Management of Ankle Sprains
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 that 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 an ankle or mid-foot fracture within 7 days after the injury. Testing in a weight-bearing position is recommended
Ultrasound: 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 the quality of the equipment. Ultrasound is an investigation less sensitive than an MRI in the diagnosis of an acute ligament injury.[9][10]
MRI: the gold standard for investigating intra-articular damage.[10] Assists with a diagnosis of the acute tears of the anterior talofibular and calcaneofibular ligaments, however, false-positive findings can be challenging for the referring physician. MRI is not considered a routine investigation in the acute ankle injury because of the high cost of the test, limited accessibility, and high incidence of this type of injury. MRI can be very helpful in the diagnosis of suspected additional injuries including syndesmotic injury, tendon pathologies or in case of chronic ankle instability requiring further investigation. [10]
CT scan: is not routinely ordered as a diagnostic tool in ankle sprain injury. The recommendation is based on each case individually.
Management[edit | edit source]
The following are the guidelines suggested by the National Athletic Trainers’ Association (NATA) and published in 2013[9]. The second guidelines are taken from a 2020 publication by the World Journal of Orthopaedic (WJO).[4] Category A in NATA publication means that the recommendations are based on "consistent and good-quality patient-oriented evidence", and category B is defined by " inconsistent and limited- quality patient-oriented evidence". In their guidelines, the authors Halabchi F and Hassabi M (2020) use clinical evidence levels 1, 2 and 3:
Level 1: evidence is obtained from at least one properly designed randomised controlled trial.
Level 2: evidence from a meta-analysis of all relevant randomised controlled trials.
Level 3: evidence obtained from well-designed controlled trials without randomisation.
Acute Phase[edit | edit source]
Rehabilitation Goals:
- Pain reduction: NICE and EASY, eg., external support worn up to one year post injury.[11]
- Progressive return to motion: POLICE (Protection, Optimal Loading, Integrated Control Exercises).[11]
- Restoring body self-perception: tasks to be purposeful, progressive (from simple to complex), relevant. [11]
RICE[edit | edit source]
In the acute phase of ankle sprain injury, the treatment of choice is RICE, including Rest, Ice, Compression, Elevation.
- Rest: treatment protocol includes elevation of the injured leg 15-25 cm above the level of the heart to assist with lymphatic drainage.
- Ice: is considered a routine therapy for 3-7 days after the injury for pain and swelling reduction. There is limited evidence in reducing symptoms associated with an ankle sprain (Level 1) and no evidence in reducing swelling and decreasing pain (Level 2)
- Compression: applied for management of swelling and for quality of life improvement. Compression modalities include elastic bandaging or splints. The effectiveness of compression has limited support in research (Level 2)
- Elevation: No control trials were conducted to support the effectiveness of elevation in the treatment of ankle sprains.
Immobilisation[edit | edit source]
- Grade I and II ankle sprain: early mobilisation and functional support allowing functional rehabilitation (level 1, category A)
- Grade III ankle sprain: 10 days of immobilisation using a below-knee cast or rigid brace (level 2, category B), followed by controlled therapeutic exercises (category B)
- Immobilisation in a form of ankle brace allow loading and protection of the damaged tissue (level 2) and it should be used for a minimum of 6 months following the moderate or severe sprain. A semi-rigid brace or lace-up brace is better than an elastic bandage (level 1) and more effective than rigid or elastic tape (level 2). This type of bracing is recommended for individuals with a prior history of ankle sprains.
- Kinesio Taping may not provide sufficient mechanical support for unstable joint(level 1)
- Lack of the randomised controlled trials in the initial management for medial or syndesmosis sprains with immobilisation [10]
- The choice of support depends on the severity of injury
Electrical stimulation[edit | edit source]
No evidence in the literature supporting the use of modality in pain or oedema reduction.
Weight Bearing[edit | edit source]
Early protected weight-bearing up to 2 weeks for all grade sprains assists with [12]
- reduction of swelling
- restoration of the normal range of motion
- return to normal activity
- preventing mechanical instability long-term
Manual Therapy[edit | edit source]
Manual techniques included in the management of acute ankle sprains are anterior to posterior talocrural glides and talocrural distraction in the neutral position.[13] In addition soft tissue massage and manual lymphatic drainage techniques are recommended. Active dorsiflexion passive range of motion can be performed in both positions of weight-bearing or non-weight-bearing.[4]
The application of manual therapy resulted in:
- pain reduction (level 1)[14]
- reduction of stiffness
- improved ankle dorsiflexion(level 1, category B)
- improved stride length
- better proprioceptive awareness
- functional recovery (level 2, category B)
Exercises[edit | edit source]
Therapeutic exercises are considered the main component of the rehabilitation program for the acute ankle sprain, however, no specific content and training volume has been determined. [4]The expected results of performing exercises are: reduction in recurrent injuries, preventing ankle instability, shortening a recovery time, improvement in self-reported function (level 1).
Exercises should be:
- supervised (level 1)
- based on the conventional program (level 2)
and they should include:
- range of motion exercises (category B)
- stretching exercises (category B): start with open chain in all planes, dorsiflexion stretch with upper extremity assist, progress to closed chain. Heel cord stretching should be initiated as soon as possible.
- strengthening exercises (category B): start immediately for grade I and II sprains, may need to be postpone for grade III sprain, inversion and eversion of the ankle should be minimised. Protocol should include: slow movements performed within pain limits and high repetitions (Example: 2-4 sets x 10 repetitions). Start with isometrics in frontal and sagittal planes, progress to isotonic resistive exercises with weights, elastic bands or manual resistance, add movement in all planes.
- neuromuscular and proprioceptive (level 2)
Neuromuscular Reeducation[edit | edit source]
Early implementation of neuromuscular retraining within the first week of injury results in higher overall activity levels without increasing pain
proprioceptive exercises resulted in significant improvement in ankle functional outcome measures, such as the Star Excursion Balance Test and Functional Ankle Disability Index.
Proprioceptive neuromuscular facilitation (PNF) strengthening exercises that isolate the desired
Balance training should be performed throughout rehabilitation and follow-up management of ankle sprains to reduce reinjury rates. Evidence Category: A[9]
Subacute Phase[edit | edit source]
Neuromuscular training programs typically include balance and proprioception tasks with recurrent voluntary or involuntary destabilization during exercise.
exercises: inversion, eversion
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]
Ideally, athletes may return to play when he or she has full, painless range of motion and strength is restored. The athlete should be able to complete sport specific activities without recurrent symptoms. Although ligament healing time may require a period of 6 to 12 wk, time to return to sport varies greatly [10]
Resources
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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 4.2 4.3 4.4 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
- ↑ 10.0 10.1 10.2 10.3 10.4 Chen ET, McInnis KC,Borg-Stein J. Ankle Sprains: Evaluation, Rehabilitation, and Prevention. Current Sports Medicine Reports 2019 (June);18(6): 217-223.
- ↑ 11.0 11.1 11.2 McKeon PO, Donovan L. A Perceptual Framework for Conservative Treatment and Rehabilitation of Ankle Sprains: An Evidence-Based Paradigm Shift. J Athl Train. 2019 Jun;54(6):628-638.
- ↑ Knapik DM, Trem A, Sheehan J, Salata MJ, Voos JE. Conservative Management for Stable High Ankle Injuries in Professional Football Players. Sports Health. 2018 Jan/Feb;10(1):80-84.
- ↑ Loudon JK, Reiman MP, Sylvain J. The efficacy of manual joint mobilisation/manipulation in the treatment of lateral ankle sprains: a systematic review. Br J Sports Med. 2014 Mar;48(5):365-70.
- ↑ Cleland JA, Mintken PE, McDevitt A, Bieniek ML, Carpenter KJ, Kulp K, Whitman JM. Manual physical therapy and exercise versus supervised home exercise in the management of patients with inversion ankle sprain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2013;43(7):443-55.
