Make Sure You’re Up To Date On The New Clinical Guidelines for Ankle Sprains

Are you treating your patients’ ankles sprains using the most current best evidence? We just recently wrote an article for you all providing some information on creating an effective and comprehensive balance training program for your patients who have suffered an ankle sprain. [1] Phil Page PhD, PT, ATC, CSCS, FACSM, LAT gave us some insight on his top five ankle sprain rehabilitation exercises.

The “Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline” was recently published in the British Journal of Sports Medicine. [2] By using current evidence, researchers were able to provide an updated multi-disciplinary guideline for comprehensive ankle injury management. Let’s take a look at the recommendations for diagnosis, treatment, and prevention.

Ankle injuries account for 22.6% of all injuries among U.S. high school athletes. Athletes of some sports are at higher risk for an ankle sprain. Studies have shown that football, soccer and basketball are the sports with the highest rates for ankle injuries. [3] Female athletes also experience a higher percentage of ankle injuries than male athletes.

Many different factors could put your athlete at risk for an ankle sprain. Deficiencies in proprioception and range of motion (ROM) following an initial lateral ankle sprain (LAS) can increase your athlete’s chance of having recurrent ankle sprains. After taking into consideration the specific factors that will affect the likelihood your athlete will experience an ankle sprain, a rehabilitation program can be created to avoid a LAS or reduce recurrent ankle sprains.

There are two different diagnostic tests that are recommended in this current practice.

1. Ottawa Ankle Rules
• Recommended to first rule out a fracture in lieu of radiographic diagnosis
2. Anterior Drawer Test

• Better diagnostic test for anterior talo-fibular ligament damage
• Used if delayed by 4-5 days after injury

What’s your go-to treatment that you use for ankle sprains? The guideline summarizes five different treatment techniques that can be used, discussing both the pros and cons.

RICE could easily be one of the most common treatments used after an ankle sprain. It’s a treatment that we’ve been taught since we were a young kid after getting an ankle sprain on the playground.

RICE is an acronym for four steps:

1. Rest
• Rest is required to reduce the metabolic demands of the injured tissue which can help avoid increased blood flow. It also is needed to avoid stress on the injured tissues that might disrupt the healing process. [4]
2. Ice
• Ice is commonly used to achieve cooling. “Ice” is the term used to represent the application of cryotherapy in general. Ice is used to limit the injury-induced damage by reducing the temperature of the tissues at the site of injury and consequently reducing metabolic demand, inducing vasoconstriction, and limiting the bleeding. It also can reduce pain by increasing pain threshold levels in the free nerve endings. [4]
3. Compression
• The goal of compression is to stop bleeding and reduce swelling. Compression is applied to limit the amount of edema. Controlling the amount of swelling reduces the amount of scar tissue that develops. [5]
4. Elevation

• Elevation of the injured part lowers the pressure in local blood vessels and helps to limit the bleeding. It also increases lymphatic drainage, reducing and limiting edema and its resultant complications. [5]

While this has been a treatment that has been around for quite some time, is it as reliable as some may think? It was found that although it is one of the most commonly used treatments for ankle sprains, there is no evidence that RICE is beneficial for acute LAS…alone! “RICE should be used as a part of a multi-modal treatment including exercise,” says Dr. Page, who wrote a recent article on the ice controversy..“I was not surprised to see the conclusion in the text that the evidence is 'unclear' in the use of ice on acute ankle injuries. There simply are not enough well-controlled RCTs can support RICE's efficacy when used alone. Clinically, we always combine ice with other interventions such as exercise.”

So, let’s take a look at other treatments that can be used in combination with RICE.

Also known as NSAIDS, non-steroidal anti-inflammatory medications were another recommendation found in the guidelines.

In a study using NSAIDS for treating acute ankles sprains, “superior results were reported for oral NSAIDS when compared with placebo concerning pain on weight bearing on short term, pain at rest on short term, and less swelling on short and intermediate term.” [7] However, the guideline suggested that NSAIDS may impede the healing process by limiting inflammation.

Dr. Page explains that there is no direct evidence that these medications do delay healing. “The authors stated that NSAIDS may "delay the natural healing process," based on a review commentary published 15 years ago in a non-peer reviewed journal, rather than basing this comment on at least one well-controlled study with evidence that NSAIDS do, in fact, delay the healing process.”

There are also potential side effects of medication, as noted in the Clinical Practice Guideline.

There are few cases where an ankle sprain needs immobilization. In these cases of severe ankle sprains or fractures, it is still recommended that the maximum amount of days the athlete remains immobile is 10 days. Immobilization is very discouraged unless necessary; instead, “functional support” is recommended for 4-6 weeks. Functional support involves the use of ankle braces or other support such as taping.

Are you prescribing exercise to your athletes and patients suffering from LAS? Even if you are, you may be missing out on prescribing the correct exercises. In order to prescribe the exercise, the person injured needs to seek medical attention. Unfortunately, half of the population who suffer a sprained ankle do not seek the necessary medical attention.

Since exercise is arguably the most important aspect of LAS treatment, you should continue to educate your patients and athletes to seek medical attention when needed. Chronic ankle instability, as well as predisposed joint degeneration, can be caused due to the lack of performing appropriate rehabilitation.

According to the research, proprioceptive exercise can reduce the risk of recurrent injury and incidence of functional instability. In order to speed up recovery after an ankle sprain, you should begin therapeutic exercise quickly.

Dr. Page says, “Neuromuscular and proprioceptive exercises in particular are most effective; these include balance and stabilization exercises progressed through unstable surfaces such as balance boards and foam pads. Supervised exercise prescription leads to faster return to sport, and should focus on proprioception, strength, coordination and function.”

Check out our Injury Management Series on ankle sprains to see some of Dr. Page’s recommendations for ankle rehabilitation exercises.

Per the guidelines, exercise should always be preferred over surgery and only used for athletes who need a quick return to their sport or for patients are not responding to conservative treatment. In all other cases, you should help return your athlete to their sport with proprioception, strength, coordination and functional exercise.

A study was done comparing supervised exercise alone to supervised exercise in combination with manual therapy in those who were suffering from an ankle sprain. The authors noted, “The combination of manual therapy and a supervised exercise program was superior to a home exercise program alone in the treatment of ankle sprains, because the combined program provided better pain relief and improved function.” [8] Therefore, adding manual therapy techniques such as joint mobilization may enhance the effects of exercise.

In an ideal world, you would not have to treat an ankle sprain at all! The only way to limit the amount of ankle sprains you see is by focusing on preventing them. Your athlete doesn’t want to experience one and be taken out of their game, so what can you do to take all steps to avoid that from happening?

““As stated earlier, neuromuscular exercises can reduce the incidence of recurrent ankle sprains; however, evidence does not support a preventive effect of neuromuscular exercise on first-time ankle sprains. Both ankle braces and tape (athletic tape, rigid strapping tape, and kinesiology tape) have been shown to reduce the incidence of recurrent ankle sprains,” says Dr. Page.

Bracing or taping should be decided through personal preference and what works for the individual athlete or patient. Dr. Page added, “Don’t be worried about going out and buying specific shoes because the guideline concluded that there’s no evidence that any different footwear will help prevent spraining your ankle!”

Check out the video below to get some more quick information from Dr. Phil Page on the new Clinical Practice Guideline for ankle sprains!

Sources:

[1] http://www.performancehealthacademy.com/articles/are-you-prescribing-the-wrong-ankle-sprain-rehabilitation-exercises.html

[2] https://www.ncbi.nlm.nih.gov/pubmed/29514819

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978459/

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396304/

[5] https://www.ncbi.nlm.nih.gov/pubmed/24474583

[6] https://www.jospt.org/doi/full/10.2519/jospt.2013.0504

[7] https://www.ncbi.nlm.nih.gov/pubmed/24474583

[8] https://www.ncbi.nlm.nih.gov/pubmed/24474583