gms | German Medical Science

7th EFSMA – European Congress of Sports Medicine, 3rd Central European Congress of Physical Medicine and Rehabilitation, Annual Assembly of the German and the Austrian Society of Physical Medicine and Rehabilitation

Austrian Society of Physical Medicine and Rehabilitation

26.-29.10.2011, Salzburg, Österreich

A novel approach to acute ankle sprain alphabet exercises

Meeting Abstract

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7th EFSMA – European Congress of Sports Medicine, 3rd Central European Congress of Physical Medicine and Rehabilitation. Salzburg, 26.-29.10.2011. Düsseldorf: German Medical Science GMS Publishing House; 2011. Doc11esm094

doi: 10.3205/11esm094, urn:nbn:de:0183-11esm0948

Veröffentlicht: 24. Oktober 2011

© 2011 Konin et al.
Dieser Artikel ist ein Open Access-Artikel und steht unter den Creative Commons Lizenzbedingungen ( Er darf vervielfältigt, verbreitet und öffentlich zugänglich gemacht werden, vorausgesetzt dass Autor und Quelle genannt werden.



Objective: Despite the fact that several peer-reviewed articles and a myriad of other lay sources recommend the ankle alphabet exercise as an effective and safe rehabilitation modality, none of these sources to our knowledge have reported on the effectiveness of the specific exercise itself. It is well accepted amongst clinicians that lateral ankle sprains that occur as the result of an inversion movement comprise the majority of the mechanisms associated with overall ankle sprain injuries. The anterior talofibular ligament (ATFL), and the calcaneofibular ligament (CFL) are the two main ligamentous soft tissue structures located on the lateral aspect of the ankle that undergo tension with associated triplanar motion that includes inversion, adduction, and plantar flexion. After reviewing the directional movements associated with routine ankle alphabet exercise routines, it appears to us that a large portion of the letters of the alphabet when “spelled out” lend themselves to positions directed in the same pattern as that of the mechanism of injury, most likely placing the injured ligaments on further tension. This in turn would lead to increased pain and discomfort associated with the directional movement toward associated ligamentous instability, particularly in the acute phases of rehabilitation.

Material/Methods: We developed a quadrant configuration that sought to duplicate the starting position, directional movement, and ending position of the ankle while performing the alphabet exercise for each individual letter. While viewing the quadrant from an anatomical position, the four sections can be referred to as upper left (UL), upper right (UR), lower left (LL), and lower right (LR). Furthermore, each quadrant can be visually converted to reflect anatomical movement directional terms, with the upper quadrants relating to dorsi flexion and the lower quadrants relating to plantar flexion. Similarly, the left and right quadrants represent inversion and eversion movements, depending upon whether one is assessing the left or right ankle. 13 volunteer certified athletic trainers with experience ranging 1–24 years participated in the study. Each was familiar with the alphabet exercise protocol and was provided verbal directions to complete the alphabet grid provided with each letter in a quadrant format.

Results: After performing the various movements associated with the alphabet exercise protocol for each letter, it was discovered that many letters involve movements that recreate the mechanism of ankle injury, potentially leading to increased pain and ankle instability (Tables 1a-d). Some letters, furthermore, demonstrated movements in all quadrants. Letters to avoid for all ankle sprains while performing alphabet exercises: A C D E G O P Q R S X Z.

Conclusion: In accordance with our theory that some letters of the alphabet serve to promote a safer environment for early phases of rehabilitation associated with an acute ankle sprain, other letters when performed as part of the acute phase would likely not promote a comfortable scenario for one to exercise within. Ironically, certain letters, when drawn with the ankle, actually cross into all four quadrants. While in sub-acute and advanced progressive phases of rehabilitation a gradual increase of tensile force to the healing ligament and proprioceptive movement in direction of the unstable position may serve to facilitate a protocol toward optimal recovery, it is our recommendation that these letters be used with caution or even avoided altogether from an alphabet exercise program during the acute phase. The timeframe for which such directional movements should be added to a person’s rehabilitation protocol should always be person specific and consider all of the possible factors associated with the injury and the goals of return to participation.


Anandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle injuries. Br J Sports Med. 2005;39:e14.
Fong DT, Chan YY, Mok KM, Yung P, Chan KM. Understanding acute ankle ligamentous sprain injury in sports. Sports Med Arthrosc Rehabil Ther Technol. 2009;1:14.
McKeon PO, Mattacola CG. Interventions for the prevention of first time and recurrent ankle sprains. Clin Sports Med. 2008;27:371-82, viii.
Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of ankle sprains. Am Fam Physician. 2001;63:93-104.