Management of Ankle Sprains: Difference between revisions
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== Introduction == | == Introduction == | ||
Ankle sprains are considered one of the most frequent traumatic | Ankle sprains are considered one of the most frequent traumatic injuries. Yeung et al, 1994, in an epidemiological study of unilateral ankle sprains, reported that the dominant leg is 2.4 times more vulnerable to sprain than the non-dominant one.<ref name=":0">Yeung MS, Chan KM, So CH, Yuan WY. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1332043/pdf/brjsmed00014-0042.pdf An epidemiological survey on ankle sprain.] Br J Sports Med. 1994 Jun;28(2):112-6. </ref>There were reports proposing that the greater the level of plantar flexion the higher the likelihood of sprain. <ref>Wright IC, Neptune RR, van den Bogert AJ, Nigg BM. The influence of foot positioning on ankle sprains. J Biomech. 2000 May;33(5):513-9.</ref>A conservative treatment is the common approach to an ankle injury. The prognosis is generally good, but there is a number of factors influencing the full recovery.<ref name=":2">Ferreira JN, Vide J, Mendes D, Protásio J, Viegas R, Sousa MR. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336189/pdf/eor-5-334.pdf Prognostic factors in ankle sprains: a review.] EFORT Open Rev. 2020 Jun 1;5(6):334-338. </ref>These factors, when identified early, can change the treatment protocol to a more aggressive approach.<ref name=":2" /> | ||
== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
| Line 46: | Line 46: | ||
== Classification Grading Systems == | == Classification Grading Systems == | ||
The severity of the ligament injury | The severity of the ligament injury is defined by grade I, II, or III of the ankle sprain. There is also a functional grading which divides ankle sprains into mild, moderate and severe sprains. | ||
Mild and moderate sprains are usually grades I. ''A mild sprain'' is characterised by the patient's inability to run and jump, difficulty with stair climbing, and presence of discomfort. In this type of sprain the ligaments are intact. | |||
''Moderate sprains'' require support to walk, there is the presence of significant pain, swelling and bruising. | |||
''Severe sprains'' are grades III sprains where weight bearing is impossible, pain is high and the patient needs further testing towards ankle fracture. Immobilisation is usually required for 10 days or more and surgery often becomes the treatment of choice. | |||
== Diagnostic Procedures == | == Diagnostic Procedures == | ||
Clinical assessment including Ottawa Ankle and Foot Rules can be supported by: | Clinical assessment including Ottawa Ankle and Foot Rules can be supported by other investigations including: | ||
'''X-ray:''' allows to rule out ankle or mid-foot fracture within 7 days after the injury. Testing in weight bearing position is recommended | '''X-ray:''' allows to rule out ankle or mid-foot fracture within 7 days after the injury. Testing in weight bearing position is recommended | ||
'''Ultrasound''': it is considered a good diagnostic tool for ligamentous injury, functional impairments, and joint instability. | '''Ultrasound''': it is considered a good diagnostic tool for ligamentous injury, functional impairments, and joint instability. Diagnostic accuracy depends on the skills of the personnel performing the task and quality of the equipment. Ultrasound is an investigation less sensitive than an MRI in diagnosis of an acute ligament injury.<ref name=":4">Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy W, Richie D; National Athletic Trainers' Association. [https://watermark.silverchair.com/1062-6050-48_4_02.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAtkwggLVBgkqhkiG9w0BBwagggLGMIICwgIBADCCArsGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQM7izOuCntVdvyXS15AgEQgIICjGxz1qnxHIGWX4vicTkttcgccL6ELWFmJ923Pk16b-ZFr3YlySMcIjjxv2AuGYwzWbjE37yGwhWEhweeTPV4PutNUf0kqZxliYGC-s2axsDk-S1WCKDM-K5_tEeixi0PNCAXCyUDEKs9DyDaQ2ToKGwmBUaslHuzlZBZuIiR7tsc9rXe3_UqhXf43zP_r1V4O7VbAM4rm-fj5M3bOCKK3HQKCKJmuW_vajcwSsQJroZiZvtRvoEBxgKm9hRya_6dkSRt4UT1Zdha_HJ04oo1QefoW7sDbXHFf4gASG3A7Qx0J3QsqlO6TUW26lCmouO_eFway0fbJQSp-1aeSQFbyMrBepHaH3a-xPZCw6-epsQ_yU59Hd6uPPgF9jN-M54GZmGnamsHBP712llDwrsQLZrb3kW-PWQs0o-d6XA6HJ5ja0_vsyhKtvv5twJfEoNFsf5CCE-ZB-KGVgiewSZ8ovn88j0whC581EJE9Dw-DSly9QeyVpV_-z4aZtWt00KTX1r9hSn5M3SS2l8A50DZFg-SJPGGOqwA1Un9rQe8It4EglPLAqLSVajY3YbWWPml7UsyzbMOPrV21CNMPDvR5OHMaCSbWgJvG_-40T7HLW_UKy9edj0t1K8E7JFUSGns2R9FcS5-MruUvjEFNtT2JQeV1Lm_43pIQn8In7uvuAvdpLwxfyQo7IK2MR5z2N-NqvTKQzg7eO6e-P-I8VTuVhJOmmMGuCRdO2NrKFGTUKmozirzeavwXLOA3ZkT_dUv7zqx6NfxM_uPi8T7PAk0qkthpZF5AvM9yqWmC8jYhKxiHenKq8F4pbAsFM0qq3hBJ-t15ct9u_G84AgzOHOEsAcJ9SVkRNvR-SY1z5M National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes.] J Athl Train 2013; 48: 528-545</ref> | ||
| Line 59: | Line 66: | ||
== Management == | == Management == | ||
The National Athletic Trainers’ Association (NATA) suggests the following guidelines in the management and prevention of ankle sprains in the athletic population | |||
=== Acute Phase === | === Acute Phase === | ||
Balance training should be performed throughout reha- bilitation and follow-up management of ankle sprains to reduce reinjury rates.40–42 Evidence Category: A<ref name=":4" /> | |||
Functional rehabilitation is more effective than immobi- lization in managing grade I and II ankle sprains.30,31 Evidence Category: A<ref name=":4" /> | |||
Grade III sprains should be immobilized for at least 10 days with a rigid stirrup brace or below-knee cast and then controlled therapeutic exercise instituted.30,32 Evi- dence Category: B | |||
Rehabilitation should include comprehensive ROM, flexibility, and strengthening of the surrounding muscu- lature.30,31,38,39 Evidence Category: B | |||
Passive joint mobilizations and mobilizations with movement should be used to increase ankle dorsiflexion and improve function.43–45 Evidence Category: B | |||
=== Subacute Phase === | === Subacute Phase === | ||
=== Chronic Phase === | === Chronic Phase === | ||
Clinicians working with athletes should implement a multi-intervention injury-prevention program lasting at least 3 months that focuses on balance and neuromuscular control to reduce the risk of ankle injury. Athletes with a history of ankle injury may benefit more from this type of training.60–63 Evidence Category: A<ref name=":4" /><br><br> | |||
== Resources <br> == | == Resources <br> == | ||
Revision as of 07:10, 27 January 2022
Introduction[edit | edit source]
Ankle sprains are considered one of the most frequent traumatic injuries. Yeung et al, 1994, in an epidemiological study of unilateral ankle sprains, reported that the dominant leg is 2.4 times more vulnerable to sprain than the non-dominant one.[1]There were reports proposing that the greater the level of plantar flexion the higher the likelihood of sprain. [2]A conservative treatment is the common approach to an ankle injury. The prognosis is generally good, but there is a number of factors influencing the full recovery.[3]These factors, when identified early, can change the treatment protocol to a more aggressive approach.[3]
Clinically Relevant Anatomy[edit | edit source]
Lateral Ankle Sprain[edit | edit source]
The literature suggests that 85% of ankle sprains involve lateral ligaments. [4]The anterior talofibular ligament (ATFL) of the lateral ankle ligament complex is the most frequently damaged when lateral ankle sprain occurs. Their anatomical location and the mechanism of sprain injury mean that the calcaneofibular (CFL) and posterior talofibular ligaments (PTFL) are less likely to sustain damaging loads.
Medial Ankle Sprain[edit | edit source]
On the medial side the strong, deltoid ligament complex [posterior tibiotalar (PTTL), tibiocalcaneal (TCL), tibionavicular (TNL) and anterior tibiotalar ligaments (ATTL)] is injured with forceful "pronation and rotation movements of the hindfoot". [5]
Syndesmotic Ankle Sprain[edit | edit source]
The stabilising ligaments of the distal tibiofibular syndesmosis are the anterior-inferior, posterior-inferior, and transverse tibiofibular ligaments, the interosseous membrane and ligament, and the inferior transverse ligament. A syndesmotic ankle sprain occurs with combined external rotation of the leg and dorsiflexion of the ankle.
Risk Factors and Outcome[edit | edit source]
Predisposing factors are the risk factors for ankle sprains. [3] Identifying risk factors helps the clinician to choose the most appropriate treatment regimen given the fact that these risk factors have a significant impact on the patient's recovery.[3]They are divided into two categories:intrinsic and extrinsic.
Intrinsic risk factors for outcome prediction include:[5]
- Age and gender: female athletes have a 25% greater risk of suffering from a grade 1 ankle sprain[6]
- Height and weight: increase in height or weight proportionally increases the risk of sprain due to an increased magnitude of inversion torque
- Activity level
- The grade of injury
- functional status
- Associated injury, especially previous sprain
- Limb characteristics including limb dominance, anatomic foot type and foot size, joint laxity, anatomic alignment, range of motion of the ankle-foot complex: abnormalities in foot biomechanics such as pes planus, pes cavus, and increased hindfoot inversion were risk factors for lower extremity overuse injury[7]
- Muscle strength
- Posture, particularly postural sway: increased sway leads to a 7-fold increase in ankle sprains [8]
Extrinsic risk factors for outcome prediction include:
- level of competition: the higher the level, the number of ankle sprains increases
- ankle bracing or taping: introducing this intervention early on can lower the incidence of ankle sprains
- shoe type
- lack of warm-up stretching
- landing technique after jump[4]
In summary, the following prognostic factors suggest good clinical outcomes after foot and ankle injury: younger age, low-grade sprain, low activity level, good functional status, good neuromuscular function, no associated injury.[3]Long lasting symptoms with functional limitations can be predicted based on the presence of systemic laxity, joint geometry, limb and foot malalignment, re-sprain, and multi-ligament injury.[3]
Classification Grading Systems[edit | edit source]
The severity of the ligament injury is defined by grade I, II, or III of the ankle sprain. There is also a functional grading which divides ankle sprains into mild, moderate and severe sprains.
Mild and moderate sprains are usually grades I. A mild sprain is characterised by the patient's inability to run and jump, difficulty with stair climbing, and presence of discomfort. In this type of sprain the ligaments are intact.
Moderate sprains require support to walk, there is the presence of significant pain, swelling and bruising.
Severe sprains are grades III sprains where weight bearing is impossible, pain is high and the patient needs further testing towards ankle fracture. Immobilisation is usually required for 10 days or more and surgery often becomes the treatment of choice.
Diagnostic Procedures[edit | edit source]
Clinical assessment including Ottawa Ankle and Foot Rules can be supported by other investigations including:
X-ray: allows to rule out ankle or mid-foot fracture within 7 days after the injury. Testing in weight bearing position is recommended
Ultrasound: it is considered a good diagnostic tool for ligamentous injury, functional impairments, and joint instability. Diagnostic accuracy depends on the skills of the personnel performing the task and quality of the equipment. Ultrasound is an investigation less sensitive than an MRI in diagnosis of an acute ligament injury.[9]
Management[edit | edit source]
The National Athletic Trainers’ Association (NATA) suggests the following guidelines in the management and prevention of ankle sprains in the athletic population
Acute Phase[edit | edit source]
Balance training should be performed throughout reha- bilitation and follow-up management of ankle sprains to reduce reinjury rates.40–42 Evidence Category: A[9]
Functional rehabilitation is more effective than immobi- lization in managing grade I and II ankle sprains.30,31 Evidence Category: A[9]
Grade III sprains should be immobilized for at least 10 days with a rigid stirrup brace or below-knee cast and then controlled therapeutic exercise instituted.30,32 Evi- dence Category: B
Rehabilitation should include comprehensive ROM, flexibility, and strengthening of the surrounding muscu- lature.30,31,38,39 Evidence Category: B
Passive joint mobilizations and mobilizations with movement should be used to increase ankle dorsiflexion and improve function.43–45 Evidence Category: B
Subacute Phase[edit | edit source]
Chronic Phase[edit | edit source]
Clinicians working with athletes should implement a multi-intervention injury-prevention program lasting at least 3 months that focuses on balance and neuromuscular control to reduce the risk of ankle injury. Athletes with a history of ankle injury may benefit more from this type of training.60–63 Evidence Category: A[9]
Resources
[edit | edit source]
add appropriate resources here
References[edit | edit source]
- ↑ Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med. 1994 Jun;28(2):112-6.
- ↑ Wright IC, Neptune RR, van den Bogert AJ, Nigg BM. The influence of foot positioning on ankle sprains. J Biomech. 2000 May;33(5):513-9.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Ferreira JN, Vide J, Mendes D, Protásio J, Viegas R, Sousa MR. Prognostic factors in ankle sprains: a review. EFORT Open Rev. 2020 Jun 1;5(6):334-338.
- ↑ 4.0 4.1 Halabchi F, Hassabi M. Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World J Orthop. 2020 Dec 18;11(12):534-558.
- ↑ 5.0 5.1 Beynnon BD, Murphy DF, Alosa DM. Predictive Factors for Lateral Ankle Sprains: A Literature Review. J Athl Train. 2002 Dec;37(4):376-380.
- ↑ Hosea TM, Carey CC, Harrer MF. The gender issue: epidemiology of ankle injuries in athletes who participate in basketball. Clin Orthop Relat Res. 2000 Mar;(372):45-9.
- ↑ Kaufman KR, Brodine SK, Shaffer RA, Johnson CW, Cullison TR. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med. 1999 Sep-Oct;27(5):585-93.
- ↑ McGuine TA, Greene JJ, Best T, Leverson G. Balance as a predictor of ankle injuries in high school basketball players. Clin J Sport Med. 2000 Oct;10(4):239-44.
- ↑ 9.0 9.1 9.2 9.3 Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy W, Richie D; National Athletic Trainers' Association. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train 2013; 48: 528-545
