the movements the body does on the field nor has there been any type of conditioning given to the player.
Lack of fitness leads to fatigue that leads to more stress on the ligaments to dynamically stabilize the ankle Joint.
Since there has been no retraining for the ankle it is very susceptible to twisting again.
What most people do not know is that it takes almost a full year for the ligament or ligaments in the ankle to 100% healed.
While it is possible for everything to be fine in a clinic it does not account for the surface, amount of time of a practice, being around other people, the ability to react to different game situations or the fitness needed to compete.
This is why it is necessary to go through all the steps. Injuries are part of the game and proper rehabilitation from the clinic to the field is essential to prevent long term consequences.