Ankle Sprain Treatment & Management

Pain reduction is essential, but improvement of any loss of motion, strength, and/or proprioception is equally important.^{[4, 5, 6]} For recurrent lateral ankle sprains, treatment should begin with a trial of conservative therapy for approximately 2-3 months.

It is generally accepted that for most patients, operative repair of third-degree ATFL tears and medial ankle ligament tears does not contribute to an improved outcome. One of the few absolute indications for surgery in patients with sprained ankles is a distal talofibular ligament third-degree sprain that causes widening of the ankle mortise. A second indication is a deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise.

Physical therapy during the recovery phase is aimed at the patient regaining full ROM, strength, and proprioceptive abilities.

The acute phase of treatment should last for 1-3 days after the injury. The goals of acute treatment are to control pain, minimize swelling, and maintain or regain ROM.

RICE/PRICES

Rest, ice, compression, and elevation (ie, RICE) are the mainstays of acute treatment; more comprehensively, the combination of protection, relative rest, ice, compression, elevation, and support (PRICES) is used.^[1]

Protective devices include air splints or plastic and Velcro braces. Most sprains can be treated without casting. Depending on the severity of the sprain, protective devices are used for 4-21 days. Criteria for discontinuing use of a device include minimal swelling and pain at the site of injury. The ROM should be smooth, particularly with dorsiflexion and plantar flexion.

Relative rest is advocated, because it promotes tissue healing. Advise the patient to avoid activities that cause increased pain or swelling. Advocate early, pain-free movements during this time. Encourage patients to take their ankle out of their brace and move it through a pain-free ROM. Aggressive pain-free ROM is recommended. Having patients spell the letters of the alphabet with their foot and ankle several times per day is one simple activity to recommend even in an acute care setting.

Use ice to control swelling, pain, and muscle spasm. As a rule, do not apply ice or cold packs directly to the skin; wrap the pack in a towel before use. Recommend that the patient apply ice for 15-20 minutes, 3 times daily. Contrast baths can be used 24-48 hours after injury.

Recommend the use of compression with an ACE wrap, an elastic ankle sleeve, or a lace-up ankle support. Advise the patient that further support of the ankle can be facilitated by wearing high-top, lace-up shoes. This can help to minimize edema.^[10]

Encourage elevation of the injured ankle to facilitate the reduction of swelling. Advise the patient to keep the ankle above the level of the heart.

Support can include taping or the use of lace-up ankle supports with combination hook-eye (ie, Velcro) straps.^[10]

Ankle braces

Immobilization can aid healing but can hinder it as well. Acutely protecting the weakened, painful area is appropriate, but prolonged immobilization leads to muscle atrophy and loss of motion. Limited stress creates a stronger scar formation, because the collagen fibers line up parallel to the stress instead of at random. For these reasons, limited immobilization with a stirrup or lace-up ankle brace is usually used, whereas casting is avoided. (See the images below.)

However, results from the Collaborative Ankle Support Trial (CAST) indicated that there are benefits to the use of a below-knee cast for 10 days. CAST was a randomized, controlled trial designed to estimate the clinical effectiveness and cost-effectiveness of 3 methods of ankle support compared with double-layer, tubular compression bandage. The below-knee cast and the Aircast brace (applied 2-3 days after injury, to allow time for swelling to resolve) offered cost-effective alternatives to tubular bandages for acute, severe ankle sprains, with the below-knee cast having the advantage in terms of overall recovery at 3 months. Because no differences in long-term outcome were noted, the investigators suggested that practitioners should consider likely compliance and acceptability to patients when choosing a brace.^[41]

Occasionally, the use of posterior splinting and crutches with non–weight-bearing ambulation is helpful for more severe ankle sprains (ie, when foot motion and weight bearing are extremely painful). Usually, the use of a posterior splint is limited to a few days, and weight bearing as tolerated is encouraged.

In general, ankle splints are applied to minimize movement and provide support and comfort by stabilizing an injury at that joint. Splints are primarily used to stabilize injuries to bones until the patient can be evaluated by a consultant, such as an orthopedic surgeon. Splints are also used to achieve immobilization for primary healing or in the presurgical period. All patients with injuries that are splinted should be referred for evaluation by a consultant in a timely fashion (usually within 2-3 d).

To see complete information on Splinting, Ankle, please go to the main article by clicking here.

Ankle braces have been shown to be effective in preventing some types of ankle sprains.^{[42, 43, 44, 45, 46, 47, 48]} The use of high-top shoes has been proposed to prevent ankle injuries, but study results have been mixed.^{[47, 48, 49, 50]}

Ankle taping can increase ankle stability by at least 2 mechanisms: limitation of motion and proprioception.^[51] For a single treatment, ankle taping is less expensive than either a brace or an athletic shoe. Initially, the effectiveness of ankle taping is similar to bracing.^{[52, 53]} However, studies have demonstrated a significant loss of effectiveness after 24 minutes of activity^[54] ; moreover, ankle taping becomes virtually ineffective after periods as short as 40 minutes.^[55]

The effectiveness of ankle taping is highly dependent on the expertise of the individual who performs the taping. Although the primary effect is improved proprioceptive function, taping may also cause variable effects on motor performance. Ankle taping has the potential to either enhance or hinder the function of the peroneal muscles, depending on the location and technique with which the ankle was taped. Thus, having an experienced, certified athletic trainer (ATC) or physical therapist do the taping usually produces optimal results. In general, athletes without easy access to an ATC or physical therapist may find an ankle brace easier to use and more effective.

To see complete information on Ankle Taping and Bracing, please go to the main article by clicking here.

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in treating sprains is somewhat controversial.^[56] Some physicians argue that the anti-inflammatory effects of NSAIDs are helpful in decreasing swelling, which ultimately increases the speed of recovery. Others believe that acutely used NSAIDs can lead to increased swelling if, owing to platelet inhibition, bleeding occurs.^{[56, 57]}

If NSAIDs are not used, acetaminophen (Tylenol, Panadol, Anacin Aspirin Free) or other pain medicines may be required for pain control in some athletes with moderate to severe ankle sprains.^[58]

For recurrent lateral ankle sprains, treatment should begin with a trial of conservative therapy for approximately 2-3 months. The treatment goals include the patient regaining full strength in the affected ankle, being provided protective support as needed, and returning to activity participation. These goals are accomplished through ROM and strength exercises, sports-specific functional progression, protective support as needed, and weight-bearing, multidirectional balance exercises.^[59]

Other therapeutic strategies include the use of lateral heel wedges, peroneal muscle strengthening, proprioceptive/coordination exercise, taping, and ankle-foot orthoses with ankle and subtalar support.^[60] However, these options are seldom accepted on a long-term basis (especially in athletes), and surgical stabilization is, in many cases, the treatment of choice.

For recurrent sprains that involve the medial ligaments, slight modifications to the conservative treatment of lateral sprains are used. These include ankle stirrup bracing, casting, and orthoses (in addition to physical therapy). Once again, if these measures are unsuccessful, surgical intervention is necessary.

In syndesmotic injuries, when a diastasis has been present for longer than 3 months, significant arthritic changes have probably begun. Diastasis refers to any loosening in the attachment of the fibula to the tibia at the inferior tibiofibular joint. In most cases, arthroscopic evaluation of the ankle joint is helpful in determining the best course of management. Surgical options are discussed below.

Chronic instability of the subtalar joint frequently requires surgical intervention. Despite this, the treatment is initially nonsurgical and is similar to the conservative management of recurrent or chronic lateral ankle instability. This includes peroneal strengthening, proprioceptive training, Achilles tendon stretching, and the use of a brace. Taping of the ankle by an athletic trainer can be of benefit, especially when a subtalar sling modification is incorporated.

In most patients, operative repair of third-degree ATFL tears and medial ankle ligament tears does not contribute to an improved outcome. One of the few absolute indications for surgery in patients with a sprained ankle is a distal talofibular ligament third-degree sprain that causes widening of the ankle mortise. A second indication for surgical treatment of acute ankle sprains is a deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise. In selected young patients with high athletic demands who have both anterior talofibular and calcaneofibular complete ruptures, surgical repair may be the treatment of choice. Further research is needed to determine the best treatment for complete double-ligament lateral ankle sprains.

Surgical procedures for chronic ankle instability and sprains vary greatly in their ability to correct subtalar instability. A review of the literature showed the Watson-Jones procedure to be associated with subjective instability 20-90% of the time, and the Evans procedure, 20-33%. In addition, with the Evans procedure, a persistent anterior drawer sign was found in 45-60% of patients. In the Chrisman-Snook procedure, 13-30% of patients had subjective persistent instability. Decreased inversion is common with all these procedures.

For more information, see Surgical Interventions in Ankle Sprain.

Athletes with ankle sprains may return to activities as permitted by their symptoms. The physician may have to design a strict regimen of activities, because many athletes have a tendency to ignore pain during activities. In general, individuals should start with in-line activities (eg, jogging) and then progress to forward-backward and side-to-side activities. Pivoting and cutting activities are added only when the athlete is minimally symptomatic with the previous activities.

Return-to-play criteria during the recovery phase (3 d to 2 wk post injury) include the following:

• Full, pain-free active and passive ROM
• No pain or tenderness
• Strength of ankle muscles 70-80% of that on the uninvolved side
• Ability to balance on 1 leg for 30 seconds with eyes closed

Return-to-play criteria during the functional phase (2-6 weeks postinjury) include the following:

• Normal ROM of the ankle joint
• No pain or tenderness
• Satisfactory clinical examination
• Strength of ankle muscles 90% of the uninvolved side
• Ability to complete functional examination

The treatment plan during the recovery phase is aimed at the patient regaining full ROM, strength, and proprioceptive abilities. Strengthening is started with isometric exercises and advanced to the use of elastic bands or surgical tubing, as shown below.

Strengthening is performed in the following 4 cardinal ankle motions: dorsiflexion, plantar flexion, eversion, and inversion. Strengthening of the peroneals, which act as dynamic stabilizers of the ankle, is critical.

Proprioception rehabilitation begins with single-leg-stance exercises in a single plane and progresses to multiplanar exercises. The patient stands on the injured side with the foot and arch in a neutral position and holds the foot of the uninjured side off the ground. For safety, this exercise should be completed near a wall. Initially, the patient looks at the feet and attempts to hold the position. When the patient can comfortably and easily hold the position for 3 minutes, he/she changes the focus of the eyes to a location in front of the body. When the patient can comfortably and easily hold the position with the eyes looking forward for 3 minutes, the position is then held with the eyes closed. A modified Romberg test may be useful in evaluating the progression of proprioceptive rehabilitation.

Other useful exercises include the use of a balance or tilt board, as shown below; these can be made by attaching a dowel or half of a croquet ball to the bottom of a piece of plywood. The athlete stands on the board and attempts to control balance while touching the board to the floor in a controlled manner to complete various patterns (eg, 4 points of the compass). Finally, the athlete advances to functional drills, jogging, sprinting, and cutting, and then progresses to figure-of-eight and carioca drills.^[61]

Studies have shown that at least 40% of acute ankle sprains result in residual ankle symptoms at 6 months.^{[62, 63]} At least 10-20% of acute ankle sprains result in residual ankle instability, pain, or other chronic symptoms.^{[64, 13, 65]}

If pain persists despite rehabilitation, further workup is indicated. Diagnoses to consider include the following:

• Chronic lateral ankle instability typically is accompanied by a feeling of instability by the patient. Swelling is noted with activity, and recovery is prolonged.
• Intra-articular meniscoid lesions represent localized fibrotic synovitis in the lateral ankle following inversion sprains. The condition also is known as impingement syndrome.
• Peroneal tendon subluxation is due to detachment of the peroneal retinaculum from its normal insertion on the posterior border of the fibula to the lateral surface of the fibula.
• Talar dome fracture occurs with inversion and eversion injuries, but it may not be readily seen on radiographs.
• Anterior process fracture of the calcaneus occurs with inversion injuries. Patients commonly display bony tenderness rather than ligamentous point tenderness.
• Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy, can develop after ankle sprains. The reason for this is unknown; however, the condition may arise from an abnormal response to disuse and/or splinting of the foot and ankle. Early, controlled activity and rehabilitation may prevent the development of CRPS.

The prevention of future ankle sprains depends on the type of activity in which the patient is engaged. Certain sports (eg, soccer, basketball, volleyball) have a high incidence of ankle sprains.^{[1, 10, 66, 67, 68]}

Athletes must understand the importance of adequate training and conditioning to prevent future injury or to minimize injury severity. An adequate warm-up period and a gradual transition into activity are general principles that also can be applied to prevent future injury. The athlete should wear shoes with good stability and, if possible, should exercise on even surfaces.^[67] High-top shoes, lace-up ankle braces, Velcro ankle braces, and/or ankle taping may add stability during activities and prevent further injury.^[69]

Consultations are seldom indicated unless the physician suspects that the ankle or a fracture is unstable. Most ligamentous injuries and fractures heal well after 4-6 weeks of guarded weight-bearing and guarded motion, along with a progressive rehabilitation program (as previously outlined). Surgical intervention by an orthopedic or podiatric surgeon may be warranted in these situations. The clinician simply has to determine a comfort level in treating a particular condition. Once that level has been exceeded, consultation with the appropriate specialist is indicated.