Ankle Sprain Management

Aka: Ankle Sprain Management, Ankle Proprioception, Ankle Rehabilitation

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II. Indications

  1. Protocol intended for uncomplicate Lateral Ankle Sprain
  2. Other Ankle Sprain with caution (progress more slowly)
    1. Medial Ankle Sprain
    2. High Ankle Sprain

III. Management: Overall Lateral Ankle Sprain Strategy

  1. Precautions
    1. Distinguishing Grade of sprain is initially difficult in first week (swelling interferes with laxity testing)
    2. If red flags, despite negative xray, safest to posterior splint, Crutches and follow-up in 7-10 days
  2. Lateral Grade I sprain (ATF ligament tear)
    1. Routine care as below and no Splinting needed
  3. Lateral Grade II sprain (partial ATF and CF disruption, stable)
    1. Care as below and consider prefab ankle support (e.g. air cast splint)
  4. Lateral Grade III sprain (complete ATF, CF ligament disruption, unstable)
    1. Posterior splint and Crutches for 7-10 days
    2. Air cast Ankle Brace after the first 7-10 days
    3. Physical therapy directed program similar to below
    4. Consider orthopedic referral for signs of persistent instability
  5. Children with Ankle Sprains
    1. Be suspicious of Growth Plate injury (weaker than ligaments) in children with Ankle Sprains
    2. Rotational injuries are a risk for Tillaux Fracture (with anterior tibial Epiphyseal PlateFracture)
    3. Suspect a Grade I Epiphyseal Fracture (Salter-Harris Fracture) if XRays are negative
      1. Lateral Ankle Sprains with Grade I Epiphyseal Fractures heal well with bracing
      2. Removable ankle splints are as effective as longer splints and casts
      3. Boutis (2016) JAMA Pediatr 170(1):e154114 +PMID: 26747077 [PubMed]
      4. Boutis (2007) Pediatrics 119(6):e1256-63 +PMID: 17545357 [PubMed]

IV. Management: First 1-2 days: RICE-M

  1. Local Cold Therapy (Avoid initial heat)
    1. Effective only in combination with elevation and compression
  2. Rest and elevation
  3. Crutch walking for 2 to 3 days
    1. Indicated for severe Ankle Sprain with pain limiting ambulation
  4. Support (preferred over elastic compression wrap alone)
    1. Air cast splint
      1. May be preferred over more restrictive Splinting
      2. Allows for plantar flexion and dorsiflexion, while still providing medial and lateral support
      3. Consider elastic compression wrap (e.g. ACE wrap) or
    2. Ankle lace up support alone (e.g. Swedo ankle lace-up)
      1. May also be used later in cutting sports to prevent recurrent Ankle Sprain
  5. Start early range of motion as soon as possible
    1. See below for days 3-5
    2. Concentrate on ankle dorsiflexion
    3. Avoid in High Ankle Sprain or suspected Fracture related to Ankle Sprain
  6. NSAIDS
    1. Use with caution if suspect cartilage damage (delays healing)
  7. Avoid measures with low efficacy
    1. No benefit with Therapeutic Ultrasound
    2. No benefit with hyperbaric oxygen

V. Management: Days 3-5: Function (Mild-Moderate sprains)

  1. Weight Bearing as tolerated
  2. Early Active range of motion
    1. Perform each Exercise three times daily
      1. Repeat Exercises 10 to 15 days
      2. Apply ice before and after Stretching
    2. Specific stretches
      1. Ankle Dorsiflexion (Towel pulls foot toward face)
      2. Ankle Plantar flexion
      3. Ankle Circumduction
      4. Ankle "Alphabet writing" (draw letters with foot)
    3. Efficacy
      1. Results in earlier return to work and sport
      2. Kerkhoffs (2001) Arch Orthop Trauma Surg 121:462-71 [PubMed]

VI. Management: Days 4-7: Strengthening

  1. Walk 50 feet bid on more difficult terrain
    1. Start on hard, flat floor
    2. Progress to uneven surface
  2. Exercises: Isometric and Isotonic
    1. Technique
      1. Isometric stretch against wall or other foot
      2. Isotonic stretch (resistance from Rubber strap)
    2. Perform each Exercise three times daily
      1. Repeat Exercises 10 to 15 repetitions
      2. Apply ice before and after Stretching
    3. Specific stretches
      1. Ankle inversion
      2. Ankle eversion
      3. Ankle plantar flexion and dorsiflexion
  3. Exercises: Isometric
    1. Technique
      1. Two sets of 10 repetitions bid
    2. Specific Exercises
      1. Toe curls
      2. Marble pickups
      3. Toe raises
      4. Heel Walking
      5. Toe Walking
  4. Wrapping/Bracing ankle if needed
    1. See Special Topics below

VII. Management: Week 1 and later

  1. Activity tolerated
    1. Static Bicycling
    2. Fast Walking
  2. Severe pain with activity
    1. Short Leg Walking Cast or CAM Walker boot for 4 weeks

VIII. Management: Titrate back to full activity when walking without pain

  1. Jog 50% and walk 50%
    1. Increase distance 1/8 mile per time
  2. Jog in straight line pattern
    1. Forward
    2. Backward
  3. Jog in other patterns
    1. Run circle pattern
    2. Run zig-zag pattern
  4. Progression without pain allows return to activity

IX. Management: Special Topics

  1. Short Leg Walking Cast or CAM walking boot (used for 4 weeks)
    1. Used less now due to adverse effects
      1. Decreases Range of motion
      2. Atrophy risk
    2. Indications
      1. Pain refractory to conservative therapy
      2. Independent walking
    3. Alternative (Removable devices for Exercise)
      1. Ankle/Foot Orthosis (AFO)
      2. Sugar tong
      3. Air cast
      4. Compression stocking (controls swelling)
  2. Orthopedic referral indications
    1. Ankle Fracture or dislocation
    2. Neurovascular compromise
    3. Tendon rupture or subluxation
    4. Wound penetration of joint
    5. Ankle Syndesmotic Injury
    6. Mechanical locking or catching symptoms
    7. Symptoms out of proportion to mechanism of injury
  3. Surgery Indications
    1. High level athletes
    2. Significant High Ankle Sprain
    3. Excellent outcome for unstable sprain
    4. Jones Fracture
  4. Chronically Unstable Ankle (prior third degree sprain, lateral ligament laxity, recurrent Ankle Sprain)
    1. Lateral heel and sole wedge (0.3 cm)
      1. Prevents inversion
    2. Lace-up Ankle Brace (e.g. Swedo Ankle Lace-Up)
    3. Athletic Taping
      1. More variable efficacy based on taping technique
      2. May be better tolerated by athletes
    4. Surgical Reconstruction

X. Prevention

  1. Proprioception
    1. Re-training proprioception prevents repeat Ankle Sprain
    2. Activities
      1. Static one-leg standing (balancing) with eyes closed for 30-60 seconds
      2. Balance on one leg and play catch with another person
      3. One leg mini-squats with the other leg extended in different directions
      4. Wobble board with one leg (5-10 reps twice daily)
        1. Circular wooden platform with hemispheric base
        2. Shift balance to move wobble board in circle path
  2. Strengthening
    1. See above under strengthening
    2. Plyometrics
      1. Scissor hops
        1. Start: Lunge position
        2. Jump and land with other foot forward
      2. Standing squat jumps
        1. Start: squat position
        2. Jump and land softly
      3. Bounding
        1. Take large bounding steps at 50% of maximal bounding speed
  3. Stretching
    1. Toe raises
    2. Heel cord stretches
  4. External ankle support (e.g. ankle lace-up)
    1. Recommended for ankle protection in high risk sports
    2. Recommended if prior Ankle Sprain at least for the first 6-12 months after injury

XI. Resources: Patient Education

  1. Information from your Family Doctor
    1. http://www.familydoctor.org/healthfacts/010/
  2. Landon: Ways to build ankle strength for top performers
    1. http://www.active.com/fitness/Articles/12_Ways_to_Build_Ankle_Strength_for_Top_Performance.htm

XII. References

  1. Orman and Ramadorai in Herbert (2016) EM:Rap 16(3): 8-9
  2. Rifat (1996) Am Fam Physician 53(8):2491-8 [PubMed]
  3. Rubin (1996) Am Fam Physician 54(5):1609-18 [PubMed]
  4. Sitler (1995) Sports Med 20(1):53-7 [PubMed]
  5. Swain (1993) Postgrad Med 90(3):91-100 [PubMed]
  6. Tiemstra (2012) Am Fam Physician 85(12): 1170-6 [PubMed]
  7. Wolfe (2001) Am Fam Physician 63(1):93-104 [PubMed]
  8. Ivins (2006) Am Fam Physician 74:1714-26 [PubMed]

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