Managing an Ankle Sprain - Evidence Based
Long Story Short!
Multimodal therapies (manipulative, mobilisation, soft tissue release therapies, massage, exercise rehabilitation, dry-needling, multi-joint techniques) have good supportive evidence for managing Grade I & II and Grade III non-surgical ankle sprains.
Ice Therapy techniques are effective with pain management but does not make any difference to the outcome of joint swelling, joint function or pain at rest.
Bracing improves short term swelling, joint function and decreases painful ankle motions and disability.
Early weight-bearing improved overall symptoms, return to normal activity, resorted range of motion and decreased swelling.
Appropriate exercise rehabilitation programs will significantly reduce the recurrence of ankle sprains, by progressing ROM, strengthening and proprioceptive exercises.
Strength programs that incorporated proximal muscular of the hip, thigh and trunk improves the prevalence of chronic ankle instability problems.
Athletes shouldn’t return to competition until sports specific movements are completed perfectly to prevent reinjury occurrence.
Ankle injuries are common. A study conducted by Garrick concluded that ankle injuries account for 10-30% of sporting injuries.(1) A systematic review by Hong concluded that the ankle was the most common site to injury in 24 out of 70 sports.(2) Within the general population epidemiological data from the West Midlands emergency unit in 2005 recorded that 600-700 people out of 100,000 will have an ankle sprain or fracture per year.(3)
Of ankle injury statistics, 85% of injuries are inversion ‘lateral’ ankle sprains.(4) Eversion 'medial' ankle sprains are less common and syndesmotic 'high' ankle sprains account for between 11-17% of ankle sprains in athletic populations.(5) After initially injuring an ankle, it is 80% likely that a sprain will reoccur.(6) 40% of these individuals will develop chronic mechanical instabilities.(7,8)
The cause of chronic symptoms and injury reoccurrence is due to prolonged functional instability, joint stiffness, loss of joint motion and scar tissue.(9,10) Ankle sprain symptoms, including pain, crepitus, weakness, stiffness and instability, will persist if the injury remains untreated.(9)
It is essential that a proper diagnosis of injured structures is obtained early in the management process through a thorough history and physical assessment. With this information, an individualized evidence based treatment intervention plan can be developed and therapy can begin. Appropriate management of ankle sprain injuries in athletes is vital to successful recovery and return to sport.
Types of Ankle Injuries
The ankle joint is comprised of numerous structures which extend and attach into the foot, that can all be damaged during ankle sprain injuries. The three major joint articulations include the talocrural (Tibia/ Fibular/talus), subtalar (talus/calcaneus) and distal tibiofibular syndesmosis (tibia/fibular).(11) These joints are supported by numerous ligaments and membranous structures.
Although lateral sprains are the most common ankle injury, other presentations or differential diagnoses can be mistaken for and/or occur with a lateral ankle sprain.(11) These include medial ankle sprain, high-ankle sprain, fracture, cuboid syndrome and an osteochondral (OCD) lesion.
The lateral or outside portion of the ankle is comprised of the anterior talofibular ligament (ATFL), Calcaneal Fibular Ligament (CFL) and the Posterior Talofibular Ligament (PTFL). Damage to these three ligaments are more common to Inversion 'Lateral' ankle sprains and is caused by forced inversion and plantar flexion of the foot and ankle. Isolated ATFL injuries account for approximately 70% of all lateral ankle sprains.(2) In extensive inversion sprain injuries, fractures to the base of the fibular or fifth metatarsal may occur.
Forced plantar flexion and excessive inversion can also damage the lateral forefoot region and be diagnosed as cuboid syndrome.(11,12) Cuboid syndrome presents as pain and swelling over the cuboid being the dorsolateral region of the foot.(11)
High ‘syndesmotic’ ankle sprains are more commonly caused by forced external rotation and/or hyper-plantar flexion of the foot and ankle. Less common mechanisms of injury can include eversion, inversion in plantar flexion and internal rotation of foot and ankle.(13) The structures involved in high ankle sprains include the tibia and fibular, interosseous membrane and four ligaments; the Anterior Inferior Tibiofibular (AITFL), Posterior Inferior Tibiofibular (PITFL), Interosseous (IOL) and Transverse Tibiofibular Ligaments (TTFL).(13)
The medial or 'inside' area of the ankle is comprised of the deltoid ligament. Damage to the deltoid ligament is common to eversion 'medial' ankle sprains. Medial ankle sprains are caused by forced eversion and/or external rotation of the foot and ankle. The deltoid ligament is made up of five different ligaments. The superficial anterior component of the deltoid ligament includes the Tibionavicular (TNL), Spring (SL) and Tibiocalcaneal ligaments (TCL). The deep component of the deltoid ligament includes the Anterior Tibiotalar (ATTL) and the Posterior Tibotalar Ligaments (PTTL). (5)
If pain and injury does not improve after 4-6 weeks, it is important to consider an OCD lesion of the ankle within the talar dome. Confirmation of diagnosis is generally proven through MRI. Osteochondritis dissecans occur with traumatic sports ankle injuries and presented with persistent pain, instability, crepitus and/or locking symptoms.(11,14,15)
Table of Classification: Lateral Ankle Sprains (LAS), Medial Ankle Sprains (MAS) and High Ankle Sprains (HAS)
Treatment
The main goal when treating ankle injuries is to gain full range of motion, achieve optimal strength of the involved muscles and return static and dynamic stability to its normal capability.(16)
Manual therapy (manipulative, mobilisation, soft tissue release therapies, massage therapies) applied early for soft tissue injuries promotes better healing, a decrease in pain and inflammation, prevention of further injury and promotion of normal joint mobility.(17)
Brantingham et al. reviewed evidence on manipulative therapy techniques for ankle sprains. There was good evidence for manipulative and mobilisation techniques when combined with multimodal or exercise therapy when managing ankle sprains.(18,19)
Manual therapy techniques combined with exercise rehabilitation and rest, ice, compression and elevation (RICE) were effective in diminishing pain and swelling, and improving range of motion (ROM), joint mobility and function for the subjects with acute and subacute ankle inversion sprains. Mobilisation techniques for Grade II ankle sprains produced an increase in Joint ROM and mobility.(18)
Chronic recurrent ankle inversion sprains improved successfully with a multimodal approach of manipulative and mobilisation therapies combined with exercise rehabilitation. Joint proprioception, function, pain reduction and ROM all improved after these multimodal treatment interventions.
Bracing is an effective choice of management for improving joint function and decreasing symptoms of ankle sprains. Bracing has proven to be effective in short-term swelling management and disability as well as preventing painful ankle motions.(11)
Kerkhoffs et al. found that early weight bearing with support improved overall symptoms, return to normal activity, restored range of motion and decreased swelling.(20) Lynch & Rebstrom add that weight bearing and movement improved the recovery of ankle mobility and produced a quicker return to activity without impairing long term stability in grade III non-surgical ankle sprains.(21) Therefore, as soon as gait pattern is not antalgic, weight bearing should be encouraged as soon as possible.(22)
Intermittent Cryotherapy (icing) techniques have been proved effective for managing pain in acute and sub-acute Grade I and II ankle sprains. Over a one-week period, a protocol of 10 minutes of icing, followed by removal for 10 minutes, then reapplied for 10 minutes proved more effective than one 20 minute application for reducing pain.(23) This 10-minute protocol was repeated again after 2 hours. Cryotherapy treatment did not make any difference to the outcome of joint swelling, joint function or pain at rest.(23)
It is important to not neglect peroneal musculature when treating with lateral ankle injuries, as they provide an important role in support for lateral ankle strength and stability. Dry Needling therapies has been thrilling new evidence for improving function and decreasing pain of lateral ankle sprains when inserted in peroneal muscle trigger points.(24)
Management
The recurrence of injuring ankles is very high. A study by van Rinj et al showed that after a 1 year follow up 5-25% of patients still experienced pain and instability.(25) After a 3 year follow up 34% reported reinjury of the ankle.(25) It is of high importance that a proper exercise rehabilitation program is applied, progressive in load and ability to prevent chronic pain and instability, and recurrence of rolling the ankle.
Exercise rehabilitation including ROM exercises, strengthening exercises for soft tissue structures (muscle/tendon/ligament) and neuromuscular control exercises that begin early in the rehabilitation process improved ankle, foot and lower leg function in lateral and syndesmotic sprains.(26,27)
Strengthening exercises for the ankle should consist of full ranges of motion of each movement. Holme et al found that reinjury rate was significantly reduced after a year when a balance and strength training program was initiated the first week after an acute ankle sprain.(28) Banded exercises using resistance bands or tubing which stress ankle motions concentrically and eccentrically were effective in rehabilitating ankle sprains.(22)
Subjects with chronic ankle instability only had strength related problems with eccentric plantar flexion.(22) Therefore, ROM concentric ankle strengthening exercises would prove ineffective in most chronic instability cases. Eccentric strengthening exercises should be introduced at later stages of acute and subacute sprains, and early in chronic instability cases.
Exercise therapies should always include balance and proprioceptive training. Proprioception is the bodies internally generated afferent information system or specific sensory and awareness feedback system. The ankle is rich with proprioceptive feedback providing kinesthesia, resistance, joint and force senses for postural control and joint stability. Ankle sprains demonstrate proprioceptive deficits, especially in chronically unstable ankles. For subjects with chronic ankle instability, balance training progressing from stable to unstable surfaces improved functional performance, postural control and decreased the risk or recurrence of injury.(29,30) Mohammedi showed that proprioceptive training was more effective than orthotics or strength training in reducing the rates of ankle sprains in soccer players.(31)
For Athletes
Athletes should not be allowed to return to play until they demonstrate completion of all sports-specific proprioceptive tasks during their ankle rehabilitation. There is much benefit for acute and subacute injuries as it is for chronic injuries to prepare an athlete for specific-sporting movements and prevent reinjuring the ankle joint. Sports-specific movements i.e. change of direction, single leg hops, bounding should be introduced as the last stage of exercise rehabilitation once normal rehabilitative protocols (ROM, strengthening and non-sport-specific proprioception exercises) have been completed.
Proprioceptive deficits in athletes that have ankle stability issues have impaired the ability to take and transfer load in jumping, landing and directional change exercises.(22) Single leg balance and strength training programs for the lower limb and proximal hip and trunk areas proved significant in reducing chronic ankle instability.(32,33)
The occurrence of ankle instability was increased with athletes that had poor stability and strength through trunk, hip and knee mechanics.(34) It is important that treatment, rehabilitation and strength training protocols address the entire biomechanics of the lower limb to allow for correct force distribution throughout exercise movements. This prevents incorrect muscular force conduction through movements and overload on certain joints such as the ankle.
Conclusion
Multimodal therapies (manipulative, mobilisation, massage, exercise rehabilitation, dry-needling, multi-joint techniques) have good supportive evidence for managing Grade I & II and Grade III non-surgical ankle sprains.
Cryotherapy techniques are effective with pain management but does not make any difference to the outcome of joint swelling, joint function or pain at rest.
Bracing improves short term swelling, joint function and decreases painful ankle motions and disability.
Early weight-bearing improved overall symptoms, return to normal activity, resorted range of motion and decreased swelling.
Appropriate exercise rehabilitation programs will significantly reduce the recurrence of ankle sprains, by progressing ROM, strengthening and proprioceptive exercises.
Strength programs that incorporated proximal muscular of the hip, thigh and trunk improves the prevalence of chronic ankle instability problems.
Athletes shouldn’t return to competition until sports specific movements are completed perfectly to prevent reinjury occurrence.
References
1. Garrick JG. The frequency of injury, mechanism of injury and epidemiology of ankle sprains. The American Journal of Sports medicine. Dec 1977; 5(6):241-2
2. Fong D.T., Hong Y., Chan L.K., Yung P.S., Chan K.M. A systematic review on ankle injury and ankle sprain in sports. Sports Med. 37:73–94. 2007
3. Bridgman S.A., Clement D., Downing A., Walley G., Phair I., Maffulli N. Population-based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains. Emerg Med J. 20:508–10. 2003
4. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train.37:364–75. 2002
5. Stufkens S.A., Van der Bekerom M.P.J., Knupp M., Hintermann B., Van Dijk N.C. The Diagnosis and Treament of Deltoid Ligament Lesions in Supination-External Rotation Ankle Fractures: A Review. Strat Traum Limb Recon. 7:73–85. 2012
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