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Another twisted ankle

Lateral ankle ligament sprains are one of the most frequently encountered injuries in a sports clinic. Health professionals should be familiar with their presentation and differential diagnosis. Chapter 38 of Clinical Sports Medicine (CSM4ed), ‘Acute ankle injuries’, details lateral ligament anatomy, assessment and management. Owners of the textbook can view five masterclasses after registering with the Clinical Sports Medicine website (Ankle examination, Plaster short leg posterior splint, Basic ankle rehabilitation, When to investigate after an ankle injury, Differentiating flexor hallucis longus tendinopathy from posterior impingement).

It is important that clinicians regularly refer to research evidence to guide their practice. Clinical guidelines summarise the best available research evidence to help clinicians deliver safe, up-to-date clinical care. A recent clinical guideline1 published in the BJSM provides clinicians with several take-home messages to help guide evidence-based practice:

Assessment

  • Intrinsic risk factors for ankle sprain include limited ankle dorsiflexion, reduced ankle proprioception and a past history of ankle injury
  • High-risk sports include indoor volleyball, rock climbing, basketball and field sports.
  • Among soccer players, artificial turf increases the risk of injury. Defenders and forwards are at higher risk due to higher contact with other players
  • After 2 weeks, a simple lateral ankle sprain should demonstrate a rapid decrease in pain levels. Deviation from this clinical pattern may be the first clue in the differential diagnosis of another problem
  • Increased ligament laxity after injury can contribute to chronic ankle instability
  • The Ottawa Ankle Rules have been developed to rule out fractures after acute ankle injuries and are strongly recommended in the emergency room of hospitals and in general practice
  • If a haematoma is present accompanied by local pressure pain at palpation or a positive anterior drawer test is present or both, it is most likely that at least a grade 2 lateral ankle ligament rupture exists

Management

  • The use of ice and compression, in combination with rest and elevation, is an essential aspect of treatment in the acute phase
  • The effectiveness of ultrasound, laser and other electrotherapies in the acute phase of ankle sprain is yet to be determined
  • A short period of plaster immobilisation or similar rigid support facilitating a rapid decrease of pain and swelling can be helpful in the acute phase (0-48 hours)
  • Functional treatment for 4 to 6 weeks is preferable to immobilisation in a cast
  • Some form of exercise therapy should always be incorporated in the management plan and should ideally include proprioception, strength, coordination components
  • Manual mobilisation of the ankle may only have limited short-term effects
  • A lace-up brace or a semi-rigid brace is preferable and recommended. The use of sports tape can be considered
  • Functional conservative management is preferred over surgical approach. However, based on consensus expert opinion surgical treatment may be considered on an individual basis, and may be more appropriate for professional athletes

Prevention

  • Balance and co-ordination exercises can be undertaken, especially in the first 12 months after ankle injury
  • The use of a brace or sports tape can be considered, especially after ankle injury
  • Exercise therapy should be maintained to reduce recurrence

A recent systematic review found that a combination of sports tape or brace and neuromuscular training will achieve the best preventative outcomes.3 This finding is important when you consider the financial burden of injury and the potential negative impact of ankle sprains have on both the individual and the team or club.

Those who have suffered an ankle sprain may be interested in the findings of a recent observational study.2 This study demonstrated that resting pain and episodes of instability at the three month mark post injury were predicative of ongoing symptoms at one year. Therefore, clinicians should routinely assess athletes at the 3 month mark to ensure adequate recovery has occurred. At the three month mark, preventative measures can be maintained or introduced if they are inadequate. To help understand persistent pain after ankle sprain and appropriate reassessment, Chapter 38 of the textbook includes a section on the ‘problem ankle,’ and provides information on important differential diagnoses and other complications which may have developed as a result of injury.

You can listen to a BJSM podcast by the authors of the Guideline by clicking here.

References

  1. Kerkhoffs GM, van den Bekerom M, Elders LAM et al. ‘Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline’ Br J Sports Med 2012;46:854–860
  2. van Middelkoop M, van Rijn RM, Verhaar JAN et al. ‘Re-sprains during the first 3 months after initial ankle sprain are related to incomplete recovery an observational study’ Journal of Physiotherapy 2012 Vol. 58: 181-188
  3. Verhagen EALM, Bay K ‘Optimising ankle sprain prevention: a critical review and practical appraisal of the literature’ Br J Sports Med 2010;44:1082–1088

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