-Spell the alphabet slowly with affected ankle, motions should be pain free. 2x/hr. Discontinue if symptoms worsen.

Rehab: Restore proper range of motion, strength, proprioception and balance = return to preinjury function and reduce the likelihood of chronic ankle instability

For the most common type of ankle sprain (lateral ankle sprain).

-Start with gentle PROM administered by the provider, 3 sets of 10 with 3-5 second holds at end range, with care taken to avoid additional damage to the injured ligament.

-The patient themself can do AROM 1-3 sets of 15 reps 3 times a day, but avoid directions that could damage the injured ligament, especially in the case of a severe sprain

- Stretching the achillies tendon can also be beneficial especially if the foot is imobilized, to maintain range of motion in the ankle.

- Long term goals are to restore normal stride biomechanics, reduce pain, and restore ability to perform ADLs. If the patient is an athelete we would be seeking to return them to play.

-To measure these outcomes, we would assess the patient during our initial visit and followup visit using ROM, the OPS pain scale, and the PSFS. We would also observe the patient's gate and posture, noting if they limp or if they have an antalgic posture.

Another exercise you can do to strengthen your core is the dead bug. You would do this by laying on your back with your legs bent to 90 degrees, and arms extended towards the ceiling. We will want to make sure that the core is always engaged to make sure that the low back stays against the floor. Then you will slowly lower your right arm and left leg towards the floor with your core kept tight. Then return them both to the starting position and do the same with the other side. Aim for 8-12 reps per side.

Lastly, another exercise one may do is the plank. You will start by laying face down with your elbows right under your shoulders. Then you will use this position to push your body up, keeping a straight line from your head to your toes. You can do this by making sure that your core is engages and that your glutes do not go too high or too low. Hold this position for 20-60 sec while continuing to breath. Then come back down when you are down and repeat as many times as you can. Aim to do this exercise 2X/day.

The mechanism begins with an acute overextension or excessive load on the lumbar musculature, often caused by sudden movements, improper lifting techniques, or repetitive strain. In response to tissue damage, the body releases pro-inflammatory mediators such as prostaglandins, histamine, and cytokines, which increase vascular permeability and attract immune cells to the site of injury. The inflammation leads to localized swelling, pain, and increased sensitivity of nociceptors which end up amplifying the perception of pain. The nervous system then initiates a muscle spasm causing involuntary contractions of the surrounding musculature in hopes of preventing further injury from occurring in the affected area. Although this is a protective mechanism, it can contribute to prolonged stiffness and dysfunction in the lower back. Excessive or repeated strain can lead to fibrosis and scar tissue formation, reducing flexibility and increasing the risk of future injury.

Heel raises progression: start with bilateral (double) heel raises with the patient holding onto something for balance and decreased load. Start with 10x 1/day. Once the patient can do 20 without pain, move to single leg heel raises (still holding onto something). Once they can do 20 of those without pain, remove the support. Next step is to perform it on a slant board or a stair which would let the heel drop into a stretch). Next would be heel walks and toe walks. The final step in the progression is heel raises with 3-4 hops.

Always make sure it isn't painful. Discomfort is okay, but if it lingers or is actually painful, the patient should stop the exercise and go back to the pain free step.

• How to: Sit or stand with a straight back and shoulders, while placing one arm behind in the arch of your back to help stabilize. With the other hand, gently pull your head towards one shoulder until you feel a stretch on the side of your neck. Hold this position for 15-30 seconds and repeat on the other side. repeat this process once every hour.

• Benefit: The upper trapezius muscles are commonly tight after whiplash traumas; this stretch will help to decrease neck stiffness and pain caused by this agitated muscle.

• How to: sit up straight with your back, shoulders and neck in a neutral position. Place the palm of your hand against your forehead and gently push your forehead into your hand while applying pressure back with your hand to keep your head still. Hold this for 10 seconds and then relax. Repeat this on the right and left side of your head as well as the back of your head. Repeat this about 3 times a day

• Benefit: This exercise strengthens the deep muscles of the neck without exposing it to excessive motion, which is ideal for whiplash recovery.

To perform: Find a comfortable spot where the feet can be flat on the floor. Put the foot about halfway onto a small towel on the floor. Keeping the heel on the ground, curl the toes to pull the towel towards you scrunching it up. Continue this motion until the you have scrunched up the whole towel and there isn't any more to pull.

Another way to start is to have them do 10 reps, 3x/day and work up to curling the whole towel. Changing towel size could also increase the difficulty as well when tolerated.

Outcome Measure – OPS Scoring

CMT and STM manual therapies can effectively help treat and reduce reduce neck pain and stiffness. Applying heat and ice, along with the use of NSAIDs can also assisting in treating acute pains and improve a patients’ therapeutic outcome.

Goal 2: Increase Mobility & Flexibility

Outcome Measure – Cervical AROM/PROM Assessment

Gentle stretching and mobilization techniques can be utilized to return cervical ROM to normal limits. Such practices can also help alleviate muscular tension in the neck, shoulders and upper back and assist in reducing pain with fast, unguarded movements.

Goal 3: Improve Strength & Stability

Outcome Measure – PSFS Scoring

Strengthen the deep neck flexors and the upper back muscles via home care and rehabilitation exercises as well as conditioning core stability to help reduce overwork of the neck during ergonomic and prolong postural activities.

Nociceptive response from peripheral nerve irritation and central sensitization of the nervous system also occurs. As such, this level of dysfunction may also lead to decreased proprioception, which often presents symptoms of dizziness, muscle imbalances/hypertonicity, and increased ANS reactivity. Psychological speaking, anxiety and stress will increase nociception and tighten the muscles as well. All these factors add to the delay in the normal healing process.

The presentation of chronic whiplash can be highly variable. Therefore, compliance to a personalized treatment plan of manual manipulation therapies, cervical rehabilitation exercises, and nerve desensitization techniques are recommended.

• How to: Sit up straight with your arms at your sides. squeeze your shoulder blades back and down as if you were trying to pinch something between them. Hold for 10 seconds then release slowly. Perform 3 sets of 10 twice a day.

• Benefit: This strengthening exercise targets the muscles in the upper back and shoulders, which will help improve posture and relieve shoulder and neck tension.

• How to: Begin on your hands and knees with a neutral spine. I would then follow the bird-dog progressions with this patient, but in this case, I will stop at raising their arm and extending the contralateral leg while maintaining a level back, pelvis and neck. I will have them hold this position for a couple of seconds and then repeat on the other side. I would like to see the patient perform 10 reps on each side 2 time a day.

• Benefit: This exercise strengthens the core and the back, and promotes strength and stability of the entire spine, which can help to decrease the strain put on the neck and the upper back.

• How to: Sit or stand up straight with your feet hip-width apart. Place your hands behind your head with your elbows to the side. Gently arch your upper back backwards by opening up your chest and bringing your elbows slightly back. Hold this for 15-30 seconds, and repeat this 3-5 times a day

• Benefit: This stretch is helpful for improving spinal mobility and counteracting the rounded posture that can develop from neck pain.

• How to: Begin by either sitting or standing with a straight back and shoulders. next, gently tuck your chin towards your chest, as if you were trying to give yourself a double chin but make sure you aren't tilting your head down too far. Hold this for 10 seconds and then return to starting position. Repeat this 10 times for a total of 3 sets/day

• Benefit: This stretch will target the deep muscles in the neck and improve posture, which will decrease the stress put on the neck.

However if the patient can tolerate it we would recommend that the patient perform isometric exercises to help maintain functionality in the ankle. Or other low ankle impact exercises such as stationary cycling may be recommended.

We also would want to examine all of the biomechanics of the patient and may prescribe strengthening based on those even before giving targeted exercises for the ankle. For example if the patient sustained their injury due to an imbalance in their gate related to the hip muscles, then we could and likely would give them exercises to improve their biomechanics in order to protect them from future sprains. It is also likely that the patient will be able to perform hip exercises without pain or much risk of injury to the foot.

Generally once the patient can bear weight on the ankle, or when they enter the "subacute" phase, that is when we want to start our primary strengthening program. Generally in almost all ankle injury cases the calf muscles are a primary target for strengthening and stretching. Ankle stabilizors and intrinsic muscles of the foot.

Exercises we would recommend would include toe crunches, heel raises, and general strengthening of hip muscles. We would likely ask the patient to perform heel raises 10 reps, 3 times a day as tolerable.

After the patient is able to perform basic exercises without pain we would increase the difficulty and move into performing resisted ROM motions with the foot, proprioceptive training, and sensorymotor exercises. Specifically we would transition them to using a balance board if able or other devices which offer a slanted surface.

In the third phase of our program we would transition into having the patient run and possibly jump. If they have sport specific requirements we would transition into those activities as well. The third phase would be scaled to the abilities of the patient.

Grades I and II result in microscopic tears in the stabilizing ligaments of the ankle. Grade III sprains involve comprimization of the syndesmotic structions and or complete tears of the ligaments with the possibility of fractures.

Most commonly the Anterior Talofibular Ligament (ATFL), and the Calcaneofibular ligament (CFL) are sprained in the foot. These are associated with an inversion sprain/lateral ankle sprain. ATFL is the weakest ligament in the lateral complex. The Posterior Talofibular (PTFL) is the least commonly injured ligament in a lateral ankle sprain.

The Deltoid ligament is less commonly sprained as it is the strongest of the ankle ligaments. It is injured during an Eversion/medial ankle sprain.

A high ankle sprain involves injury to the ligamentus structures of the tibia and fibula at their distal end. The syndesmotic ligaments which hold them together are injured and usually involve more trauma, and can occur in conjunction with other ankle sprains. These are almost exculsively seen in sport settings given the force required for injury. Most commonly these occur during external rotation and/or ankle dorsiflexion.