Nathan McNeil, MD
CAQ in Sports Medicine
Anatomy
AJR Am J Roentgenol 138:683, 1982
Dwight Freeney
Injured right ankle in AFC championship
game
 He’s been in a walking boot all week
 Reports are that he has a torn ligament
on the lateral (outside) part of his ankle
 He’s been using Hyperbaric oxygen
treatments as well as an “ARP device”

Lateral Ankle Sprains
The Anterior talofibular
ligament (ATFL) is the
most common ligament
injured.
 The Calcaneofibular
ligament (CFL) may also
be injured
 The injury is graded
from I-III based on laxity
(instability), swelling and
pain with weightbearing.
 Caused when an athlete
inverts (rolls inward) his
ankle

High Ankle Sprains


Less common injury
caused by eversion
(roll outward) and
external rotation of the
ankle
The force gets
transferred through
the syndesmosis
(intraosseus
membrane) and the
tibiofibular ligaments
that hold the tibia and
fibula together.
High Ankle Sprains


This injury is much
more serious because
it may result in
diastasis (spreading)
of the ankle joint with
weight-bearing.
Depending on the
severity, it may be
treated with
syndesmotic screws
(figure to left) or
casting and crutches
www.wheelessonline.com
Discussion




Dwight Freeney appears to have the less
serious lateral ankle sprain
Compare to Terrell Owens who had a severe
variation of the “high ankle” sprain associated
with a fibular fracture called a Masionneuve
injury.
According to ESPN reports Dwight Freeney
has a grade III (complete ligament tear) injury.
He is currently listed as questionable and his
ability to play is dependent on his ability to
regain stability, strength and pain-free motion
Discussion--Rehab
According to reports from ESPN, Dwight
Freeney has been using hyperbaric oxygen
treatments as well as an ARP device.
 Hyperbaric oxygen therapy uses increased
oxygen concentration and pressure in a
chamber

 It’s typical application is for treatment of a diving
side effect called decompression sickness or
“the bends”
 It’s also commonly used to promote wound
healing, particularly with anaerobic infections
Discussion--Rehab

To date, there is no convincing evidence that hyperbaric oxygen
therapy helps ankle sprains

A randomized double-blind study of 32 subjects with acute ankle sprains to
compare treatment with hyperbaric oxygen at 2 atmospheres absolute pressure (N
= 16) (treatment group) with treatment with air at 1.1 atmosphere absolute pressure
(N = 16) (control group) in a hyperbaric chamber. Each group received three
treatments at their respective pressures : one for 90 minutes and two for 60
minutes each. Mean age, severity grade, and time to treatment (treatment group,
34.3 ± 6.3 hours; control group, 32.6 ± 4.6 hours) were similar in both groups. Joint
function measured by a functional index improved from 0.40 ± 0.2 to 6.3 ± 0.4 with
hyperbaric oxygen and from 0.8 ± 0.3 to 5.3 ± 0.6 with air. The change from initial to
final evaluation was significantly greater in the treatment group. Foot and ankle
volume by water displacement decreased from 1451 ± 57 ml to 1425 ± 63 ml with
hyperbaric oxygen and from 1403 ± 50 ml to 1371 ± 45 ml with air (no difference
was noted between hyperbaric oxygen treatment and air treatment using a two-way
analysis of variance). Subjective pain index fell from 3.3 ± 0.5 to 0.8 ± 0.3 with
hyperbaric oxygen and from 2.6 ± 0.3 to 0.3 ± 0.2 with air. No differences were
noted in passive or active range of motion when comparing hyperbaric oxygen
treatment with air treatment. Time to recovery was the same in both groups
(treatment, 16.0 ± 6.3 days; control, 15.4 ± 2.8 days). Regression analysis to
determine the influence of time to treatment, initial severity of injury, hyperbaric
oxygen, and age showed no effect of hyperbaric oxygen treatment on time to
recovery.
Am J Sports Med September 1997 vol. 25 no. 5 pp 619-625
Discussion--Rehab
The ARP device that Freeney is using is
a form of electrical stimulation.
 In general, electrical stimulation is
thought to relieve pain and inflammation,
strengthen muscle, and reduce
abnormal muscle tone.
 However, there is no good evidence that
it significantly contributes to faster
rehabilitation

PHYS THER Vol. 87, No. 1, January 2007, pp. 53-65
Ankle Rehab Evidence

A review of effective treatments published in 2008



They asked which intervention(s) best augment early mobilization and external
support after an acute ankle sprain?
What is the most appropriate method of preventing re-injury?
Design: A systematic review of randomized controlled trials published from 1993 to
April 2005. Participants: People with an acute ankle sprain. Intervention: Any
pharmacological, physiotherapeutic, complementary or electrotherapeutic
intervention added to controlled mobilization with external support. Immobilization,
surgical intervention, and use of external ankle supports in isolation were excluded.
Outcomes: Pain, function, swelling, re-injury, and global improvement; assessed at
short, intermediate, and long-term follow-up. Results: 23 trials were included with a
mean PEDro score of 6/10. There was strong evidence that non-steroidal antiinflammatory drugs can reduce pain and improve short-term ankle function. There
was moderate evidence that neuromuscular training decreases functional instability
and minimizes re-injury; and that comfrey root ointment decreases pain and
improves function. There was also moderate evidence that manual therapy
techniques improve ankle dorsiflexion. There was no evidence to support the use of
electrophysical agents or hyperbaric oxygen therapy. Very few long-term follow-ups
were undertaken, and few studies focused on preventing long-term morbidity.
Conclusions: Non-steroidal anti-inflammatory drugs, comfrey root ointment, and
manual therapy can significantly improve short-term symptoms after ankle sprain,
and neuromuscular training may prevent re-injury. More high quality studies are
needed to develop evidence-based guidelines on ankle rehabilitation beyond the
acute phases of injury management
Australian Journal of Physiotherapy. 54(1):7-20, 2008
Conclusion
Dwight Freeney is a right DE, thus he will
need to push off his right ankle to attack
Drew Brees
 At present time, there is no evidence that
ARP or hyperbaric oxygen therapy will
significantly increase his chance of faster
recovery
 By playing, it’s unlikely he will risk
significant further injury; however, his
explosiveness and mobility will be
decreased
