Management of Ankle Sprains

Introduction

Ankle sprains are considered one of the most common traumatic injuries. Yang et al. [1] conducted an epidemiological study on unilateral ankle sprains and found that the dominant leg was 2.4 times more likely to suffer from ankle sprains than the non-dominant leg. [1] It was also reported that The more plantarflexed you are at landing (i.e. when you hit the ground), the more likely you are to sprain. [2] Conservative management is the most common treatment for ankle injuries. The prognosis is generally good, but there are many risk factors that affect recovery. [3] These Factors detected early can signal practitioners to take a more aggressive approach during an initial conservative treatment period. [3]

Clinically Relevant Anatomy

Lateral Ligaments

Lateral Ankle Sprain

The literature indicates that 85% of ankle sprains involve the lateral ligaments. [4] When a lateral ankle sprain occurs, the anterior talofibular ligament (ATFL) of the lateral malleolus ligament complex is most commonly damaged. Anatomic location and mechanism of injury imply that The calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL) are less likely to withstand damaging loads.

Medial Ligaments

Medial Ankle Sprain

On the medial side, the powerful deltoid ligament complexes [posterior tibiotalar (PTTL) tibiotalar (TCL) tibioscaphoid (TNL) and anterior tibiotalar ligament (ATTL)] are injured by the powerful pronation and rotational movements of the rear foot. [5]

Syndesmosis Ligaments

Syndesmotic Ankle Sprain

The stabilizing ligaments of the inferior tibiofibular syndesmosis are the anterior inferior ligament, posterior inferior and transverse ligament, interosseous ligament, and inferior transverse ligament. syndesmotic sprain Dorsiflexion of the leg and ankle.

Risk Factors and Outcome

Various predisposing factors have been identified as risk factors for ankle sprains. [3] These risk factors can have a significant impact on a patient’s recovery, so it is important for clinicians to identify risk factors in order to select the most appropriate treatment options. [3] They are Divided into two categories: intrinsic and extrinsic.

Intrinsic risk factors for outcome prediction include:[5]

• Age and sex: Female athletes have a 25% higher risk of grade I ankle sprains[6]
• Height and weight: An increase in height or weight increases the risk of sprains proportionally because the magnitude of reverse torque increases
• The grade of injury
• Functional status
• Related injuries, especially previous sprains
• Limb characteristics: Limb dominance Anatomical foot shape and foot joint laxity Anatomical alignment Range of motion of the ankle-foot complex including foot biomechanical abnormalities such as flat feet and increased hindfoot pronation are risk factors for lower extremity overuse Injuried. [7]
• Muscle strength
• Posture especially postural swing: Increased swing was associated with a 7-fold increase in ankle sprains[8]

External risk factors for outcome prediction include:

• Level of play: Higher level of play = more ankle sprains
• Ankle bracing or taping: early introduction of this procedure can reduce the risk of recurrent ankle sprains
• Shoe type
• Lack of warm-up stretching
• Landing technique after a jump[4]

In summary, the following prognostic factors predict a good clinical outcome after foot and ankle trauma:[3]

• Younger age
• Low-grade sprain
• Low activity level
• Good functional status
• Good neuromuscular function
• No associated injury[3]

Long-term symptoms with functional limitations can be predicted based on presence.

• Systemic laxity
• Joint geometry
• Limb and foot malalignment
• Re-sprain
• Multi-ligament injury[3]

Classification Grading Systems

Grades of Ankle Sprains

Muscle injuries can be classified as grade I II or III depending on their severity. They can also be classified as moderate and severe uncomplicated tumors based on a functional classification system.

• Grade I represents a minor injury that does not extend the tendon
• Grade II has macroscopic stretching but the ligament remains intact or may be partially torn if severely strained
• Grade III is a complete rupture of the tendons

Mild and moderate fractures are usually grades I and II, respectively. Characterized by the patient’s inability to run and jump easily when climbing stairs and discomfort. In this tumor, the tissue is intact.

Moderate dislocations require assisted walking where there is considerable pain with swelling and scarring.

Severe ulcer is a grade III ulcer that is severe and requires further examination if the patient has a fractured ankle. Immobilization is usually required for 10 days or more and surgery is often the treatment of choice.

Diagnostic Procedures

Other assessments including:

X-ray: allows to rule out an ankle or midfoot fracture within 7 days of the injury. Testing in a weight-bearing environment is recommended.

Ultrasound: considered as a good tool to assess ligamentous injury weak function and joint instability. The accuracy of the test depends on the skill of the personnel performing the test and the condition of the equipment. Ultrasound is less sensitive than MRI in the diagnosis of severe infection the biggest in football.[9][10]

MRI Ankle Sprain

MRI: the gold standard for assessing nerve damage.[10] It helps to identify severe tears of the anterior talofibular and calcaneofibular ligaments. But a false-negative diagnosis can be a challenge for the referring physician. MRI is not considered a routine examination in. acute ankle injury because of the high cost of the test and limited accessibility and the high incidence of this type of injury. MRI can be very helpful in suspecting other injuries including syndesmotic injury tendon pathologies or in case of significant chronic ankle instability further research.[10]

CT scan: not routinely recommended as a diagnostic tool in ankle injuries. The recommendation is made on a case-by-case basis.

Management

The earlier the musculoskeletal rehabilitation care began after ankle fracture, the greater the likelihood of recurrence and the decrease in medical costs related to the lower ankle.[11]

An algorithm for acute ankle sprain. From: Halabchi F Hassabi M. Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World J Orthop. 2020 Oct 18;11(12):534-558.

The following are the guidelines issued and published in 2013 by the National Athletic Trainers’ Association (NATA).[9] The second set of guidelines is adapted from a document published in 2020 by the World Journal of Orthopedic (WJO).[4] Part A in the NATA publication indicates that the recommendations are based on consistent and positive patient-related evidence and defined by inconsistent and poor-quality patient-related evidence in category B. Halabchi and Hassabi[4] in their guidelines published in the WJO use levels 1 2 and 3 of clinical evidence to support their recommendations:

Level 1: evidence is obtained from at least one well-designed randomized controlled trial.

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

Level 3: obtain evidence from well-designed randomized trials without randomisation.

Acute Phase

Rehabilitation Goals:

1. Pain reduction. Activities should be performed NICE (i.e. non-steroidal anti-inflammatory ice compression elevation) and EASY (i.e. wearing external aids up to one year post-injury).[12]
2. A gradual return. Follow the POLICE acronym (Safety Optimal Loading Integrated Control Exercises).[12]
3. The restoration of the body itself. The tasks performed should be purposefully ongoing (from simple to complex) and appropriate. [12] .

RICE

In the acute phase of an ankle sprain, the treatment of choice is RICE, which consists of resting ice compression elevation.

• Rest: Treatment options include elevating the injured leg 15-25 cm above the level of the heart to aid in lymphatic drainage.
• Ice: Considered a routine treatment for 3-7 days after an injury to reduce pain and swelling. There is limited evidence that it reduces symptoms after an ankle sprain (Grade 1), and there is no evidence that it reduces swelling and reduces pain (Grade 2).
• Compression: Used to control swelling and improve quality of life. Compression methods include elastic bandages or splints. The effectiveness of compression has limited research support (Grade 2).
• Elevations: No controlled trials have been conducted to examine the effectiveness of elevations for ankle sprains.

RICE enjoys a high reputation in the world of orthopedics. Other acronyms for Soft Tissue Injury Principle exist and you can read more about them by clicking on the following links: Price (Protection Rest Ice Compression Lift) Police and Peace and Love.

Immobilisation

1. Ankle Lace-Up Brace

   Grade I and II Ankle Sprains: Recommendations include early mobilization and functional support for functional recovery (Grade 1 Category A).

2. Grade III Ankle Sprain: Immobilize with a below-knee cast or rigid brace for 10 days (Grade 2, Category B) followed by controlled therapeutic exercises (category B).

• Immobilization in the form of an ankle brace loads and protects damaged tissue (Class A Level 2) [13] and should be used for at least 6 months after a moderate or severe sprain. Semi-rigid or lace-up braces are preferred over elastic bandages (Grade 1) etc. More effective than rigid or elastic tape (grade 2). This type of brace is recommended for anyone with a history of ankle sprains.
• Kinesio taping may not provide adequate mechanical support for unstable joints (Grade 1).
• Randomized control trials are not available at baseline for medial or syndesmotic sprains with immobilisation. [10] .
• The choice of aid depends on the severity of the injury.

Modalities

• Electrical stimulation: no evidence in the literature to support the modality used in reducing pain or edema (level 1).
• Laser: no evidence for the use of laser to reduce pain and edema (section 1).
• Therapeutic ultrasound: no effect on pain edema activity and return to play (level 1). Ultrasound is not indicated for the management of ankle sprains.[13]
• Shortwave diathermy: no evidence for use in the management of ankle sprains (level 2).

Weight Bearing

‘Protected weight bearing for 2 weeks early for all types of fractures helps to:[14]

• Swelling reduction
• How to restore normal motion
• Return to normal activity
• Preventing prolonged mechanical instability

Manual Therapy

Manual techniques involved in the management of severe ankle sprains consist of anterior to posterior talocrural glides and talocrural distraction in a neutral position.[15] In addition, techniques such as soft tissue massage and manual lymphadenectomy are recommended. Dorsiflexion passive form of movement can be performed in both positions with or without weight bearing.[4]

The use of hand therapy resulted in:

• Pain reduction (level 1)[16]
• Reduction of stiffness
• Improvement of ankle dorsiflexion(level 1 category B) .
• Improvement in stride length
• Better proprioceptive awareness
• Functional recovery (section 2 section B) .

Exercises

Therapeutic exercise is considered an important part of the rehabilitation program for acute ankle fractures. But no specific content and training levels were specified.[4] The expected outcome of exercise is: decreased injury recurrence preventing ankle instability reduction in recovery time for self-reported activity improvement (stage 1).

Exercises should be supervised (Level 1) or based on a regular program (Level 2) and should include the following:

• Range of Motion Exercises (Class B)
• Stretching Exercises (Category B): Begin with an open chain of dorsiflexion extension in all planes, progressing to a closed chain with upper body assistance. The heel rope stretch should be started as soon as possible.
• Strengthening exercises (category B): Grade I sprains begin immediately, Grade II sprains may need to be delayed for Grade III sprains inversion, and ankle eversion should be minimized. The protocol should include slow movements performed within pain limits and high repetitions (eg: 2-4 sets x Repeat 10 times). Beginning with isometric views of the frontal and sagittal planes, progress to isotonic resistance exercises, increasing motion in all planes using weighted elastic bands or manual resistance.

These pictures show examples of progressive active range of motion exercises. The video below shows an example of the progression of strengthening exercises:

• Neuromuscular re-education and proprioceptive exercises (Level 2)

[22]

Neuromuscular Re-education

Neuromuscular reeducation activities performed in acute ankle sprains include:

• Proprioceptive neuromuscular facilitation (PNF) exercises. The use of PNF resulted in significant improvements in ankle functional outcome measures including the Star Excursion Balance Test (SEBT). Implementation of neuromuscular training during the first week of injury increased free pain decreased activity level and inflammation (level 1).
• Balanced training. This exercise should be performed at all stages of preparation (phase A).[9]

Subacute Phase

Rehabilitation goal:

1. To develop a return to work plan with activity limitations and restrictions on participation.

During this phase of the rehabilitation process for a broken ankle, the focus is on:

• Neuromuscular training programs include balance and proprioception tasks with periods of confusion during exercise. Standing balance exercises should be combined with starting on one leg off a board and continuing to maintain balance in an unstable position including both and then an injured leg and the hand support is gradually removed. The same sequence is repeated on the BAPS board.
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