Lateral ankle sprains account for almost a quarter of all sports injuries and are a common presentation to Emergency Departments. Conventional treatments are varied and range from immobilization and minimal wrapping to surgical repair. ScientiFIT investigates the efficacy of treatment protocols and prevention of ankle sprains.
Ankle Sprains – Establishing the Basics
Ankle Sprain – Definition
A lateral ankle sprain is the rupture of one, two or all three ligaments on the outside of an ankle; grades I, II and III, respectively. One should also distinguish “acute” sprains versus “chronic” instability, the latter being subsequent looseness of the ankle and recurrent sprains months after a traumatic event.
Ankle Sprain – Predisposing Factors
While causation is not supported by studies, it has been suggested that activities with vertical jumping and fast cutting movements (i.e., basketball, tennis, volleyball), running on uneven surfaces, high arches and tight heel cords and more importantly, history of previous sprains are factors that correlate with acute injuries.
Investigating Treatment and Prevention of Ankle Sprains
To RICE or not to RICE
Rest, use of intermittent application of Ice (20 minutes per hour), a Compression wrap, along with Elevation has proven to be an appropriate protocol for pain management and reduction of swelling. The RICE protocol shows better results when compared to heating pads, ice alone and compression alone. Of note, RICE is only useful in the first 24-36 hours after injury and may have a detrimental effect on rehabilitation if used longer.
Cast immobilization and Weight Bearing
Review of scientific literature shows that long immobilization (4 weeks or more) is significantly less effective when compared to other means of functional therapy. Cast immobilization is noted to be slightly effective only when it is performed for less than a week and in grade III ankle sprains. Functional bracing and continued weight bearing is superior in early recovery.
Over-the-counter NSAIDs (i.e. Advil, Aspirin, Naproxin) are used both for pain management and anti-inflammation. A review of literature shows no scientific evidence either for or against anti-inflammatory use in ankle sprains. Though reduction of swelling plays a role in healing, use of medications alone has not shown conclusive results.
Preferred Functional Therapy
Multiple studies compare efficacy of semi-rigid braces, elastic bandages, taping and immobilization boots, as well as casting following lateral ankle sprains. A systematic review of these papers suggests that when used for 4-6 weeks, a lace up or semi-rigid ankle brace (air cast) is superior to any other intervention both transiently and long term.
Rehab and Prevention
In an acute injury, the main objective is pain relief, but starting sub-acutely after injury, the rehabilitation targets restoration of range of motion without loss of proprioception (i.e. sense of balance). A mainstay of rehabilitation and recovery is functional physical therapy. This includes early weight bearing, ankle range of motion exercises, proprioception training (on a balance board or comparable techniques) and early return to activity with external bracing. Physical therapy usually begins with supervision of a sport physical therapist and exercises are then continued at home. Once recovered, prevention of future ankle sprains is primarily mediated by use of ankle braces and continued balance training. Taping, though popular amongst most athletes, has not shown comparable results.
Foot orthosis and shoe gear
Although a plethora of biomechanical studies link ankle instability with pathological foot types (i.e. abnormally high arches), which are managed vis-à-vis foot orthosis, studies have not been sufficiently powered to link use of orthotics with prevention of ankle injuries. Moreover, low or high top shoe gear has not been thoroughly investigated in prevention of ankle sprains.
Surgical repair in an acute setting is controversial . While surgical repair is performed in both acute and chronic settings, studies provide extensive support for the efficacy of surgical intervention in chronic ankle instability .
Seeking medical care
Distinguishing the extent of an injury is important in any setting. In an athlete, early and correct diagnosis of an injury is the key to early return to activity. ScientiFIT recommends seeking medical care if there is any doubt in extent of the injury, especially if bruising, pain on bone, pain with compression and pain with weight bearing persist on the morning after the injury.
Ankle Sprains – Conclusion
Following an injury:
- Seek medical care to rule out a fracture, high ankle sprain or dislocation and to start the treatment process.
- Treat an acute injury with Rest, intermittent Icing, Compression, Elevation for the first day. • Start early weight bearing in a lace up or semi-rigid ankle brace as soon as pain is managed.
- Start a functional therapy routine targeting range of motion exercises and proprioception training within the first week and increase sport-specific exercises at the start of 4th week of rehab.
- Prevention is the key and using a supportive lace up or semi-rigid brace during activity is the best option.
- Corrective orthotics are helpful but its role in prevention needs further investigation.
- Surgery could be beneficial in properly diagnosed ankle instability cases, and should be ultimately discussed with a specialist.