June 2018

Management of acute ankle sprains: To immobilize or not?

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Functional rehabilitation training protocols typically consist of stability and postural control exercises aimed at recovering from the proprioceptive defect that occurs after an ankle injury and preventing recurrent sprains by improving stabilometric results.

By Audris Tien, DPM, Jarrod Shapiro, DPM, FACFAS, FACFAOM, Jonathan Labovitz, DPM, FACFAS, CHCQM

It is a common medical provider’s experience to examine a patient with a chief complaint of ankle pain after sustaining an ankle sprain. Ankle sprains are the most common musculoskeletal injury, accounting for 10–30% of all musculoskeletal injuries in the athletic population.1 It is estimated that 1 in every 10,000 persons sustains an ankle inversion injury every day in the United States.2 Lateral ankle sprains account for 85% of all ankle sprains.1 The most common injury mechanism is inversion of the plantarflexed foot, causing damage to the lateral ligament complex of the ankle.3 The anterior talofibular ligament (ATFL) is the weakest of the lateral ankle ligament complex and is most frequently injured.4 Brostrom conducted an extensive clinical study of ankle ligament injuries and found that an isolated, complete rupture of the ATFL was present in 65% of acute ankle sprains, while a combination injury involving the ATFL and calcaneofibular ligaments (CFL) occurred 20% of the time.5-7

Many classification systems, both anatomical and functional, have been described for lateral ankle sprains:8

  • Grade I injuries involve stretched ligaments without macroscopic tearing, little swelling or tenderness, minimal or no functional loss, and no mechanical instability of the joint.
  • Grade II injuries involve a partial macroscopic tear in the ligament with moderate pain, swelling, and tenderness over the involved structures. There is some loss of ankle joint movement and mild to moderate instability.
  • Grade III injuries involve a complete rupture of the ligament with marked swelling, hemorrhage, and tenderness. Loss of function is evident, with abnormal motion and instability of the joint.

A more useful clinical approach divides these injuries into stable and unstable injuries based on the findings of the anterior drawer and talar tilt test.8 Despite the high prevalence of ankle injuries, non-surgical management remains controversial and centered around this question: should we immobilize the acute ankle injury or not?

Despite the extremely high prevalence of ankle sprain injuries as well as the drive toward evidence-based medicine, there are surprisingly few well-conducted level 1 studies to guide therapy for healthy young adults or the elderly.

What is functional rehabilitation?

With so much emphasis on functional rehabilitation as the mainstay of treatment, it is prudent to outline its essential components. Functional treatment can be divided into three phases:9

  1. RICE therapy (rest, ice, compression, elevation)
  2. Limited immobilization when needed
  3. Early, active range of motion exercises.

According to Tscherne et al,10 functional treatment can be defined as a form of therapy in which the involved segment of the locomotor system is either not immobilized at all or the immobilization is incomplete and lasts only for a limited time. In the acute phase after an injury, the main objectives are pain relief and reduction of swelling, which are addressed by a short period of immobilization. However, as quickly as possible after the injury, treatment is aimed at restoring range of motion and proprioception. Full weight bearing is one of the most important aspects of early rehabilitation.11

Functional rehabilitation is an extension of the traditional elements of physical therapy, incorporating agility and proprioceptive training, in addition to strength and flexibility with the goal of returning to pre-injury levels of activity while reducing the risk of recurrent injury.12 Goals of the progressive rehabilitation program include:13

  • restoring range of motion (especially dorsiflexion)
  • restoring strength (especially the peroneal muscles)
  • restoring proprioception
  • returning to activity safely.

Specific to ankle sprains, functional rehabilitation training protocols typically consist of stability and postural control exercises aimed at recovering from the proprioceptive defect that occurs after an ankle injury and preventing recurrent sprains by improving stabilometric results.14 Devices commonly used by physical therapists that aid in stability training are the wobble balance board/biomechanical ankle platform system (BAPS) or ankle disk. The positive effects of these methods on proprioception have been demonstrated in various studies.15-17 The rehabilitative protocol for an ankle sprain injury is based on building strength of the peroneal muscles and regaining normal proprioceptive function and protective reflexes.

Functional rehabilitation vs cast immobilization

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Generally, there are two approaches to conservative treatment of the acute ankle sprain: immobilization (usually with a cast) and functional rehabilitation. Almost all authors have concluded that grade I or II ankle sprains recover quickly with non-operative management and with a good prognosis.9 Multiple studies18-22 have advocated for functional treatment instead of 4-week cast immobilization as it provides more rapid recovery of ankle mobility, early return to work and physical activity without compromising mechanical stability of the ankle. Furthermore, functional treatment is free of the complications of cast immobilization, such as joint stiffness, muscle atrophy, loss of proprioception, and increased risk of deep vein thrombosis. A single-blinded randomized controlled study by Lamb et al23 compared the effectiveness of three different mechanical supports (Aircast® brace, Bledsoe® boot, or below-knee cast) against double-layer tubular compression bandage in promoting recovery after severe ankle sprains. They found that a 10-day duration of complete immobilization in a below-knee cast or, alternatively, the Aircast® brace resulted in faster recovery than if the patient used only the tubular compression bandage. However, the advantages conferred by the treatments other than tubular compression bandage decreased over time as differences in outcomes were much more pronounced at 3 months than at 9 months. Furthermore, a major shortcoming of this study was that it compared different methods of immobilization but did not take functional treatment into consideration.

The quality of currently available evidence to guide therapeutic treatment is poor. The 2015 randomized control trial by Naeem et al18 that compared functional treatment to plaster-of-paris casting failed to describe the various treatment arm protocols, leaving out pertinent information such as length of immobilization in the cast and denoting only “TG” for the functional treatment group. With such omissions, these authors and other readers can only presume that the functional treatment group only received Tubigrip® compression stockings. Given the limited protocol details, their findings of functional rehabilitation besting casting is impossible for others to validate in terms of pain reduction and improved functional stability.

Additionally, the heavily cited Cochrane review published by Kerkhoff19 in 2002 that favored functional treatment when compared with immobilization was withdrawn from publication in 2013 due to being substantially out of date. The Cochrane review in its entirety is unavailable to be viewed by readers, thus limiting the review of current literature by the authors of this article and corroboration of other articles citing Kerkhoff’s review. There has been no new systematic review of that caliber published since then. The review by Vuurberg20 in 2018 does not change the currently accepted recommendations of advocating for functional supports over immobilization.

For grade III sprains, treatment is also controversial. Some researchers advocate for early mobilization for all types of injuries, while others manage grade III ligament injuries with cast immobilization or surgical repair.24 A nonsystematic review by Kannus et al9 examined seven studies that had three treatment groups: primary surgical repair followed by casting versus casting alone versus functional rehabilitation. They found that four of the seven authors recommended functional treatment without any reservations, with the exception of the high-functioning athlete in whom primary surgical repair may be the preferred treatment option. The general consensus of this review is early rehabilitation should be the mainstay of management.11 If such treatment fails to restore the patient to pre-injury levels of activity after a considerable period of time, surgical repair can be performed later.25 Most authors appear to agree: immobilization should probably never be used, including Grade III injuries despite the literature’s controversial recommendations on this issue.11,26

From RICE to PRICE

RICE—rest, ice, compression, and elevation—is the generally accepted first-round treatment for inflammation after an acute ankle sprain.27-28 Inflammation causes pain, edema, hyperalgesia, and erythema, all of which can limit the patient’s ability to perform the rehabilitation required for proper healing.29 However, we now know that protecting the ankle after an acute ligamentous injury plays a significant role in controlling the swelling and inflammation that can occur in the first 24-48 hours after an injury; as such, PRICE—Protection, Rest, Ice, Compression, and Elevation—should become the new clinical mnemonic for the treatment of inflammation after trauma. A short period of immobilization to protect the injured ankle facilitates a rapid decrease in pain and swelling. A randomized control trial with 51 patients by Bilgic and colleagues concluded that treatment of acute ankle sprains with an elastic bandage was more effective than a splint in reducing edema after 7 days of treatment. The authors postulated that the elastic bandage preserves joint motion, thereby reducing the extent of edema.30 Accumulation of fluid and edema around an injury site increases tissue damage, delays healing, and results in some degree of chronic disability.31 Although there is insufficient evidence available from randomized control trials to determine the effectiveness of RICE therapy for acute ankle sprains,20,32,33 we believe that the use of ice and compression, in combination with protection, rest, and elevation are important aspects of treatment in the acute ankle sprain. A short period of protection and immobilization is indicated during the acute phase to control pain and swelling, but early functional rehabilitation should begin as soon as possible.

Role of External Supports

There is a plethora of removable external products to support the injured ankle during the acute inflammatory phase, including the Air-Stirrup Ankle Brace®, lace-up braces, and taping. The superiority of one external support over another is debated rigorously in the literature.33-35 A Cochrane Collaboration meta-analysis33 published in 2002 demonstrated lace-up bracing or semi-rigid bracing had better results when compared with the use of an elastic bandage or taping in terms of more rapid return to work and activity and decreased swelling at short-term follow up. However, it must be noted that this Cochrane review also has been withdrawn from publication due to its substantial age.

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Conclusion

Despite the extremely high prevalence of ankle sprain injuries as well as the drive toward evidence-based medicine, there are surprisingly few well-conducted level 1 studies to guide therapy for healthy young adults or the elderly. Based upon a review of the literature and available evidence, our recommendation for all acute ankle sprains includes short-term immobilization in a cast or a removable semi-rigid or lace-up brace for 7-10 days followed by early, functional rehabilitation. After a short period of immobilization, patients should be encouraged to weight-bear as tolerated as early as possible. However, they may require a period of protected weight bearing in a removable lace-up or semi-rigid ankle brace prior to gradual return to regular shoe gear. Supervised functional rehabilitation should begin with the goal of returning patients to their pre-injury level of activity. A functional rehabilitation program that emphasizes proprioception training remains at the core of the treatment for ankle sprains, but a short period of immobilization allows the patient to navigate the acute inflammatory phase of healing and progress to functional treatment more rapidly with better long-term-return to activity.

Dr. Tien is a second-year resident at Chino Valley Medical Center in Chino, CA. Dr. Shapiro is the residency director of Chino Valley Medical Center and associate professor at Western University of Health Sciences in Pomona, CA. Dr. Labovitz is Assistant Dean of Clinical Education and a professor at Western University of Health Sciences in Pomona, CA.

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One Response to Management of acute ankle sprains: To immobilize or not?

  1. Casper Ozinga says:

    A very interesting article especially in the area of apparent lack of research.
    Should there be a a Grade 4? This would include the description of grade three but as well common fractures like the distal end of the fibula and the base of the 5th Metatarsal. This possibility is frequently ignored by attending physicians and off course will only show up in an x ray

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