Ankle Sprain Management

Aka: Ankle Sprain Management

1. Indications
   1. Protocol intended for Lateral Ankle Sprain
   2. Other Ankle Sprain with caution (progress more slowly)
      1. Medial Ankle Sprain
      2. High Ankle Sprain
2. Management: First 1-2 days: RICE-M
   1. Local Cold Therapy (Avoid heat)
   2. Rest and elevation
   3. Crutch walking for 2 to 3 days
   4. Air cast splint
      1. Preferred over Soft Compression Dressing
   5. Start early range of motion as soon as possible
      1. See below for days 3-5
      2. Concentrate on ankle dorsiflexion
   6. NSAIDS
      1. Use with caution if suspect cartilage damage
   7. No benefit with Therapeutic Ultrasound
3. Management: Days 3-5: Function (Mild-Moderate sprains)
   1. Weight Bearing as tolerated
   2. Early Active range of motion
      1. Perform each Exercise three times daily
         1. Repeat Exercises 10 to 15 days
         2. Apply ice before and after Stretching
      2. Specific stretches
         1. Ankle Dorsiflexion (Towel pulls foot toward face)
         2. Ankle Plantar flexion
         3. Ankle Circumduction
         4. Ankle "Alphabet writing" (draw letters with foot)
      3. Efficacy
         1. Results in earlier return to work and sport
         2. Kerkhoffs (2001) Arch Orthop Trauma Surg 121:462-71
4. Management: Days 4-7: Strengthening
   1. Walk 50 feet bid on more difficult terrain
      1. Start on hard, flat floor
      2. Progress to uneven surface
   2. Exercises: Isometric and Isotonic
      1. Technique
         1. Isometric stretch against wall or other foot
         2. Isotonic stretch (resistance from rubber strap)
      2. Perform each Exercise three times daily
         1. Repeat Exercises 10 to 15 repetitions
         2. Apply ice before and after Stretching
      3. Specific stretches
         1. Ankle inversion
         2. Ankle eversion
         3. Ankle plantar flexion and dorsiflexion
   3. Exercises: Isometric
      1. Technique
         1. Two sets of 10 repetitions bid
      2. Specific Exercises
         1. Toe curls
         2. Marble pickups
         3. Toe raises
         4. Heel walking
         5. Toe walking
   4. Wrapping/Bracing ankle if needed
      1. See Special Topics below
5. Management: Week 1 and later
   1. Activity tolerated
      1. Static Bicycling
      2. Fast Walking
   2. Severe pain with activity
      1. Short Leg Walking Cast for 4 weeks
6. Titrate back to full activity when walking without pain
   1. Jog 50% and walk 50%
      1. Increase distance 1/8 mile per time
   2. Jog in straight line pattern
      1. Forward
      2. Backward
   3. Jog in other patterns
      1. Run circle pattern
      2. Run zig-zag pattern
   4. Progression without pain allows return to activity
7. Prevention
   1. Proprioception
      1. Re-training proprioception prevents re-injury
      2. Activities
         1. Static one-leg standing with eyes closed
         2. Wobble board with one leg (5-10 reps twice daily)
            1. Circular wooden platform with hemispheric base
            2. Shift balance to move wobble board in circle path
   2. Stretching
      1. Toe raises, heel cord stretches
   3. External ankle support (e.g. ankle lace-up)
      1. Recommended for ankle protection in high risk sports
      2. Recommended if prior Ankle Sprain
8. Management: Special Topics
   1. Short Leg Walking Cast (used for 4 weeks)
      1. Used less now due to adverse effects
         1. Decreases Range of motion
         2. Atrophy risk
      2. Indications
         1. Pain refractory to conservative therapy
         2. Independent walking
      3. Alternative (Removable devices for Exercise)
         1. Ankle/Foot Orthosis (AFO)
         2. Sugar tong
         3. Air cast
         4. Compression stocking (controls swelling)
   2. Orthopedic referral indications
      1. AnkleFracture or dislocation
      2. Neurovascular compromise
      3. Tendon rupture or subluxation
      4. Wound penetration of joint
      5. Ankle syndesmotic injury
      6. Mechanical locking or catching symptoms
      7. Symptoms out of proportion to mechanism of injury
   3. Surgery Indications
      1. High level athletes
      2. Significant High Ankle Sprain
      3. Excellent outcome for unstable sprain
      4. Jones Fracture
   4. Chronically Unstable Ankle (lateral ligament lax)
      1. Lateral heel and sole wedge (0.3 cm)
         1. Prevents inversion
      2. Lace-up Ankle brace
      3. Taping or bracing
      4. Surgical Reconstruction
9. Resources: Patient Education
   1. Information from your Family Doctor
      1. http://www.familydoctor.org/healthfacts/010/
10. References
    1. Rifat (1996) Am Fam Physician 53(8):2491-8
    2. Rubin (1996) Am Fam Physician 54(5):1609-18
    3. Sitler (1995) Sports Med 20(1):53-7
    4. Swain (1993) Postgrad Med 90(3):91-100
    5. Wolfe (2001) Am Fam Physician 63(1):93-104
    6. Ivins (2006) Am Fam Physician 74:1714-26