Acute ankle sprain: an update

Acute ankle injury, a common musculoskeletal injury, can cause ankle sprains. Some evidence suggests that previous injuries or limited joint flexibility may contribute to ankle sprains. The initial assessment of an acute ankle injury should include questions about the timing and mechanism of the injury. The Ottawa Ankle and Foot Rules provide clinical guidelines for excluding a fracture in adults and children and determining if radiography is indicated at the time of injury. Reexamination three to five days after injury, when pain and swelling have improved, may help with the diagnosis. Therapy for ankle sprains focuses on controlling pain and swelling. PRICE (Protection, Rest, Ice, Compression, and Elevation) is a well-established protocol for the treatment of ankle injury. There is some evidence that applying ice and using nonsteroidal antiinflammatory drugs improves healing and speeds recovery. Functional rehabilitation (e.g., motion restoration and strengthening exercises) is preferred over immobilization. Superiority of surgical repair versus functional rehabilitation for severe lateral ligament rupture is controversial. Treatment using semirigid supports is superior to using elastic bandages. Support devices provide some protection against future ankle sprains, particularly in persons with a history of recurrent sprains. Ankle disk or proprioceptive neuromuscular facilitation exercise regimens also may be helpful, although the literature supporting this is limited.     

The Ubiquitous Lateral Ankle Sprain: Time to Reconsider Our Management?

Ankle sprains are one of the more common musculoskeletal injuries among physically active individuals, but these are not benign injuries. The rate of recurrence, the chronicity of symptoms, and the rising costs of the evaluation and management of lateral ankle sprains should give us pause. Lateral ankle sprains are simultaneously over- and undertreated, creating a burden on the health care system. Rethinking our approach to the management of lateral ankle sprains is important to improving patient outcomes.     

History of ankle sprain as a risk factor of future lateral ankle sprain in athletes

Despite the attention and focus lateral ankle sprains receive in athletic training practice and research, they remain the most common injury in many sports. Whereas the functional limitations and time loss from lateral ankle sprains are apparent, consistently reducing their incidence is less certain. One important step in preventing lateral ankle sprains is identifying their risk factors. Although previous literature summaries suggest that specific risk factors are inconclusive in predicting lateral ankle sprains, recent literature investigating the predictors of ankle sprains should be included as evidence. Determining the primary risk factors for lateral ankle sprains may lead to good prevention programs, which in turn may decrease time lost because of injury.     

Braces and splints for musculoskeletal conditions

Braces and splints can be useful for acute injuries, chronic conditions, and the prevention of injury. There is good evidence to support the use of some braces and splints; others are used because of subjective reports from patients, relatively low cost, and few adverse effects, despite limited data on their effectiveness. The unloader (valgus) knee brace is recommended for pain reduction in patients with osteoarthritis of the medial compartment of the knee. Use of the patellar brace for patellofemoral pain syndrome is neither recommended nor discouraged because good evidence for its effectiveness is lacking. A knee immobilizer may be used for a limited number of acute traumatic knee injuries. Functional ankle braces are recommended rather than immobilization for the treatment of acute ankle sprains, and semirigid ankle braces decrease the risk of future ankle sprains in patients with a history of ankle sprain. A neutral wrist splint worn full-time improves symptoms of carpal tunnel syndrome. Close follow-up after bracing or splinting is essential to ensure proper fit and use.     

Population based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains

Objectives: To estimate the incidence of ankle sprains and severe ankle sprains attending accident and emergency (A&;E) units; to describe current practice for severe ankle sprains in A&;E units in the United Kingdom. Methods: Crude age and sex specific incidence rates were calculated for four health districts from cases ascertained from data on seven A&;E clinical information systems. Case records of patients with ankle sprains at an A&;E unit in another health district were audited and the proportion of severe ankle sprains calculated. UK A&;E units were surveyed about their usual treatment of patients with severe ankle sprains. Results: The estimate of the crude incidence rate of ankle sprains was a minimum of 52.7 per 10 000, rising to 60.9 (95% CI 59.4 to 62.4) when figures were adjusted for the proportion of patients without a diagnostic code (13.7%). There were important age-sex differences with unadjusted rates observed from 127.8 per 10 000 (CI 115.5 to 140.0) in girls aged 10–14 years to 8.2 (CI 4.2 to 12.3) in men aged 70–74 years. As 14% of ankle sprains attending A&;E were classed as severe, this would equate to 42 000 severe ankle sprains per year in the UK. In the UK wide survey, there was a response rate of 79% (211 of 266). Among the responders, Tubigrip was used routinely in 55%, below knee casts in 3%, and braces in 2%. Boots were not used routinely in any unit. Conclusion: While there is considerable variation in severe ankle sprain management in UK A&;E units, most are treated with the minimal mechanical support of Tubigrip.     

Management of ankle sprains

Without adequate care, acute ankle trauma can result in chronic joint instability. Use of a standardized protocol enhances the management of ankle sprains. In patients with grades I or II sprains, emphasis should be placed on accurate diagnosis, early use of RICE (rest, ice, compression and elevation), maintenance of range of motion and use of an ankle support. Sprains with complete ligament [corrected] tears (grade III) may require surgical intervention. Although early motion and mobility are recommended, ligamentous strength does not return until months after an ankle sprain.     

Evidence-based treatment for ankle injuries: a clinical perspective

The most common ankle injuries are ankle sprain and ankle fracture. This review discusses treatments for ankle sprain (including the management of the acute sprain and chronic instability) and ankle fracture, using evidence from recent systematic reviews and randomized controlled trials. After ankle sprain, there is evidence for the use of functional support and non-steroidal anti-inflammatory drugs. There is weak evidence suggesting that the use of manual therapy may lead to positive short-term effects. Electro-physical agents do not appear to enhance outcomes and are not recommended. Exercise may reduce the occurrence of recurrent ankle sprains and may be effective in managing chronic ankle instability. After surgical fixation for ankle fracture, an early introduction of activity, administered via early weight-bearing or exercise during the immobilization period, may lead to better outcomes. However, the use of a brace or orthosis to enable exercise during the immobilization period may also lead to a higher rate of adverse events, suggesting that this treatment regimen needs to be applied judiciously. After the immobilization period, the focus of treatment for ankle fracture should be on a progressive exercise program.     

Kinesthetic awareness in subjects with multiple ankle sprains

The purposes of this study were 1) to determine whether decreased kinesthetic awareness occurs in individuals with recurrent ankle sprains and 2) to determine whether the one-legged standing balance test can be used to differentiate between ankle instability in injured and uninjured ankles. Thirty athletes between 18 and 24 years of age with multiple sprains of one ankle and no reported sprains of the other ankle were tested to compare their ability to detect passive plantar flexion and standing balance in each ankle. Luce's choice theory was used to analyze subjects' responses. Subjects had significantly greater difficulty detecting passive motion in the ankle with sprains as compared with the uninjured ankle. Subjects also performed a one-legged standing balance test on both the injured and uninjured legs. In 20 subjects, either the subject or observer reported balance deficits on the injured side as compared with the uninjured side. The results of this study demonstrate the need for clinicians to evaluate kinesthetic deficits and to design exercise programs to improve kinesthetic awareness and decrease ankle instability in individuals with multiple ankle sprains.     

Management of chronic ankle pain using joint mobilization and ASTYM? treatment: a case report

Treatment of ankle sprains predominately focuses on the acute management of this condition; less emphasis is placed on the treatment of ankle sprains in the chronic phase of recovery. Manual therapy, in the form of joint mobilization and manipulation, has been shown to be effective in the management of this condition, but the combination of joint mobilization and manipulation in tandem with ASTYM® treatment has not been explored. The purpose of this case report is to chronicle the management of a patient with chronic ankle pain who was treated with manual therapy including manipulation and ASTYM treatment. As a result of a fall down stairs 6 months previously, the patient sustained a severe ankle sprain. The soft tissue damage was accompanied by bony disruptions which warranted the patient spending 3 weeks in a walking boot. At the initial evaluation, the patient reported difficulty with descending stairs reciprocally and not being able to run more than 4 minutes on the treadmill before the pain escalated to the level that she had to stop running. After five sessions of therapy consisting of joint mobilization, manipulation and ASTYM, the patient was able to descend stairs and run 40 minutes without pain.     

The initial effects of a Mulligan's mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains

Physiotherapists frequently use manipulative therapy techniques to treat dysfunction and pain resulting from ankle sprain. This study investigated whether a Mulligan's mobilization with movement (MWM) technique improves talocrural dorsiflexion, a major impairment following ankle sprain, and relieves pain in subacute populations. Fourteen subjects with subacute grade II lateral ankle sprains served as their own control in a repeated measures, double-blind randomized controlled trial that measured the initial effects of the MWM treatment on weight bearing dorsiflexion and pressure and thermal pain threshold. The subacute ankle sprain group studied displayed deficits in dorsiflexion and local pressure pain threshold in the symptomatic ankle. Significant improvements in dorsiflexion occurred initially post-MWM ( F(2,26) = 7.82, P = 0.002 ), but no significant changes in pressure or thermal pain threshold were observed after the treatment condition. Results indicate that the MWM treatment for ankle dorsiflexion has a mechanical rather than hypoalgesic effect in subacute ankle sprains. The mechanism by which this occurs requires investigation if we are to better understand the role of manipulative therapy in ankle sprain management.     

The use of Bioptron light (polarized,polychromatic, non-coherent) therapy for the treatment of acute ankle sprains

Purpose The purpose of this study was to investigate the efficacy of Bioptron light therapy for the treatment of acute ankle sprains. Method A parallel group, single-blind, controlled study was carried out in patients with grade II acute ankle sprains. Patients were randomly allocated into two treatment groups (n?=?25 for each). Both groups received cryotherapy, and the test group also received Bioptron light therapy. All treatments were performed daily for 5 d. Evaluations included self-reported pain via a visual analogue scale, degree of ankle edema, and ankle range of motion via goniometry carried out before the treatment and at the end of the treatment. Results The test group showed the largest magnitude of improvement for all evaluations at treatment five, and the between-group differences observed were statistically significant (p?Conclusions These data provide preliminary evidence of the efficacy of Bioptron light therapy supplemented with cryotherapy for the treatment of acute ankle sprains; however, larger studies are required to confirm these results.

• Implications for Rehabilitation

• Ankle sprains are common acute injuries among professional and recreational sports players but also among people in general.

• Cryotherapy is the first-standard treatment of acute ankle sprains.

• Phototherapy such as Bioptron light has been recommended supplement to cryotherapy to reduce the symptoms of ankle sprains.

• The results of the present trial showed that using BIOPTRON LIGHT and cryotherapy the rehabilitation period of acute ankle sprains can be reduced.

     

Fractures and Chronic Recurrence are Commonly Associated with Ankle Sprains: a 5-year Population-level Cohort of Patients Seen in the U.S. Military Health System

BackgroundWhereas ankle-foot injuries are ubiquitous and affect ~16% of military service-members, granularity of information pertaining to ankle sprain subgroups and associated variables is lacking. The purpose of this study was to characterize and contextualize the burden of ankle sprain injuries in the U.S. Military Health System.MethodsThis was a retrospective cohort study of beneficiaries seeking care for ankle sprains, utilizing data from the Military Health System Data Repository from 2009 to 2013. Diagnosis and procedural codes were used to identify and categorize ankle sprains as isolated lateral, isolated medial, concomitant medial/lateral, unspecified, or concomitant ankle sprain with a malleolar or fibular fracture. Patient characteristics, frequency of recurrence, operative cases, and injury-related healthcare costs were analyzed.ResultsOf 30,910 patients included, 68.4% were diagnosed with unspecified ankle sprains, 22.8% with concomitant fractures, (6.9%) with isolated lateral sprains, (1.7%) with isolated medial sprains and 0.3% with combined medial/lateral sprains. Pertaining to recurrence, 44.2% had at least one recurrence. Sprains with fractures were ~2-4 times more likely to have surgery within one year following injury (36.2% with fractures; 9.7% with unspecified sprains) and had the highest ankle-related downstream costs.ConclusionFractures were a common comorbidity of ankle sprain (one in five injuries), and operative care occurred in 16.4% of cases. Recurrence in this cohort approximates the 40% previously reported in individuals with first-time ankle sprain who progress to chronic ankle instability. Future epidemiological studies should consider reporting on subcategories of ankle sprain injuries to provide a more granular assessment of the distribution of severity.Level of evidence3b     

The efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains

OBJECTIVE: The purpose of this study was to determine the efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains. DESIGN: A single-blind, comparative, controlled pilot study. SETTING: Technikon Natal Chiropractic Day Clinic. PARTICIPANTS: Thirty patients with subacute and chronic grade I and grade II ankle inversion sprains. Patients were recruited from the public; they responded to advertisements placed in newspapers and on notice boards around the campus and local sports clubs. INTERVENTION: Each of the 15 patients in the treatment group received the ankle mortise separation adjustment. Each of the 15 patients in the placebo group received 5 minutes of detuned ultrasound treatment. Each participant received a maximum of 8 treatment sessions spread over a period of 4 weeks. MAIN OUTCOME MEASURE: Patients were evaluated at the first treatment, at the final treatment, and at a 1-month follow-up consultation. Subjective scores were obtained by means of the short-form McGill Pain Questionnaire and the Numerical Pain Rating Scale 101. Objective measurements were obtained from goniometer readings measuring ankle dorsiflexion range of motion and algometer readings measuring pain threshold over the ankle lateral ligaments. A functional evaluation of ankle function was also used. RESULTS: Although both groups showed improvement, statistically significant differences in favor of the adjustment group were noted with respect to reduction in pain, increased ankle range of motion, and ankle function. CONCLUSIONS: This study appears to indicate that the mortise separation adjustment may be superior to detuned ultrasound therapy in the management of subacute and chronic grade I and grade II inversion ankle sprains.     

Radiographic comparison of plain films in second- and third-degree ankle sprains

A literature search failed to demonstrate any investigations of the plain films of the ankle to determine whether there were any measurable differences in the ankle mortise, which would differentiate between a second and a third degree ankle sprain, thus obviating the need for stress views. In this study, the authors independently measured the distances between the talus and tibia at eight predetermined sites on the lateral and mortise views. This was done blindly so that neither author knew which cases were second- or third-degree ankle sprains. Only definite third-degree ankle sprains, as defined by a positive anterior drawer sign and/or a positive inversion stress test result on clinical evaluation, were included. The authors found there was severe interobserver variability. The authors thus feel that there is no clinically significant measurement on plain films of the ankle that can be used to differentiate accurately between second and third degree ankle sprains, and current reliance on clinical findings and subsequent stress x-ray films is appropriate and must remain the non-operative standard for evaluation of this problem.     

Ankle joint evertor-invertor muscle torque ratio decrease due to recurrent lateral ligament sprains

OBJECTIVE: To determine an ankle inversion-eversion movement range part where evertor/invertor muscles torque ratio is altered after recurrent ankle lateral ligament sprains. DESIGN: The ankle evertor/invertor muscles torque ratios were determined in the different range parts of angular positions by the muscle isokinetic movements. BACKGROUND: It is important to determine the movement range part where the evertor muscle weakness after the ankle lateral ligament sprains is more expressed and a repeated trauma of the lateral ligaments is more probable. METHODS: Twenty-eight male handball players participated in the tests using an ankle isokinetic inversion-eversion movement investigation dynamometer system. Thirty-three ankle joints were uninjured, but 23 underwent recurrent lateral ligament sprains. RESULTS: The ankle evertor/invertor muscles torque ratio for the sprained ankles was significantly lower in comparison with the uninjured joints in inversion positions at 50 degrees and 60 degrees of the range of movements in all applied velocities, except the slowest movement (30 degrees /s). CONCLUSIONS: The recurrent ankle lateral ligament sprains reduced the evertor/invertor muscles torque ratio in the inversion positions of the range of movements and therefore the evertor muscle weakness was more expressed in the beginning of the eversion movement.     

Aberrancy of the midtarsal locking mechanism as a causative factor in recurrent ankle sprains

A case is presented relating excessive midtarsal pronation to chronic inversion sprains of the ankle. Motions of the midtarsal joints are discussed and theory of the midtarsal locking mechanism is examined. The necessity of proper orthotic management is emphasized in the treatment of excessive midtarsal pronation.     

Sonographic diagnosis of a medial talar avulsion fracture

Occult talus fractures can be easily misdiagnosed as simple ankle sprains, resulting in painful nonunion, arthrosis, avascular necrosis, and long‐term disability. We present a case of ankle injury with medial talar fracture that was negative on plain radiography but was diagnosed with sonography. Sonography is a valuable tool in screening ankle sprains and may assist clinicians in diagnosing the nature of ankle injury, thus guiding the most appropriate therapeutic strategy. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound 41 :570–573, 2013.     

Childhood Soccer Injuries Treated in U.S. Emergency Departments

Objectives: Soccer, an increasingly popular sport among children in the United States, is a common precipitant to injury‐related emergency department (ED) visits. The authors estimated the number of children treated in EDs for soccer‐related injuries and described the nature of these injuries. Methods: Data from the 2000 National Electronic Injury Surveillance System All Injury Program were used to estimate the overall number and rate of soccer injuries in children, calculate injury rates per 1,000 children, and describe the body regions affected and types of injuries. Results were stratified by five‐year age groups (5–9 years, 10–14 years, and 15–19 years). Results: Approximately 144,600 children sustained soccer‐related injuries in 2000 for a rate of 2.36 injuries per 1,000 children. Injury rates increased with age (0.8, 5–9 year olds; 3.1, 10–14 year olds; 3.2, 15–19 year olds). Common types of injuries were strains/sprains (36.7%), fractures (23.0%), and contusions (20.9%). Fractures decreased with age; sprains/strains increased with age. Commonly injured body regions varied by age. Wrist and finger injuries were most common (12.7% and 12.4%, respectively) in the youngest group; in the 10–14‐year‐old group, ankle and wrist injuries were most common (15.7% and 13.6%, respectively). In the oldest age group, ankle injuries were most common (21.9%), followed by knee injuries (17.6%). Conclusions: Substantial numbers of children were treated in EDs for soccer‐related injuries. Injury types and affected body regions varied by age. Injury prevention efforts to reduce soccer‐related injuries may need to be age specific.     

Syndesmotic ankle sprain

Ankle sprain injuries are the most common type of joint sprain. The prevalence of ankle joint sprains accounts for 21% of joint injuries in the body. Although somewhat rare, high-ankle or syndesmotic ankle sprains occur in up to 15% of ankle trauma. This article will present the pathomechanics of the high-ankle or syndesmotic sprain.     

Usefulness of ultrasonographic detection of talocrural effusion in ankle sprains.

OBJECTIVE: Ankle sprain severity is difficult to assess initially in the emergency department, yet it governs treatment decisions. Ultrasonography readily shows fluid present in the talocrural joint, which is difficult to assess by physical examination. The purpose of this study was to evaluate the prevalence of ultrasonographic talocrural joint effusion in moderate and severe ankle sprains and to determine the cause of effusions by magnetic resonance imaging (MRI). METHODS: Consecutive patients 18 to 55 years of age with moderate and severe ankle sprains within the previous 48 hours were included if they had no history of abnormalities in the same ankle within the last 12 months. When ultrasonography with the ankle in the neutral position showed talocrural effusion, MRI was performed within 8 days. RESULTS: Of the 110 patients (83 men and 27 women; mean age, 24.2 years), 40 (36.4%; 95% confidence interval, 27.6%-46.1%) had joint effusion on ultrasonography and MRI. In 39 of these 40 patients, MRI visualized damage to the anterior talofibular ligament (positive predictive value, 97.5%; 95% confidence interval, 85.3%-99.9%), accompanied in 5 (12.8%) cases by damage to the calcaneofibular ligament. In 14 (35%) cases, MRI showed cartilage damage or bony contusion. CONCLUSIONS: Talocrural effusion on ultrasonography may identify patients with severe ankle sprains. Magnetic resonance imaging should be performed in patients with talocrural effusion. Further work is needed to evaluate the usefulness of MRI in acute ankle sprains without talocrural effusion.