By P.K. Daniel
High rates of chronic ankle instability in children suggest a need for better prevention and treatment of ankle sprains in young patients, but researchers are just starting to explore whether clinical approaches designed for adults will also be effective in their younger counterparts.
Study findings of surprisingly high rates of chronic ankle instability in children suggest there is a need for increased emphasis on ankle sprain prevention and rehabilitation in the pediatric population. There is some evidence that clinical strategies designed for adults can also be effective in children, but practitioners must often improvise in determining the best approaches for younger patients.
Ankle sprains and resultant chronic ankle instability are common issues among the younger population. More than half of all ankle sprains occur in individuals aged between 10 and 24 years. Teenagers and young adults have the highest rates of ankle sprain, with a peak incidence of 7.2 per 1000 person-years for those aged 15 to 19 years.1
The injury is most commonly seen in basketball, soccer, running, and ballet and other dance disciplines. Ankle injuries are the most common sports injury suffered by high school athletes, with more than 325,000 occurring each year.2-4
The only known predictor of an ankle sprain is a previous ankle sprain. It is estimated that half of people who experience an ankle sprain will have a recurrence. But, because most ankle sprains appear to resolve in two to six weeks, many patients do not seek follow-up care. A more aggressive approach to follow-up care is indicated, according to a 2012 article published in American Family Physician.5
“One of the highest risk factors [for an ankle sprain] is indeed previous history of sprain,” said Thomas W. Kaminski, PhD, ATC, director of athletic training education and professor in the Department of Kinesiology and Applied Physiology at the University of Delaware in Newark.
With the utilization of preventive tools and rehabilitative methods, this problem could be better managed, in children in particular, researchers said.
“Kids are not often rehabilitated like adults, not because we don’t know what to do, but because they are not brought to the attention of a medical practitioner or clinician,” said Australian researcher Claire Hiller, PhD, who coauthored a study on chronic ankle instability in children in the Journal of Foot and Ankle Research.6
“Older children who partake of organized sports may attend clubs or schools with an athletic trainer, but in other parts of the world it is usually only people who are aware of rehabilitation and have money who will take kids to be treated.”
In the study6 coauthored by Hiller, a postdoctoral fellow at University of Sydney’s Arthritis and Musculoskeletal Research Group, 71% of children with a history of ankle sprain had perceived instability and as many as 47% had mechanical instability (see “Rates of chronic ankle instability in children are surprisingly high,” LER:Pediatrics November 2014, page 5).
The ankle sprain is the most common athletic injury in the US, accounting for an estimated 2 million injuries per year and an estimated $4 billion in medical costs.7 And yet, ankle sprains are one of the most undertreated injuries. About half of adults do not seek initial treatment for ankle injuries.8
Practitioners suspect the number is even higher among children. Untreated, ankle sprains can result in chronic pain, muscular weakness, and instability. In fact, 30% of first-time sufferers develop chronic ankle instability (CAI).9
“It is still widely assumed by many that ankle sprains are a minor injury which will heal and don’t have long-term implications,” said Elizabeth Jean Nightingale, BAppSc(Physiotherapy), PhD, University of Sydney research fellow with the Arthritis and Musculoskeletal Research Group in Australia.
Of those who do receive initial treatment, few are referred to a certified athletic trainer or a physical therapist for rehabilitation, noted Phillip Gribble, PhD, ATC, an associate professor in athletic training at the University of Kentucky in Lexington.
“That means treatment for children falls on parents who likely don’t have adequate information to make good decisions on how to proceed with care for their child,” Gribble said.
Those who have CAI ultimately become less active because of pain, weakness, recurring sprains and episodes of “giving way.” CAI is also a known factor in development of post-traumatic ankle osteoarthritis, for which there are no effective conservative treatments.10
Lack of awareness
Lack of treatment, improper initial management, and failure to rehabilitate contribute to the risk of chronic ankle injury. Tricia Turner, PhD, ATC, associate professor in the Department of Kinesiology at the University of North Carolina at Charlotte, pointed to a lack of awareness among some practitioners as a factor contributing to potentially preventable cases of CAI. Part of the preventive process has to include the medical community, she said.
“My opinion is that most primary care or general medical physicians do not think an ankle sprain is a significant injury or that there is a need for proper rehabilitation to prevent long-term pathology [in children],” Turner said.
She attributed part of the problem to the limited numbers of studies involving children. Turner praised the study by Australian researchers but noted that it also revealed the need for further research regarding children to help practitioners understand that there is a problem.
Kaminski acknowledged practitioners are generally unaware that children are at risk for CAI.
“For the majority of us, it’s probably an afterthought,” he said. “Maybe we need to look at these kids when they’re younger and make sure that the initial ankle sprain is treated with the utmost care, and that we don’t push it and don’t get them back into competition too soon and have the risk of reinjury.”
Gribble surmises that awareness is low among the youth population because awareness is low among the adult population. He also cites a lack of access to care.
“This is probably an important cog in the problem,” he said. “Access to allied health care professionals, especially certified athletic trainers, is limited for the adolescent population in many locations.”
However, recent National Athletic Trainers Association (NATA) figures suggest this is improving. There are more than 43,000 certified athletic trainers nationally, according to the website of the Board of Certification for the Athletic Trainer. As recently as 2009, NATA estimated that only about 40% of high schools had access to a full- or part-time athletic trainer.11 But, as of 2014, approximately 55% of public high school athletes nationwide had access to a full-time certified trainer, according to the NATA website. College and professional sports groups regularly use athletic trainers.
The reported levels of ankle instability in children suggest that a majority are not seeking treatment for ankle sprains, Turner said.
“Ideally, treatment would focus initially on allowing tissue healing to occur [crutch use, bracing] and then functional rehabilitation programs would focus on strengthening the ankle and doing balance exercises,” she said. “I do not think this is practiced with the majority of children who suffer from an ankle sprain. At best they may do the acute management [ice, brace], but few go through a functional rehabilitation program [motion, strength, balance exercises].”
In the 1970s, sports medicine specialist Gabe Mirkin, MD, introduced the commonly used practice of RICE (rest, ice, compression, and elevation) for treating acute ankle sprains. However, he has reversed course, asserting on his website, (DrMirkin.com) that lengthy icing of an injury inhibits healing by reducing inflammation (drmirkin.com/fitness/why-ice-delays-recovery). He cites a review summary of 22 scientific articles that found almost no evidence that ice and compression hastened healing over the use of compression alone. However, the review said ice plus exercise may provide marginal help in healing ankle sprains.12
Limited icing immediately following an injury is acceptable, said orthopedic surgeon Howard J. Luks, MD. Luks, who is associate professor of orthopedic surgery at New York Medical College and chief of sports medicine and arthroscopy at Westchester Medical Center in New York, recommends icing in short bursts.
“Ice for five minutes at a time and then leave it off for at least thirty minutes to allow the blood flow to return to the area,” Luks said. “After a few hours, the ice will no longer be effective in managing the swelling and should be avoided.”
The American Orthopaedic Foot and Ankle Society (AOFAS), as reported on its website (aofas.org), recommends that once the pain and swelling subsides, which is typically within five to seven days, stretching exercises should be performed. According to AOFAS, the first objective is to restore ankle range of motion, followed by ankle strengthening. Working toward comfort and stability, or proprioception, is the final stage.
Established evidence13 has shown that balance training exercises, taping, and prophylactic bracing can minimize the risk of future instability in adults, and a few studies conducted in adolescents suggest that similar strategies can also be effective in pediatric populations.
“If we look at the successful interventions from the literature on CAI in adults, perhaps protocols addressing deficits in neuromuscular control and balance, as well as potential restrictions in range of motion and arthrokinematics that have exhibited success in adult populations may prove useful for the prepubescent populations,” Gribble said.
“The treatment of primary ankle sprains is practitioner-dependent, but rehabilitation in children is as for adult sprains—with balance as a part of regular practice, and strapping tape or braces may be used,” she said.
In adults, one of the best methods to improve function in patients with chronic ankle instability is through a balance training program, Turner said. Most of these balance training protocols are four to six weeks in duration. They incorporate both static balance (balancing on one leg), as well as dynamic balance (standing on one leg while reaching or performing sport-specific skills). Studies14,15 have demonstrated the usefulness of gaming programs (eg, Wii Fit balance platform) for balance training in adult populations, and the same technology could potentially be used in children.
Evidence in adolescents
Tim McGuine, PhD, ATC, a senior scientist in the Department of Orthopedics and Rehabilitation at the University of Wisconsin in Madison, coauthored a 2006 study in the American Journal of Sports Medicine (AJSM) on balance training in high school basketball players. There was a significantly lower rate of ankle sprains among 765 high school soccer and basketball players who participated in a balance training program than in a control group that performed standard conditioning exercises. In athletes with a history of ankle sprain, the risk of a recurrent sprain was cut in half in those who participated in the intervention.16
Athletes in the intervention group participated in preventive exercises for 10 minutes per day, three times per week during the season. The balance training program included five phases: (1) maintaining a single-leg stance on a flat surface with eyes open and closed; (2) performing functional sport activities such as throwing, catching, and dribbling on one leg; (3) maintaining a double-leg stance while rotating the balance board; (4) maintaining a single-leg stance on the balance board with eyes open and closed; and (5) performing functional sport activities while in single-leg stance on the board.
A 2011 AJSM study by McGuine and colleagues on high school basketball players and lace-up ankle braces also had positive results.17 The researchers found that there were 68% fewer ankle injuries in those who wore them versus those who did not. Gender differences had no bearing on the results, nor did having a previous history of ankle injury. The rate of acute ankle injury (per 1000 exposures) was .47 in the braced group and 1.41 in the control group of unbraced athletes. While braces were associated with a lower incidence of ankle injuries, bracing did not have an effect on injury severity, the study authors concluded.17
“We know now that bracing’s effective, these exercise programs are effective,” McGuine told LER.
Kaminski questioned whether the way children’s ankle injuries have been treated has been less conservative than necessary.
“Maybe we need to think in the reverse manner,” he said. “Maybe we need to be extremely cautious and extremely conservative with these young children who do suffer ankle sprains to prevent them from having recurrent instability.”
Kaminski said children should be immobilized initially and their return to activity slow and gradual. He recommended using balance training in prevention of ankle sprains, particularly in those who have had previous sprains. Kaminski also pointed to the need for preventive care and the strong evidence that prophylactic bracing, taping, and balance training can help reduce first-time ankle sprains.
Taking a conservative approach to returning to play seems to be gaining popularity among adults, as well. Minnesota Timberwolves point guard Ricky Rubio went down with a severely sprained left ankle on November 7, 2014. Rubio remained sidelined until February 2, frustrating T-Wolves fans. But Rubio’s recovery process was delayed—perceived instability in his ankle or not—because of muscle and ligament damage. Minnesota coach Flip Saunders said two medical specialists who consulted with Rubio advised that returning too soon could increase the risk of a stress fracture.
But practitioners need to remember that children are not just small versions of adults, and some aspects of ankle instability prevention may need to be managed differently for a younger population, Hiller said.
“We can certainly apply what we know about treating CAI in adults to kids, but often need to modify the regime to be age appropriate,” she said. “For example, exercises are often repetitive and adults can be assisted in compliance by logic and reason. Kids need to be given greater variety in shorter bursts. Some practitioners do not recognize this and rehabilitation may not be as successful.”
- Waterman BR, Owens BD, Davey S, et al. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am 2010;92(13):2279-2284.
- Nelson AJ, Collins CL, Yard EE, et al. Ankle injuries among United States high school sports athletes, 2005-2006. J Athl Train 2007;42(3):381-387.
- Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emerg Med 2007;14(7):641-645.
- Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train 2007;42(2):311-319.
- Tiemstra JD. Update on acute ankle sprains. Am Fam Physician 2012;85(12):1170-1176.
- Mandarakas M, Pourkazemi F, Sman A, et al. Systematic review of chronic ankle instability in children. J Foot Ankle Res 2014;7(1):21.
- Ivins D. Acute ankle sprain: an update. Am Fam Physician 2006;74(10):1714-1720.
- McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med 2001;35(2):103-108.
- Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train 2002;37(4):364-375.
- Verhagen RA, de Keizer G, Van Dijk CN. Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg 1995;114(2):92-96.
- Athletic trainers fill a necessary niche in secondary schools. National Athletic Trainers’ Association website. http://www.nata.org/NR031209. Published March 12, 2009. Accessed January 29, 2014.
- Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med 2004;32(1):251-261.
- Olmsted LC, Vela L, Denegar CR, Hertel J. Prophylactic ankle taping and bracing: a numbers-needed-to-treat and cost-benefit analysis. J Athl Train 2004;40(1):95-100.
- Laufer Y, Dar G, Kodesh E. Does a Wii-based exercise program enhance balance control of independently functioning older adults? A systematic review. Clin Interv Aging2014;9:1803-1813.
- Lange B, Flynn S, Proffitt R et al. Development of an interactive game-based rehabilitation tool for dynamic balance training. Top Stroke Rehabil 2010;17(5):345-352.
- McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med 2006;34(7):1103-1111.
- McGuine TA, Brooks A, Hetzel S. The effect of lace-up ankle braces on injury rates in high school basketball players. Am J Sports Med 2011;39(9):1840-1848.