Ankle sprains: From research to practice

Picture this: you stumble across a tweet that goes like..

“Human body: I can grow a fully formed human baby in like nine months. I’m talking brain, functioning respiratory system, eyeballs, everything.

Me: Cool. How long will it take for my twisted ankle to feel better?

Human body: seven years and it will never be the same..”

Now, if that doesn’t sum up the quirks of lateral ankle sprains, I don’t know what does. I know what you’re thinking – “Ankle sprains? That’s no big deal!” Well, let me tell you, it’s not all sunshine and rainbows when it comes to assessing and treating these pesky ankle injuries. In physically active populations, lateral ankle sprains rank as the most prevalent musculoskeletal ailment on record (1). When viewed in isolation, a lateral ankle sprain may seem like a minor injury that typically mends swiftly and requires minimal intervention. However, the reality is far from this initial perception.

A significant number of individuals who have experienced a lateral ankle sprain in the past are prone to enduring subsequent sprains. Many of them face both physical and subjective limitations, often grappling with persistent instances of ‘giving-way’, ultimately leading to the development of chronic ankle instability. It’s like having a rebellious ankle that just refuses to heal properly. Talk about being stuck between a rock and a hard place! Post-traumatic osteoarthritis of the ankle isn’t confined to middle-aged and elderly individuals; it can affect people of all ages. Beyond the physical toll, lateral ankle sprains also take a significant financial toll, with billions spent annually on initial treatment and ongoing care.

Physiotherapists often find themselves in a bit of a pickle when it comes to ankle sprains, relying on diverse treatment strategies for management. There’s no universal consensus for treating lateral ankle sprains, leaving physios guessing when making return to play recommendations to patients. The adverse effects of lateral ankle sprains and chronic ankle instability are worrisome, highlighting the urgent need for enhanced strategies to tackle these conditions effectively. Clearly, there’s a gap. But fear not, physios! There is hope on the horizon. Physio Network has been working diligently to bridge this gap between physio research and clinical practice for ankle sprains. In this blog, I’ll tell you how the research reviews by Physio Network helped me in successfully managing my patient with lateral ankle sprain.

The case

Meet our 36-year-old patient, a basketball enthusiast who found himself with a twisted ankle after attempting a layup. Despite the discomfort, he managed to hobble around with a noticeable limp. Swiftly, he applied some ice to alleviate the swelling. The patient was a walk-in without any referral. Our resilient patient revealed that this wasn’t his first ankle ordeal on the basketball court – a year ago, he had a similar incident.

Now, this patient isn’t your average Joe. He’s a dedicated professor at a local university, juggling the demands of climbing stairs, teaching and delivering lectures. And if that isn’t impressive enough, he’s also an avid trekker and runner, with a few half marathons under his belt. Surprisingly, after his previous ankle mishap, he skipped out on rehabilitation exercises and, once the pain became manageable, embarked on a high-altitude trek. A year down the line, he even completed three half marathons, though he knew his ankle wasn’t at its best. Frustrated by the recurrence of the injury, he’s determined to rehab his ankle “properly” this time. To add to the plot, he mentioned hearing a concerning “snap” during the recent trauma. He came to the clinic two days after the second ankle sprain.

The assessment

This Physio Network Review by Shruti Nambiar provides an update for evidence based clinical guidelines on diagnosis, treatment and prevention of ankle sprains. Fractures were ruled out using Ottawa rules, and four days post-injury, an anterior drawer test along with palpation was conducted to assess the damage as recommended in the review. The results indicated a suspected grade II moderate injury of the Anterior Talo-Fibular Ligament (ATFL), setting the stage for a comprehensive recovery journey. Numeric Pain Rating Scale (NPRS) was taken at 7/10 and the Foot and Ankle disability questionnaire was used. This brilliant Review by Dr Michael Reiman reminded me not to rely on one single test, as special tests are not that special – always combine the tests with proper history, palpation, weight bearing status and other subjective and objective findings. This Review promotes a comprehensive assessment approach using a biopsychosocial lens to assess how the injury is impacting the patient in front of you. The weight-bearing lunge test was performed to assess dorsiflexion range of motion. The single-leg stance test and star excursion balance tests were used to assess postural control deficiencies. Routine physical assessments were performed on both injured and uninjured sides, including muscle strength tests and gait assessment.

The treatment

As the patient had undergone three days of rest and icing before coming to the clinic, it was time for some early neuromuscular and proprioceptive training as dictated by this Review by Shruti Nambiar. The patient was seen three days a week for the first two months, and then two days a week for the next eight months. Plenty of compelling evidence supports the effectiveness of impairment-based therapeutic exercises for treating ankle sprains, as per this Review by Dr Chris Bleakley – it highlights that in the world of ankle sprains, conservative treatment is not a one-size-fits-all approach. It’s a customized journey tailored to each person’s unique needs, goals, and the severity of their sprain. The key is to gradually ease back into functional activities, with a focus on early protected activity, all while listening to your symptoms and your body’s cues.

During the initial stages, Mobilisation With Movement (MWM) was performed to improve dorsiflexion range of motion as per this Review by Robin Kerr, to promote self-management by reducing pain. Self-mobilisation methods were then taught for unsupervised use, as this Review by Dr Travis Pollen indicates they provide statistically significant improvements across a variety of outcome measures. A semi-rigid brace was also used during exercises instead of kinesiotape, as this Review by Todd Hargrove suggests kinesiotape does not provide adequate stability following an ankle sprain.

Proprioceptive training was introduced to reduce the risk of recurrent ankle sprains, as this Review by Sandesh Rangnekar indicates the benefits of proprioceptive training programs for ankle sprain rehab. Open chain strengthening exercises were completed initially, followed by closed chain exercises, with an overall focus on the plantar flexors and tibialis posterior. Controlled inversion in plantarflexion with a theraband was encouraged, and the resistance was progressively increased. Theraband was then used to practice internal rotation in standing in the later stages of rehab. Heel walks were encouraged while controlling the excessive internal rotation of the foot. Moving forwards, we used a wobble board to work the ankle in extreme ranges of motion. Single -leg functional training was performed in different planes with the use of therabands and cables once the patient was pain-free, had adequate strength and full range of motion. Hopping, jumping, cutting and jump landings were also performed along with external perturbation techniques.

The return to play

In this brilliant Review by Dr Teddy Willsey, practitioners are provided with a framework to assess the readiness of an athlete to return to sport. In this insightful Review of the framework, it outlines that the approach incorporates both psychological readiness assessments and physical testing as integral components in the athlete’s journey back to the sports field. This comprehensive approach highlights the importance of addressing not just physical recovery, but also the mental preparedness required for a successful return to sport. Although my patient was not an elite sportsman, this Review guided my decision-making process.

Wrapping up

Fear not, physios! It might be challenging to treat ankle sprains (it certainly was for me), but hope is on the horizon! The Physio Network Research Reviews are an invaluable resource for guiding the treatment of ankle sprains. When it comes to managing this common injury, it is crucial to base clinical decisions on solid research evidence. Physio Network’s Research Reviews bridge the gap between research and clinical practice, providing physiotherapists access to a wealth of up-to-date information, expert analysis, and practical insights.