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Acute lateral ankle sprain? Here's my advice...

Over the last few years evidence has changed for how best to manage acute injuries in general (to ice or not to ice? To load or not to load?). By applying the most up to date evidence to acute injuries, physiotherapists are able to support patients through the healing process and back to health.


A consensus statement was released in 2018 written by a group of medical professional in Amsterdam (see citation at end) reviewing best practice for managing acute lateral ankle sprains (LAS). Below is my summary with added opinions and experiences.


Note: you should always seek professional help to ensure an accurate clinical impression of your injury prior to commencing rehab to ensure correct treatment.

RICE...


There has been no strong evidence to suggest applying RICE (rest, ice compression and elevation) alone has any benefit.


Complete rest has very limited in tissue healing. I advise relative rest to patients which means the tissue should be loaded in a capacity it can handle (e.g. when acutely painful running 10 kilometres is not appropriate but walking for 20 minutes may help promote aspects of healing). When tissue is injured it needs time to recover and therefore will not handle the extent of activity it was prior to injury straight away.


There is contradictory evidence on the use of ice for acute injuries, having reviewed recent research my professional opinion is that it can help manage pain ONLY when applied for up to 5 minutes at a time with at least 20 minute breaks. It is thought that ice can delay the inflammatory phase (a phase of healing) and delay recovery. It can however help with pain management so the risks and benefits need to be weighed up.


Functional supports (taping and braces) should be preferential to compression supports.All elements of RICE if applied should be combined with functional exercises, manual therapy and graded return to activity.


Exercise and manual therapy...


Supervised exercise has been shown to be more beneficial than home exercises at reducing risk of re injury and both have benefits on reducing risk overall. Exercise with manual therapy has been shown to improve range of movement (stiffness is a common limitation post ankle sprain) and pain in the short term and has better effects that just exercise alone.


Manual therapy that has evidence to suggest benefits includes: mobilisations, soft tissue manipulation (deep frictions) and acupuncture (although more limited). Manual therapy that has no known benefit: Ultrasound, laser and electrotherapy.


A personalised rehabilitation programme should be followed and supervised. It can take time to recover from ligament injures (sometimes up to 12 months). You will need to be patient and do not run before you can walk (metaphorically and literally). Initially the exercises will be aimed towards more simple recovery goals (with your longer term goal in mind) and as you progress it will become more specific and functional to your specific goals.


A common mistake is to feel better and stop your rehabilitation. You need to ensure full, functional control and strength before returning to sport or activity. Although pain and swelling may have improved you will likely still have reduced balance, strength, proprioception and control in comparison to your uninjured side. To prevent chronic ankle instability and higher chances of arthritis I would strongly advise following a comprehensive rehabilitation program that includes plyometric and control exercises towards the end stages and exercises that focus on all your joints interacting, not just looking at your ankle in isolation.

Taping and immobilising...


More recently there has been debate about taping for ankle injuries. Recent research suggests tape (K-tape and sports tape) may not limit movement as once thought. In a 2018 review, evidence suggested that functional taping and supports provided better results than immobilisation (crutches, cast or boot).


If immobilisation is going to be applied it should be for up to 10 days maximum and should be followed by functional treatment.

Anti-inflammatory medication ...


Disclaimer: I am not a pharmacists and nor am I trained in providing advise on medication. Please always consult your pharmacists or GP prior to taking medication.


From the evidence the use of anti-inflammatory medication has similar debate to the use of ice when it comes to its place in tissue healing (see above). I would normally advise my patients to speak to their pharmacist and to be cautious when using this type of medication in acute injuries. There is some evidence to suggest they help pain and swelling but this should be weighed up against the potential risk of delayed healing.

Footwear...


My message when it comes to training and active shoes is clear - ITS PERSONAL PREFERENCE. Do not be sucked in by companies claiming footwear can do X, Y and Z. Find a trainer that feels comfortable, that you like the look of and that doesn't break the bank (unless you want to, of course). The 2018 consensus also suggests footwear does not have an impact on improving recovery from LAS.


I would advise that trainers that are worn down and old should be replaced but I do not necessarily think that certain trainers have better outcomes than others.


Imaging (X-ray and MRI) and surgery...


There are certain criteria that healthcare professionals follow to decide if imaging is necessary so I would advise seeking an assessment from a specialist as your first step. Imaging is often not necessary and rarely changes your treatment . Surgery is indicated in some cases but most simple ankle sprains will recover with conservative management.


To conclude, functional treatment is preferential but this should be assessed on a case by case scenario.


In summary, always seek professional advise, put the hard work in early and make sure you fully recover and regain your function before finishing your rehabilitation. You will get back to doing what you love but may need support along the way. Don't end up like this guy...





Citation

Vuurberg G,Hoorntje A, Wink LM, et al. Br J Sports Med

2018;52:956. Diagnosis, treatment and prevention of ankle sprains:

update of an evidence-based clinical guideline.



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