Ankle sprains are the most prevalent injuries in leisure and competitive sports, particularly in football, basketball, handball, and beach soccer [1-2].  During sporting activities, any sprains may enhance the wrist's range of motion and result in tissue damage, haemorrhaging, oedema, and tenderness, which are classified as sprained injuries; however, it should be noted that this damage is not entirely remedial and may be irreversible [3-4].  Scientific data indicates that around 10 to 28 percent of all sports injuries and 86 percent of ankle injuries are classified as sprains [5]. Ankle sprains often occur in sports that include leaping and lateral motions [6]. Several variables render the ankle vulnerable to re-injury in individuals with a history of ligament strain, including muscular weakness, limitations in ankle movement, and heightened sensitivity of receptors inside the ankle joint ligaments [4].  Joint receptors interfere with the transmission of collective sensory signals, thereby diminishing the messages sent from the impacted joint to the afferent pathways and affecting the functionality of deep receptors [7-8].  Functional ankle instability often arises as a common consequence after an ankle injury [9]. The joint capsule and external ligaments of the ankle are compromised owing to concurrent internal spraining and flexion under load [10].  Athletes with a history of ankle ligament strain have diminished proprioception and proprioceptive awareness, critical factors contributing to worse balance and increased risk of re-injury [11]. Chronic ankle sprain instability is not a distinct clinical entity and presents with a range of signs and symptoms [12]. Research indicates that the effects of various workouts remain inadequately understood, with inconsistent data present, and it has been proposed that a comparative analysis of diverse exercises be conducted [13].  Recurrent ankle sprains hinder the ability to maintain balance when standing [14].  Some athletes report experiencing discomfort, joint instability, functional impairment, recurrent sprains, sensations of instability, and a sense of emptiness in the ankle joint, as well as more severe sprains after first torsion [15].  In the study by Su et al. [16] balance exercises were conducted on patients with functional ankle instability over a four-week period, yielding results that demonstrated the exercises' efficacy in diminishing ankle instability and enhancing proprioception of the ankle joint in the subjects.  Ben Moussa Zoita et al. have shown that deep sensing workouts may significantly enhance stability in unstable ankles by augmenting posture and muscular control [17]. Taking into account the beneficial impact of aerobic treatment and rehabilitation on individuals with chronic ankle instability, as well as the favourable outcomes of exercise performance seen in other research [18].  A rehabilitation program is essential for those with ankle instability [19].  Conventional rehabilitation methods for this ailment often include strength training, balance training, neuromuscular training, and proprioceptive training [20].   Neglecting ankle injuries and insufficient rehabilitation may result in re-injury and may cause issues such as chronic wrist instability and mechanical and functional instability [21]. Approximately 40 to 70 percent of individuals with ankle sprains report lingering symptoms lasting from six weeks to eighteen months [12]. Scientific data indicates that inadequate postural control is prevalent in individuals with acute and chronic ankle sprains, as well as diminished functionality in those with chronic ankle instability, possibly resulting from a combination of neuromuscular control and proprioception deficits [22-23].  The buoyancy and adherence to water may facilitate movement and enhance muscular strength [24]. A review of research on chronic ankle sprains and instability rehabilitation indicates that training programs are predominantly executed in terrestrial environments, with limited studies examining the impact of aquatic exercises compared to land-based exercises on acute ankle sprain rehabilitation [25].  Consequently, owing to the incongruous findings of researchers on ankle sprains and functional impairments, this study aimed to investigate the impact of training in aquatic and terrestrial settings on pain and range of motion in athletes with a severe ankle sprain.

Research Problem

Injuries constitute a significant impediment to the physical and strategic efficacy of athletes, potentially impacting their lives within competitive arenas [26]. An injury may precipitate a cessation of athletic participation or even retirement [27]. It is uncommon to encounter a training regimen devoid of injury risk, as injuries may proliferate among athletes due to numerous errors arising from the implementation of a training methodology and insufficient experience [28].  Practicing, reducing friction, and minimising injury risk are essential to assure his continued training, participation in contests, and attainment of desired outcomes [29]. Ankle injuries, as noted by McKeon and Hoch [10] are among the most prevalent injuries, making the ankle one of the most intricate joints in the body. Delahunt et al. [30] assert that most ankle injuries are associated with physical activity, with ankle sprains being a prevalent reason for emergency department visits, representing around 7% to 10% of such visits and up to 40% of all sports-related injuries. Kolodziej et al. [31] indicate that lower limb injuries arise from movements that are disproportionate to the pressure exerted on the region and the dimensions of the ankle, with sprains resulting from pressure and tension above typical thresholds.  The functional ligaments of the ankle joint, combined with improper landings on one limb, can result in partial or complete tension of the surrounding ligaments. Rousseau [32] indicates that the joint is prone to injury when subjected to motor efforts that surpass its capabilities. Additionally, the joint's position is crucial during impact, influencing the likelihood of injury. Consequently, a lack of control over body movement places undue stress on the tendons and ligaments, rendering them excessively stretched and significantly weakened. The researchers' pedagogical engagement in injuries and sports rehabilitation at the Faculty of Physical Education and Sport Sciences revealed a significant prevalence of sports injuries among football players, particularly sprained ankle joints. This condition adversely affects players' physical and skill performance, often resulting in prolonged absences from the sport and substantial losses for clubs and teams. Consequently, the researchers prompted the design of a training program in aquatic and dry environments that aims to restore the functional efficiency of the sprained ankle joint.

Research Objectives 

The research aims to identify a  proposed training program on restoring the functional efficiency of the sprained ankle joint through:

• Designing a proposed training program in aquatic and dry environments to restore the functional efficiency of the sprained ankle joint

• Identify the effect of a proposed training program on the pain level of the ankle joint

• Identify a  proposed training effect in aquatic and dry environments on the range of motion of the ankle joint

Research Hypotheses

• There are statistically significant differences between the pre-measurements - in the aquatic and dry environments of the experimental group in the level of pain of the ankle joint and in favor of the dimensional measurement

• There are statistically significant differences between the pre - and post-measurements in the aquatic and dry environments of the experimental group in the range of motion of the ankle joint and in favor of the telemetry

• There are statistically significant differences between the pre-dimensional intermediate measurements in the aquatic and dry environments of the experimental group in the level of muscle strength of the ankle joint and in favor of the dimensional measurement

The results related to the demographics of the subjects are presented in Table 1.

The normality of the data was assessed and validated using the Shapiro-Wilk test. A two-way repeated ANOVA test was used to assess the effects of time, group comparisons, and interactions, given the characteristics of the data distribution.

Figure 1: Pre- and Post-Test Pain in Aquatic and Terrestrial Training Groups

Figure 2: Range of Motion of Dorsal Flexion Before and After the Test in Aquatic and Terrestrial Training Groups

Figure 3: Plantar Pre- and Post-Test Range of Motion in Aquatic and Terrestrial Training Groups

Figure 4: Range of Reflection Motion in Pre-Test and Post-Test in Water and Land Training Groups

Table 1: Demographic Characteristics of Participants and Independent T-Comparison of Groups in the Preliminary Test

The findings indicated that the temporal influence on the pain variable was considerable, demonstrating a substantial reduction in pain levels during the post-test for both groups.  The average pain level from the pre-test to the post-test shown a significant difference. The post-test revealed no significant difference between the two groups.  The relationship between the two groups and time was considerable.  The aquatic training group saw a more significant decrease in discomfort on the following test. The findings indicated that time substantially affected the variable of dorsal ankle flexion range of motion, demonstrating a notable reduction in dorsal ankle flexion during the following test in both groups.  The average range of motion for dorsal ankle flexion exhibited a significant difference between pretest and posttest in both the aquatic and terrestrial groups.  The group (p = 0.85) and the interaction between the groups and time were not significant (p = 0.18). ANOVA findings indicated that the temporal impact was significant on the range of motion variable for ankle plantar flexion.  The degree of plantar flexion in the post-test was markedly decreased in both groups.  The average range of motion for plantar flexion exhibited a significant difference from pre-test to post-test in both the aquatic and terrestrial groups. The disparity between the two groups (p = 0.283) and the interaction of the two groups with time was not statistically significant (p = 0.15).

The findings indicated that the temporal influence was substantial in the ankle reversal motion variable.  The reflex rate in the post-test considerably lowered in both groups.  The average range of reflex motion exhibited a significant difference between the pre-test and post-test in both the aquatic and terrestrial groups.  The post-test revealed no significant difference between the two groups (p = 0.765). The interaction between the groups and time was not significant (p = 0.95).

The findings indicated that the temporal impact was considerable in the Evergen range variable.  This indicates that the degree of overturning in the second test was markedly reduced in both groups.  The average range of motion of Everen exhibited a significant difference between the pre-test and post-test in both the aquatic and terrestrial groups.  The following test revealed no significant difference between the two groups (p = 0.132).  The interaction between the groups and time was not significant (p = 0.095).

The findings of the current study demonstrated that training in both aquatic and terrestrial environments significantly alleviated pain and enhanced the range of motion in athletes with severe ankle sprains, indicating that both modalities exerted beneficial and statistically significant effects on ankle joint pain and mobility.  The variables of pain, range of motion, and aquatic training exhibited an accelerated rate of development.  There was considerable interaction between the groups and the timing of the response.  The water group had a greater reduction in discomfort. The findings indicated that both procedures alleviated pain in the ankles of the injured athletes.  The relationship between the groups and time was significant, with the aquatic group exhibiting a higher decrease in pain compared to the land training group.  A recent research indicated comparable outcomes regarding the impact of water and ground training on chronic aspirin use in athletes, revealing a decrease in pain in both cohorts, however no statistically significant difference was seen between the two groups.  The physical qualities of water and its temperature are significant in alleviating pain and enhancing or preserving joint mobility, hence facilitating easier movement in water with less effort [33]. Warm water activates the skin and its underlying tissues, leading to a reduction in striated muscle tone, cutaneous vasodilation, and decreased peripheral vascular resistance [34]. Enhanced blood circulation eliminates receptors and toxins that exacerbate pain by increasing aerobic metabolic activity, which induces analgesia [35]. Hydrotherapy has advantages, including analgesic effects [36]. Additional factors encompass massage and skin irritation during hydrotherapy, which elicits relaxation and activates spinal nerve agents, leading to the release of pain-inducing hormones and enzymes such as enkephalins and endorphins, as well as the attenuation of pain receptor stimulation and pain mitigation in individuals suffering from discomfort [37].  Conversely, alleviating the stress on weight and joints, alongside enhancing blood circulation due to the hydrostatic pressure of water on the body, facilitates movement therapy in a pleasant and appealing environment [38]. This approach diminishes fatigue, stress, and perspiration for patients with low back pain, collectively reducing functional disability and enhancing the quality of life for these individuals [39].  The findings indicated a notable increase in range of motion in both groups, with a greater improvement seen in the aquatic training group, but it was not statistically significant.  Evidence indicates that post-injury joint mobility effectively directs collagen synthesis, accelerating the healing process; nonetheless, it may need many months to restore ligament strength. Recovery rates improve with enhanced blood flow by aquatic training [41]. Other research investigating the impact of neuromuscular training on the proprioception of the ankle joint in male football players indicated a substantial difference in reflex movements, aligning with the findings of the present study [42].  The training groups exhibited minimal interest; nonetheless, some line graph investigations indicated that the water training group shown more rapid improvement than the terrestrial training group [43].

Given the impact of aquatic and terrestrial exercises and the statistically significant differences observed in both training groups post-intervention, along with the notable interaction between time and group, it is recommended to utilise aquatic training or a hybrid of aquatic and land training for the rehabilitation of acute ankle sprains.

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