A Guide To Conservative Care For Ankle Sprains

Recurrent sprains and long-term residual symptoms are fairly common in patients who suffer ankle sprains. With this in mind, this author provides a comprehensive review of the literature and a practical guide to conservative treatment at various stages for lateral ankle sprains.

Ankle sprains account for 40 percent of all injuries in sport and 10 percent of all musculoskeletal injuries in the general population.^1,2 The majority of ankle sprains occur in individuals under the age of 35 with a sprain most likely occurring between 15 and 19 years of age.¹ This underscores the potential lifetime effect a single injury can have on an adolescent athlete if the injury goes mistreated or if the patient returns to sport before full recovery. A recent study of a large number of high school athletes revealed that the average time for return to play after an ankle sprain was only three days, far sooner than any reasonable healing or recovery could take place.³

Despite the prevalence of ankle sprains, perhaps no injury that we see as podiatrists has more controversy and misunderstanding in the proper management of the condition. This is evidenced by the fact that regardless of which medical specialty provides the treatment, a significant percentage of patients suffering an ankle sprain never fully recover.^4-6 Researchers estimate that up to 70 percent of people who experience a first-time ankle sprain will suffer another sprain in the future.^7,8 More than half of people with a first-time ankle sprain will develop long-term residual symptoms after an ankle sprain and often develop a syndrome known as chronic ankle instability.^9,10

A number of published guidelines using evidence-based medicine can help clear up some of the confusion and will guide the podiatric physician to implement sound treatment programs for patients presenting with an acute ankle sprain. Recently, an expert panel assembled by the National Athletic Trainers’ Association published a position paper on the management of the ankle sprain.¹¹ This paper as well as two other updated reviews served as the backbone of this article to provide current guidelines for treatment of the ankle sprain.^12,13   

Pertinent Pointers On Evaluating Acute Ankle Sprains At The Initial Presentation
What are the challenges on day one when evaluating the acute ankle sprain?

The initial history of the injury should include questions about the mechanism of the injury. A lateral ankle sprain forces the foot into a position of inversion and adduction while the ankle is in a plantarflexed position. This is important to determine as a syndesmosis sprain, the so-called “high ankle sprain,” has the opposite mechanism: the foot is externally rotated or abducted when the ankle is in a dorsiflexed position. This article will focus on treatment of the lateral ankle sprain and the recommendations are quite different from those relevant to the syndesmosis sprain.^12,13

In regard to lateral ankle sprains, there is isolated injury of the anterior talofibular ligament 70 percent of the time while combined injury with the calcaneofibular ligament is present in 20 percent of patients with a lateral ankle sprain.¹⁴ Determining if there has been true rupture of either of these ligaments is important in directing treatment and return to sport. Grading an ankle sprain is only important when differentiating Grade I sprains, which have only minor soft tissue microtears, from Grade II and III sprains, which have true ligament rupture and varying levels of instability.¹²

When it comes to radiographs of the injured ankle on day one, one should use the Ottawa ankle rules to rule out a fracture.¹⁵ Clinicians should consider the Ottawa ankle rules when examination of the patient reveals:
• tenderness with palpation along the tip of the posterior edge of the lateral malleolus;
• tenderness over the medial malleolus;
• tenderness at the base of the fifth metatarsal;
• tenderness over the navicular bone; and/or
• the inability of the patient to bear weight for a minimum of four steps.

In terms of using other imaging techniques such as magnetic resonance imaging (MRI) or ultrasound to determine the extent of ligament injury, such studies are not normally indicated on day one or at any time during the initial treatment of the acute ankle sprain because proper physical examination can approach the accuracy of these studies and reduce unnecessary medical expense.^16,17

Why You Should Reevaluate The Patient On Day Five
The studies conducted by Van Dijk and coworkers verified the importance of the physical examination in detecting ligament injury after an ankle sprain.^16,17 They studied 160 patients presenting with an acute ankle sprain and determined which physical exam findings most likely detected rupture of either the anterior talofibular ligament or calcaneofibular ligament, using arthrography as the confirmatory test.

Most interesting was the discovery that the initial examination within 48 hours is misleading and inaccurate in comparison to the delayed examination five days after injury.^16,17 If the examination happens in the first 48 hours, it is difficult to see any hematoma and palpation often reveals pain in a diffuse pattern. The anterior drawer test is unreliable at this time due to pain and guarding by the patient. Accordingly, examination in the first 48 hours taking into account edema, hematoma, palpable pain over the anterior talofibular ligament and calcaneofibular ligament as well as anterior drawer testing will have a sensitivity of 71 percent and a specificity of only 33 percent for detecting ligament rupture. If these same tests happen after day four, the sensitivity increases to 96 percent while the specificity improves to 84 percent.^16,17

Examination of the sprained ankle on day five should focus on hematoma, palpable tenderness over the anterior talofibular ligament or calcaneofibular ligament, and anterior drawer testing. According to the Van Dijk studies, the combination of tenderness at the anterior talofibular ligament, lateral hematoma discoloration and a positive anterior drawer test accurately detected ligament rupture in 95 percent of cases.^16,17 Conversely, a negative anterior drawer test and the absence of discoloration always indicated an intact ligament as did the absence of pain on palpation at the anterior talofibular ligament.

Since examination of the acute ankle sprain on day one is often misleading and inaccurate, clinicians should err on the side of overprotecting the injured ankle and plan to reevaluate the patient again in five days. Accordingly, one should immediately immobilize any patient with a suspected Grade II or III ankle sprain on day one. If the patient with an ankle sprain has essentially no hematoma, no tenderness over the key ligaments and has a negative anterior drawer test, the patient has a Grade I sprain. Patients with Grade I sprains will not necessarily need immobilization but all others with Grade II and III sprains should receive treatment with the protocol described below.

Key Insights On Successful Immobilization Of Sprained Ankles
Multiple studies have verified the preferred treatment of Grade II and III lateral ankle sprains is immobilization with an external support while allowing early weightbearing.^18-21 These studies showed that various forms of removable external ankle support, including the Air-Stirrup Ankle Brace (DJO Global), lace-up braces and taping, were all more efficacious than long-term cast immobilization. All studies incorporated early weightbearing in the treatment. Even severe Grade III ankle sprains appear to heal better with early weightbearing.^18-19 Researchers have shown that early weightbearing optimizes positioning of the torn lateral collateral ankle ligaments for healing while encouraging ankle dorsiflexion and restoration of the “close pack” position of this joint.²²

It is significant to note that while all of these studies were advocating the combination of early weightbearing and removable external braces for the treatment of ankle sprains, studies also noted continued long-term sequelae from ankle sprains.^6,7

After 20 years of this practice, a high quality study determined if this minimal immobilization protocol was really optimal.²³ This recent Level 1 study has caused many to reevaluate their protocol for immobilization of patients in the immediate treatment of Grade II and III ankle sprains. Lamb and colleagues conducted a multicenter randomized trial that studied 584 participants with severe ankle sprains, who used three different types of mechanical support. Patients who received the below-knee cast for 10 days had a more rapid recovery than those who had the tubular compression bandage, an Air-Stirrup brace or a walking boot. The researchers concluded that, contrary to popular clinical opinion, a short period of immobilization was the most effective strategy for promoting rapid recovery. Patients best achieved this by wearing a below-knee cast, an intervention that previous research had discouraged in favor of Air-Stirrup braces.²⁴

There is a trend toward respecting the basic science of wound healing and ligament repair. Ruptured ligaments require a minimum of one year to restore original mechanical strength as they progress through three stages of healing: inflammatory, proliferative and maturation.²⁵ Experts are beginning to recognize that during the inflammatory phase of ankle ligament repair, a short period of strict immobilization is the preferred treatment.^12,13 During the proliferative phase, which begins at approximately week four and extends to three months post-trauma,  prolonged immobilization is detrimental.^12,13 Accordingly, the use of removable external supports such as taping and bracing after day 10 has continued to be the preferred treatment of the acute ankle sprain.

A recent study compared the continuous use of taping, Air-Stirrup braces and lace-up braces during the first six weeks of treatment of Grade II and II ankle sprains.²⁵ All three protective interventions, combined with a functional rehabilitation program, gave excellent results in this prospective study. Due to the cost and convenience of application, the authors recommended bracing over taping.

Based upon this recent research, I recommend cast immobilization or a removable walking boot for seven to 10 days for all patients suffering a Grade II or III ankle sprain. Encourage weightbearing as tolerated by the patient. There is a downside to using a cast as clinicians would have to remove the device if they are performing a follow-up exam on day five. A walking boot would accomplish the same goal as a cast if the patient can be adherent and wear the device 24 hours a day during the first week of treatment. One could remove a walking boot for further examination and the application of cryotherapy. Note that the walking boot performed poorly in the Lamb study mainly because of poor adherence in comparison to the use of a non-removable cast.²³

What About Good Old-Fashioned ‘RICE’ Treatment?
During the acute phase (first five days) of treatment of the ankle sprain, most authorities continue to advocate rest, ice, compression and elevation (RICE) treatment protocols.¹² It is interesting that a review of the literature actually shows weak, if not conflicting, evidence supporting this treatment approach.^11,26

Authors have advocated cryotherapy, in the form of ice packs, ice cups, chemical cold packs and commercial cooling units, primarily to induce anesthesia and presumably reduce swelling after an ankle sprain.²⁷ Researchers have not agreed upon the preferred protocol for cryotherapy with some experts recommending application for 20 to 30 minutes and others for 10-minute intervals.²⁸ Most recommend repeating the cycles at least three times daily during the first seven days of treatment.

Compression can control swelling and hemorrhage during both the acute and subacute phases of treatment of the ankle sprain.²⁹ While there is a lack of evidence for any one form of compression over another, I recommend the use of compression sleeves simply due to their ease of application and reuse on a day-to-day basis.

It is interesting to see the evidence supporting the use of non-steroidal anti-inflammatory drugs (NSAIDs) during the acute and subacute phases of ankle sprain recovery.^30-32 The National Athletic Trainers’ Association panel deemed the evidence supporting the use of NSAIDs in the treatment of the ankle sprain as credible, and the use of these drugs appears to reduce pain and swelling while improving short-term function.¹¹ Be advised that some authorities warn against long-term use of NSAIDs, which could delay ligament repair.³³

When You Should Evaluate Patients After Day Five
Follow up with all patients after they have been wearing their removable walking boot for 10 days. Accordingly, one should see the patient with an ankle sprain on day one, day five and day 10 to monitor recovery and direct treatment. During the first 10 days, patients will have been performing RICE during this time and applying cryotherapy three times daily (the only time they are allowed to remove the walking boot).  

At day 10, the clinician must decide to move the patient out of the walking boot and substitute either a lace-up brace or an Air-Stirrup brace for the patient to wear continuously while ambulating for the next three weeks. Studies show that allowing protected motion during this phase of healing is actually beneficial and superior to strict immobilization.^18-21 Generally, if patients can ambulate without wearing a boot and demonstrate no noticeable limp, they are ready to progress to a removable ankle brace.

A Closer Look At The Functional Rehabilitation Program
It is universally accepted that we must treat the ankle sprain with a comprehensive rehabilitation program that includes muscle strengthening, mobilization to improve ankle joint range of motion and balance training.^11-13 There is no consensus about when to initiate exercises after an ankle sprain but some evidence indicates implementing exercise sooner rather than later.³⁴ Once patients have completed the period of strict immobilization in the first seven to 10 days of management of the Grade II and III ankle sprain, supervised rehabilitation should begin.

In terms of strengthening, studies have shown that patients should exercise all the muscles around the ankle joint using both concentric and eccentric techniques.^35,37 There is increasing evidence that one must address proximal musculature, including muscles surrounding the hip, in the strengthening program after an ankle sprain.^37,38

Restoring ankle joint dorsiflexion appears to be critical in the recovery from an ankle sprain as well as prevention of future sprains.³⁹ Joint mobilization techniques, which include posterior repositioning of the talus, can improve ankle joint dorsiflexion after a sprain.^41,42

The cornerstone of the ankle sprain functional rehabilitation program is balance training.^42,43 Balance training after an ankle sprain with a wobble board will improve functional performance and postural control, and reduce the risk of recurrent sprain.^43,44 Of all treatment interventions, balance training received the highest rating of supportive evidence by the National Athletic Trainers’ Association expert panel.¹¹

The podiatric physician must rely on a qualified physical rehabilitation specialist to initiate and carry out the rehabilitation program for patients who suffer a severe ankle sprain. There is little evidence that the patient alone can carry out such a program without supervision, monitoring and encouragement. If patients do not complete the program properly, a disabling syndrome known as chronic ankle instability will result.^45-48   

Day 30 And Beyond: How Long Should The Treatment Program Last?
Currently, the expected recovery from a Grade II or III lateral ankle sprain is approximately four to eight weeks.¹² Disrupted ligaments have just ended the inflammatory stage of healing at four weeks and the proliferative phase does not end until three months after the initial injury.²⁵  

Releasing an athlete to return to sport is a challenging decision for the treating podiatric physician. Richie and Izadi recently published a detailed guide for making the return to play determination for patients with ankle sprains.⁴⁹ Self-reported variables as well as specific performance tests can determine if the athlete has recovered adequately from an ankle sprain. Most importantly, dynamic balance testing and hopping tests are most helpful and predictive of recovery.^50,51

Since torn ankle ligaments have not restored full mechanical strength until one year after injury, patients who want to return to sport must wear external supports.⁵² It is unclear whether non-athletic patients benefit from wearing ankle braces beyond the standard four- to six-week rehabilitation program, but pain and instability may dictate that these patients wear braces until all symptoms subside.

There is convincing evidence that ankle bracing will prevent recurrent ankle sprains in athletes who have suffered a previous sprain.^53-55 Taping is less effective than bracing in preventing ankle sprains.^54-56

A systematic review demonstrated that athletes who had suffered a previous ankle sprain had 70 percent fewer ankle injuries with taping or bracing in comparison to those who did not wear prophylactic support.⁵⁵ Studies have not shown an endpoint to suggest when one can discontinue preventive bracing. The basic science of ligament repair would mandate a minimum of one year of prophylactic ankle bracing during sport for any athlete who has suffered a Grade II or III ankle sprain.

In Summary
Recent trends in the treatment of the lateral ankle sprain have focused on the basic science of ligament healing. The initial treatment of all Grade II and III ankle sprains now calls for strict immobilization for seven to 10 days before allowing any motion across the ankle joint. We now advocate long-term protection of the ankle in the form of removable braces for all athletes returning to sport after a serious sprain. The functional rehabilitation program is still the mainstay of treatment of the ankle sprain and balance training is the most important component. Following stricter protocols for treatment will hopefully reduce the high incidence of long-term disability that currently results from severe ankle sprains.

Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons. He is in private practice in Seal Beach, Calif. Dr. Richie writes a monthly blog for Podiatry Today. One can access his blog at www.podiatrytoday.com/blogs/doug-richie-jr-dpm/feed .

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For further reading, see “Point-Counterpoint: Preventive Bracing For Ankle Sprains: Is it Legitimate?” in the September 2011 issue of Podiatry Today, “How To Manage Lateral Ankle Sprains” in the November 2003 issue or “Mastering The Treatment Of Complex Ankle Sprains” in the March 2011 issue.