Ankle Sprain

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Definition/Description

An ankle sprain is where one or more of the ligaments of the ankle are partially or completely torn.  

Clinically Relevant Anatomy

An ankle sprain is a common injury in which one or more of the ankle ligaments is torn or partially torn. Inversion ankle sprains are the most common making up 85% of all ankle sprains.  The most commonly torn ankle ligament is the anterior talofibular ligament (ATFL) which is on the lateral aspect of the ankle.  

Epidemiology /Etiology

The most common mechanism of injury for an ankle sprain involving the lateral aspect of the ankle (commonly called a lateral ankle sprain or an inversion ankle sprain) is when the foot is forced into a combined movement of plantarflexion and inversion. In this situation the ankle would roll into an outward direction with the foot and toes moving inward toward the midline of the body.  

A less common mechanism of injury involves a forceful eversion movement at the ankle with injury to the very strong deltoid ligament complex.  

Characteristics/Clinical Presentation

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Differential Diagnosis

The Ottawa ankle rules is an accurate tool to exclude fractures within the first week after an ankle disorder. (Grade of evidence =A)

Diagnostic Procedures

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Outcome Measures

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Lower Extremity Functional Scale (LEFS) - www.manualphysicaltherapy.net/Downloads/Lower_Extremity.doc

Examination

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Medical Management

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Physical Therapy Management

CASE1: light ankle sprain (natural full recovery within 14 days):
Taping and making an appointment for a check-up to evaluate the healing of the ankle sprain
CASE2: severe ankle sprain:
In this case physiotherapy is required. Functional therapy of the ankle is shown to be more efficient than immobilisation. Functional therapy treatment will be divided in four steps, (related to the four steps in the tissue recovery after an acute ankle sprain). Inflammatory phase,Proliferative phase,  Maturation and remodelling Healing [1]

Step 1: Inflammatory (0-3 days)

Reduction of pain and swelling and improve circulation and partial foot support
Actions
The most common approach to manage ankle sprain consists of rest, ice, compression, and elevation (RICE) (grade of evidence=D)
1. Recommendations for the patient:
o REST: advise to take rest for the first 24 hours after injury
o Advise 1) to charge the foot in function of the pain, perhaps with crutches 2) to take measures to decrease the charges at work and if necessary to temporarily stop working, 3) to stop exercising in expectation to further recovery, 4) to stop exercising in expectation to further recovery
o ICE: Apply a cold application (15 to 20 minutes and this 1 to 3 times a day)
o Apply a Compression bandage. Due to the continuous swelling caused by the ankle sprain it’s more likely not to apply tape or brace.
o ELEVATION: put the foot high
2. Practice foot and ankle (functions):
Ask your patient to move toes and foot within pain limit, to improve the local circulation ex. plantar flexion, dorsal flexion, inversion and eversion of the foot.

• Step 2: Proliferation step (4-10 days)
Recovery of foot and ankle functions and activities and improve the load-carrying capacity
Actions
1. Recommendations for the patient:
o Advise the charge the foot guided by the pain, first week use crutches.
o Promote symmetrical charging and active unrolling of the foot after one week.

2. Practise foot and ankle functions and activities:
o Practice the motion (dorsal flexion included), active stability , motor coordination  and running.

3. Tape/Brace :
Apply tape as soon as the swelling is decreased. Whether you use a tape or a brace depends on the preferences of the patient. (grade of evidence=F) Boyde et al, 2005 found that the use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function compared with standard management with an elastic support bandage.

Still it remains uncertain witch treatment (brace, bandage, tape) is the best  (grade of evidence=A)

• Step 3: early remodelling (11 -21 days)

 Improve muscle strength, active (functional) stability, foot/ankle motion, mobility (walking, walking stairs, running)
Actions
1. Inform:
o Provide information about possible preventive measures (tape or brace).
o Advise to wear for appropriate shoes during sport activities. Therefore, judge the quality of the shoes in function of whether they’re appropriate or not for the particular type of sport and surface.
2. Practise foot and ankle functions and activities
o Practice balance, muscle strength, ankle/foot motion and mobility (walking, walking stairs, running). Look for a symmetric walk pattern.
o Work on dynamic stability. Start, as soon as the load-bearing capacity allows it with active loaded exercises, focused on balance and coordination exercises. Build the improvement of the loading amount on a progressive way: from statically to dynamical exercises, from partial loaded to full loaded exercises and from easy to functional multitasking exercises, alternate cycled with non-cycled exercises (abrupt, irregular exercises). Using different types of surfaces will increase the level of difficulty. (grade of evidence =A)
o Encourage the patient to continue practicing the foot abilities at home. Instruct the patient precisely where to put the accent on every exercise.
3. Bandage
o Advise to wear tape or brace during physical activities. These procedures are needed until the patient is able to execute correctly the static and dynamic exercises of balance and motor coordination.

Step 4: Late remodelling 1 (intended purpose of load-carrying capacity in ADL and work) 
Improve the regional load-carrying capacity, the walking skills and improve the skills needed during activities of daily living (in particular skills needed during work, sports and specific home activities)
Actions
1. Practise and adjust foot abilities (functions and activities)
o Practise motor coordination skills while practising mobility exercises
o Elaborate a work out program with as purpose to achieve the normal load-carrying capacity (= the load-carrying capacity before strain trauma)
o Build the improvement of the loading amount on a progressive way: from static to dynamic exercises, from partial loaded to fully loaded exercises and from easy to functional multitasking exercises, alternate cycled with non-cycled exercises (abrupt, irregular exercises), until the normal load-carrying capacity is reached. (grade of evidence =A)
o Increase the level motor coordination exercises in varied situations until the prescribed purposes are reached.
o Encourage the patient to continue practicing at home. Instruct the patient precisely where to put the accent with every exercise.

Key Research

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J Whitman, et al. Predicting short term response to thrust and non-thrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Phys Ther, 2009; 39(3):188-200. 

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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