Management of Ankle Sprains

Original Editor - Ewa Jaraczewska based on the course by Helene Simpson Top Contributors - Ewa Jaraczewska, Wanda van Niekerk, Jess Bell, Kim Jackson, Tarina van der Stockt and Nupur Smit Shah

Introduction

Ankle sprains are considered one of the most frequent traumatic injuries. Yeung et al. (1994) conducted an epidemiological study of unilateral ankle sprains and reported that the dominant leg is 2.4 times more vulnerable to sprain than the non-dominant one. There were reports proposing that the greater the level of plantar flexion the higher the likelihood of a sprain. Conservative treatment is the common approach to an ankle injury. The prognosis is generally good, but there is a number of risk factors influencing the full recovery. These factors, when identified early, can change the treatment protocol to a more aggressive approach.

Clinically Relevant Anatomy

Lateral Ligaments

Lateral Ankle Sprain

The literature suggests that 85% of ankle sprains involve lateral ligaments. The anterior talofibular ligament (ATFL) of the lateral ankle ligament complex is the most frequently damaged when a 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 Ligaments

Medial Ankle Sprain

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".

Syndesmosis Ligaments

Syndesmotic Ankle Sprain

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

Predisposing factors are the risk factors for ankle sprains. 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. They are divided into two categories: intrinsic and extrinsic.

Intrinsic risk factors for outcome prediction include:

• Age and biological sex: female athletes have a 25% greater risk of suffering from a grade I ankle sprain
• Height and weight: an increase in height or weight proportionally increases the risk of a sprain due to an increased magnitude of inversion torque.
• The grade of injury
• Functional status
• Associated injury, especially previous sprains
• Limb characteristics: limb dominance, anatomic foot type and foot size, joint laxity, anatomic alignment, range of motion of the ankle-foot complex including abnormalities in foot biomechanics such as pes planus, pes cavus, and increased hindfoot inversion were risk factors for lower extremity overuse injury.
• Muscle strength
• Posture, particularly postural sway: increased sway leads to a 7-fold increase in ankle sprains.

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 the jump.

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. 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.

Classification Grading Systems

Grades of Ankle Sprains

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.

• Grade I represents a microscopic injury without stretching of the ligament.
• Grade II has macroscopic stretching, but the ligament remains intact or with a more severe sprain it can be partially torn.
• Grade III is a complete rupture of the ligament.

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 grade 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 or more days and surgery often becomes the treatment of choice.

Diagnostic Procedures

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 test and the quality of the equipment. Ultrasound is an investigation less sensitive than an MRI in the diagnosis of an acute ligament injury.

File:MRI Ankle Sprain.jpg

MRI Ankle Sprain

MRI: the gold standard for investigating intra-articular damage. 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.

CT scan: is not routinely ordered as a diagnostic tool in ankle sprain injury. The recommendation is based on each case individually.

Algorithm to acute ankle sprain

Management

"The earlier musculoskeletal rehabilitation care started after an ankle sprain, the lower the likelihood of recurrence and the downstream ankle-related medical costs incurred".

The following are the guidelines proposed by the National Athletic Trainers’ Association (NATA) and published in 2013. The second guidelines are taken from a 2020 publication by the World Journal of Orthopaedic (WJO). 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". Halabchi F and Hassabi M (2020) in their guidelines published in the WJO, use clinical evidence levels 1, 2 and 3 to support their recommendations:

Level 1: evidence is obtained from at least one properly designed randomised controlled trial.

Level 2: evidence comes from a meta-analysis of all relevant randomised controlled trials.

Level 3: evidence is obtained from well-designed controlled trials without randomisation.

Acute Phase

Rehabilitation Goals:

1. Pain reduction. Activities should be performed NICE and EASY, eg., external support worn up to one year post-injury.
2. Progressive return to motion. Follow POLICE acronym (Protection, Optimal Loading, Integrated Control Exercises).
3. Restoring body self-perception. Performed tasks should be purposeful, progressive (from simple to complex), and relevant.

RICE

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 symptoms reduction associated with an ankle sprain (Level 1) and no evidence in reducing swelling and decreasing pain (Level 2).
• Compression: is 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.

Ankle Lace-Up Brace

Immobilisation

1. Grade I and II ankle sprain: recommendations include early mobilisation and functional support allowing functional rehabilitation (level 1, category A).
2. 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 (category A, 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).
• There is a lack of randomised controlled trials in the initial management for medial or syndesmotic sprains with immobilisation.
• The choice of support depends on the severity of the injury.

Modalities

• Electrical stimulation: no evidence in the literature supporting the use of modality in pain or oedema reduction (level 1).
• Laser: no evidence supporting the use of laser for pain and oedema reduction (level 1).
• Therapeutic ultrasound: no effect on pain, oedema, function and return to play (level 1). The use of ultrasound for the management of acute ankle sprains is not indicated.
• Shortwave diathermy: no evidence to use in the management of ankle sprains (level 2).

Weight Bearing

Early protected weight-bearing up to 2 weeks for all grade sprains assists with

• swelling reduction
• restoration of the normal range of motion
• return to normal activity
• preventing mechanical instability long-term

Manual Therapy

Manual techniques included in the management of acute ankle sprains are anterior to posterior talocrural glides and talocrural distraction in the neutral position. In addition soft tissue massage and manual lymphatic drainage techniques are recommended. Dorsiflexion passive range of motion can be performed in both positions of weight-bearing or non-weight-bearing.

The application of manual therapy resulted in:

• pain reduction (level 1)
• reduction of stiffness
• improvement in the ankle dorsiflexion(level 1, category B)
• improvement in the stride length
• better proprioceptive awareness
• functional recovery (level 2, category B)

Exercises

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. 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), or based on the conventional program (level 2) and they should include the following:

Examples for Range of Motion Exercises

• Range of motion exercises (category B)

• Stretching exercises (category B): start with an open chain in all planes, dorsiflexion stretch with upper extremity assist, progress to a 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 postponed for grade III sprain, inversion and eversion of the ankle should be minimised. The 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 reeducation and proprioceptive exercises (level 2)

Neuromuscular Reeducation

Neuromuscular reeducation activities performed in the acute ankle sprain include:

• Proprioceptive neuromuscular facilitation (PNF) exercises. The use of PNF resulted in significant improvement in ankle functional outcome measures, including Star Excursion Balance Test (SEBT). Implementation of neuromuscular training within the first week of injury resulted in pain-free higher activity level and swelling reduction (level 1).
• Balance training. This type of activity should be performed in all stages of rehabilitation (category A).

Subacute Phase

Rehabilitation goal:

1. To design a return-to-work schedule with activity limitations and participation restrictions.

In this phase of the rehabilitation program for the ankle sprain the focus is on:

• Neuromuscular training programs include balance and proprioception tasks with periods of destabilisation during exercises. Standing balance exercises initiated on one leg without a board should be incorporated and progressed towards maintaining balance on an unstable surface with both and then the injured foot and with the slow removal of hands support. The same sequence is repeated on the BAPS board.
• Inversion and eversion range of motion exercises.
• Strengthening of the proximal muscles of the hip and trunk to assist with the re-injury rate reduction
• Exercises with sport-specific perturbation for high-performance athletes finished by full-speed planned movement drills and unilateral jumps.
• Occupational training and/or work hardening program.

Chronic Phase

Multi-intervention injury-prevention program should begin in the acute phase and continue through the chronic phase for at least 3 months after the ankle sprain.

Rehabilitation goals :

1. Reduce the risk of the ankle re-injury
2. Restore full, painless range of motion
3. Return to sports/work/activities without recurrent symptoms

The program consists of :

• Balance and neuromuscular control (category A)
• Sport-specific training. Examples include plyometric training with jumping manoeuvres for a volleyball player; running and cutting drills for a soccer player. Time to return to sport will vary.
• Application of a brace or tape during sport-specific training

Important information on chronic ankle instability (CAI) you can find here

Resources

Diagnosis and Treatment of Chronic Ankle Instability: https://www.intechopen.com/chapters/69414

Mayo Clinic: Sprained ankle: https://www.mayoclinic.org/diseases-conditions/sprained-ankle/symptoms-causes/syc-20353225