Evidence-based treatment choices for acute lateral ankle sprain: a comprehensive systematic review

Key Points

1. Most patients presenting with acute ankle sprain can be managed conservatively (although contemporary surgical techniques have not yet been rigorously examined).
2. Preliminary evidence suggests flexible external supports are superior to rigid supports.
3. Few randomized controlled trials have compared different exercise protocols and the optimal exercise content and dose is unclear.

BACKGROUND & OBJECTIVE

Acute ankle sprains occur frequently, particularly in sports, with an estimated 0.9 per 1000 athletic exposures (1). Currently, most ankle sprains are managed conservatively, based on protected mobilisation combined with therapeutic exercise. Surgical management of ankle sprains is usually reserved for elite level athletes presenting with higher grades of injury.

The primary aim of this systematic review was to compare conservative management vs surgery, after acute ankle sprain. As the nature of conservative treatment can vary, the review’s secondary aims were to determine if there is evidence to inform a). an optimal method of external bracing and b). the key components (content dose) of rehabilitation protocols after ankle sprain.

Surgical management of ankle sprains is usually reserved for elite level athletes presenting with higher grades of injury.

There is much evidence that impairment based therapeutic exercises are effective after ankle sprain.

METHODS

This systematic review followed PRISMA guidelines and included a comprehensive search of 3 major databases. The authors limited inclusion to randomized controlled trials (RCTs) making any of the following comparisons: surgery vs conservative treatment; different types of external supports; different rehabilitation protocols. The Cochrane risk of bias tool was applied, and studies were categorised as having high, low or unclear risk of bias. Two reviewers independently completed all aspects of the review methods (selection, ROB assessment, data extraction) and study findings were summarised qualitatively.

RESULTS

A total of 35 RCTs were included. N=12 compared surgery to conservative management, of which, 2 (16.5%) favoured surgery, 8 (67%) favoured conservative treatment, and the remaining 2 (16.5%) found little differences. A further eight RCTs compared different types of external support, but results were mixed; the authors highlighted a trend that flexible supports were preferable to more rigid types, but this was not informed by high-level evidence. Only four RCTs made direct comparisons between different rehabilitation protocols, but again, there was no consensus on an optimal approach.

LIMITATIONS

This review addressed 3 separate clinical questions. In each case, the included studies were heterogenous (by injury grade, intervention type, outcome assessment, and follow up) and it was difficult to make any definitive conclusions. The authors were also unable to quantify effect sizes, relying instead on qualitative consensus across multiple outcome constructs. Although they reached a definitive conclusion for the first review question (conservative management is superior to surgery), the informing studies are dated; the most recently cited RCT in this field was published in 2010, with the others published 20-40 years ago.

CLINICAL IMPLICATIONS

Current evidence suggests that surgery may be best reserved for high level athletes, but there is an urgent need for future RCTs to examine the effectiveness of modern surgical techniques (e.g. minimally invasive repair, ligament augmentation, accelerated post-surgical rehabilitation). The nature of conservative management can vary and as there is no strong evidence informing the choice of external support, practitioner or patient preference may suffice.

Conservative treatment will look different depending on the individual, their goals, and the severity of ankle sprain. However, it usually starts with some restriction of movement with a graded return to functional exercise. For example, soft casts, braces, and tapes can be used initially to restrict movement. It may also be worth using cryotherapy, compression, and elevation to manage the symptoms associated with acute injury, followed by a return to early protected activity as these symptoms allow. Improving range of motion, strength and proprioception is essential to restore normal ankle function and prevent re-injury.

Although this review failed to highlight an optimal rehabilitation protocol, there is much evidence that impairment based therapeutic exercises are effective after ankle sprain (2). More refined clinical decisions relating to exercise dosing and progression must continue to be informed by expert consensus and practitioner reasoning.

+STUDY REFERENCE

Altomare D, Fusco G, Bertolino E, Ranieri R, Sconza C, Lipina M, Kon E, Marcacci M, Bianchini L, Di Matteo B (2022) Evidence-based treatment choices for acute lateral ankle sprain: a comprehensive systematic review. European Review for Medical and Pharmacological Sciences, 26(6), 1876-1884.

SUPPORTING REFERENCE

1. Herzog, MM., Kerr, ZY., Marshall, SW., Wikstrom, EA. Epidemiology of ankle sprains and chronic ankle instability. J Athl Train 2019; 54: 603-610.
2. Wagemans, J., Bleakley, C., Taeymans, J., Schurz, AP., Kuppens, K., Baur, H., Vissers, D. Exercise-based rehabilitation reduces reinjury following acute lateral ankle sprain: A systematic review update with meta-analysis. PLoS One. 2022 Feb 8;17(2):e0262023.