Acute ankle sprain which immobilization

Patient satisfaction was not substantially different in the two studies that evaluated this outcome. Limitations of the identified trials included small sample size, heterogeneity of treatment methods, and lack of standardized outcome measures. However, based on our review the current best evidence suggests a trend favoring early functional treatment over immobilization for the treatment of acute lateral ankle sprains.

The higher rate of adverse events indicates that this treatment needs to be applied judiciously in clinical practice, for example, only in patients who are able to comply with the regimen. The use of a compression stocking in addition to a cast, or electro-physical agents ultrasound, electrical muscle stimulation or interferential during the immobilization period did not improve outcomes after surgical fixation.

Since the publication of these reviews, one additional randomized controlled trial has been published; it investigated the effects of an orthosis that allowed some ankle movement after surgical fixation.

However, one case of impaired wound healing required surgical revision in the treatment group. Treatments prescribed for ankle fracture after the immobilization period typically include exercise, manual therapy, progression of mobility, and a gradual increase in activities.

Kaltenborn-based manual therapy including traction and gliding mobilization to the talocrural and talocalcaneal joints, and other hypomobile lower limb joints;. We further investigated the effectiveness of manual therapy large amplitude anterior—posterior glides of the talus in a randomized controlled trial of 94 participants.

These findings were consistent regardless of the severity of fracture. Furthermore, although the overall costs did not differ between groups, participants in the treatment group incurred more out-of-pocket costs. Our findings may only apply to the specific manual therapy technique used; however, there is some evidence in recurrent ankle sprain showing that different techniques do not lead to a difference in outcomes.

Thus, current evidence on treatments for ankle fracture after the immobilization shows that the addition of stretching or manual therapy to exercises did not enhance outcomes. This suggests that treatment for ankle fracture after the immobilization should be focused on a progressive and structured exercise program. Studies on factors that can predict or influence outcome in ankle fracture may assist clinicians in allocating treatment resources and advising patients according to the expected prognosis.

Factors found to be associated with outcomes after ankle fracture include the type of orthopedic management surgical or conservative , 11 , 53 — 57 fracture severity, 11 , 54 , 58 — 64 ankle range of motion, 54 , 65 and pain While ankle fracture managed surgically achieves better anatomical reduction than conservative means, 53 , 55 , 56 the implication of this on clinical outcomes is unclear with some authors finding no difference between surgical or conservative management, 11 , 53 , 56 some favoring surgical management, 55 and others favoring conservative management.

Classifying fracture severity according to the number of malleoli fractured appears to provide a more reliable prediction of outcome. Unimalleolar fracture has been consistently shown to be associated with better outcomes than bimalleolar or trimalleolar fracture.

Evidence-based treatment of acute ankle sprain should consist of functional support, possibly augmented by non-steroidal anti-inflammatory drugs in the early phases after injury. Manual therapy may also provide very short-term benefits after ankle sprain. Recent studies showed the additional benefits of exercise, particularly balance exercises, in reducing the risk of a recurrent sprain.

The use of electro-physical agents does not appear to enhance, and may even negate, outcomes. After ankle fracture, current evidence supports an early introduction of activity to enhance outcomes. This can be administered via the commencement of exercise or weight-bearing during the immobilization period in patients who will comply with this treatment regimen. After the immobilization period, adding adjunct treatments to a comprehensive exercise program may not improve outcome, and hence the focus of the treatment should be on exercise.

National Center for Biotechnology Information , U. J Man Manip Ther. Author information Copyright and License information Disclaimer. Email: ua. This article has been cited by other articles in PMC. Abstract The most common ankle injuries are ankle sprain and ankle fracture.

Ankle Sprain The management of ankle sprain is usually conservative and involves symptom management during the acute phase followed by a period of rehabilitation.

Evidence-based treatment of acute ankle sprain Functional support is preferable to immobilization for most ankle sprains. Open in a separate window.

Only primary outcomes are reported. For studies that did not distinguish outcomes as primary or secondary, pain intensity, disability, and range of motion outcomes if available are reported. Timing of the outcomes is for the end of treatment period and end of follow-up if available. Ankle Fracture The management of ankle fracture usually involves surgical or conservative fracture reduction, followed by a period of immobilization and rehabilitation.

Evidence-based treatment for ankle fracture during the immobilization period Most of the randomized controlled trials examining treatment for ankle fracture during the immobilization period included only subjects who had had surgical rather than conservative orthopedic management.

Evidence-based treatment for ankle fracture after the immobilization period Treatments prescribed for ankle fracture after the immobilization period typically include exercise, manual therapy, progression of mobility, and a gradual increase in activities.

Table 2 Effects of manual therapy after ankle fracture from randomized controlled trials. Prognostic factors Studies on factors that can predict or influence outcome in ankle fracture may assist clinicians in allocating treatment resources and advising patients according to the expected prognosis.

Conclusion Evidence-based treatment of acute ankle sprain should consist of functional support, possibly augmented by non-steroidal anti-inflammatory drugs in the early phases after injury. References 1. A systematic review on ankle injury and ankle sprain in sports.

Review of sports injuries presenting to an accident and emergency department. Population-based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains. A stable injury grade I demonstrates no increased laxity in the upper ankle joint, there is no complete tear of any ligament of the lateral complex.

This classification can be used in the emergency department. Injuries are classified by clinical examination and from our point of view it is most important to decide whether they are stable or unstable. Recommendation: a classification should allow reproducible and easy grading of the injury without elaborate techniques and also provide relevant information for treatment.

Consequently, classification criteria for stable and unstable injuries, based on clinical findings, is the most suitable approach for use in an emergency department or doctor's practice Figure 3. Because injuries of the lateral ligament complex are by far the most common, we will focus on their treatment.

For treatment of injuries to the syndesmosis, systematic reviews and evidence-based guidelines are available. Stable injuries grade I of the lateral complex recover quickly with non-surgical management and have an excellent prognosis. Three treatment options are available: surgery, immobilization, and functional treatment.

The main goal is to prevent residual symptoms and to provide fast recovery without harm to the patient. Recommendation: stable injuries of the lateral ligaments of the ankle should be treated using an elastic bandage and protection, rest, ice, compression and elevation PRICE , since these provide a good prognosis Figure 3 level I. Kerhoffs et al. Most trials reported a shorter time to return to normal activities after conservative treatment. This is in line with the findings of Tiling et al.

They concluded that there was no need for initial surgical treatment. This was stated in all reviews and trials analyzed. None of the studies reviewed favored surgery. Shrier et al. All the trials that supported surgery had methodical weaknesses as stated by Shrier. They concluded that primary repair and immobilization in a cast increase short-term disability compared with functional treatment, while comparable results were found during long-term follow up.

Pijneburg et al. But they still did not recommend surgery as the treatment of choice due to possible complications, higher costs, and because secondary reconstruction is equally effective to primary reconstruction of the ligaments. In an RCT, also by Pijneburg et al. Again, the authors conclude that surgery should not be the treatment of choice due to higher costs, possible complications and since secondary reconstruction produces results comparable to primary reconstruction.

However, as time to return to sports has been reported to be shorter for functional treatment, this is favored by most authors also for competitive athletes. Recommendation: conservative treatment should be favored over surgery due to comparable results with fewer complications after conservative treatment and significantly lower costs. Surgery should, therefore, be reserved for patients with persistent symptoms, particularly since secondary reconstruction of the ruptured ligaments is possible even years after the injury with results equal to those of primary repair level I.

The two approaches to conservative treatment are: i immobilization, usually using a cast, and ii functional treatment, with a short period of protection using tape, a bandage, or a brace, followed by early weight-bearing, including exercises and neuromuscular training of the ankle.

They found no findings concerning outcome in favor of immobilization. However, seven measurements of outcome produced significantly better results in favor of functional treatment. These were: number of patients who returned to sport and work, time to return to sport and work, objective instability, persistent swelling, and patient satisfaction.

They concluded that immobilization should no longer be the conservative treatment of choice for patients with acutely sprained ankles. These findings are in line with reviews by Kannus et al.

Kannus et al. Therefore, this trial does not contribute to the ongoing debate about the best treatment for acutely sprained ankles. Recommendation: there is consistent evidence that functional treatment should be considered the treatment of choice.

It leads to a faster recovery with greater patient satisfaction at lower costs Figure 3 level I. Functional treatment includes a short period of protection with tape, bandage, or an ankle brace, and allows early weight-bearing. Exercises for range of motion, and neuromuscular training of the ankle, should begin as early as possible. Consequently PRICE protection, rest, ice, compression, and elevation is appropriate in the acute stage to achieve these goals.

In a meta-analysis by Kerkhoff et al. Lace-up ankle supports reduced persistent swelling better than a semi-rigid ankle brace. However, there are not sufficient data available to allow definitive conclusions to be drawn. Further isokinetic training increased the strength of the injured leg. The study by van Rijn et al. However, reduced time to return to work means that socioeconomic savings may be high.

Recommendation: ankle braces are more convenient and cost effective than tape or elastic bandage. Consequently, unstable ankle sprains should be treated by early functional treatment using a semi-rigid ankle brace and supervised rehabilitation Figure 3 level II.

Cryotherapy has been proved to be effective in the treatment of soft tissue injuries. However, it seems to reduce swelling and the need for pain killers, particularly when used soon after the injury, and it should, therefore, be part of the initial standard regimes.

Recommendation: cryotherapy is effective in reducing pain and swelling in acute injuries of the soft tissues, especially when applied soon after the injury for 3—5 days Figure 3 level I. Ogilvie-Harris et al. No particular NSAID diclofenac, ibuprofen, piroxicam, diflunisal, or celecoxib was superior to any of the others. Their review provided reasonable evidence that patients recovered faster and with less pain when treated with NSAID.

So far there is some evidence that comfrey root ointment also can improve short-term symptoms. In addition to cryotherapy, they should be applied when treating acute ankle injuries for 3—7 days Figure 3 level I. Laser therapy, , ultrasound, , — electrotherapy, homeopathic therapy, hyperbaric oxygen therapy, prolotherapy, platelet rich plasma, hyaluronic acid or topical nitroglycerin injection were not effective, or available data were insufficient to prove their benefit in the treatment of acute ankle injuries.

In order too prove their benefit, new treatment options must be superior to placebo and to the current gold standarrd, i. Consequently, they should not be part of a standard protocol for treatment of acute ankle sprains. Recommendation: so far, none of these treatments have been shown to enhance recovery from acute ankle injuries. Therefore, they should not be considered as part of the standard regime in treating acute ankle injuries. Although current literature concerning acute ankle sprains is partly inconclusive and difficult to compare we extracted distinct trends in diagnosing and treatment of such injuries, and evaluated the level of evidence of the current literature.

Based on these findings, we developed a comprehensive algorithm Figure 3 with simple step by step decision rules. Using this algorithm helps to ensure quality of treatment. It can be easily implemented in any emergency department or doctor's practice. Physical examination is sufficient for the diagnosis of soft tissue damage. Classification into stable and unstable injuries seems to be the most practical and important approach. MRI should be performed if symptoms persist or if there is evidence of injury to the syndesmosis.

To treat injury to the lateral ligaments of the ankle, functional treatment is currently the treatment of choice, this should consist of PRICE, NSAID, early weight-bearing, and exercises for range of motion. For unstable injuries grades II and III , a semi-rigid ankle brace and supervised rehabilitation should be provided. Operative treatment is recommended in cases of chronic instability only.

Based on the currently available studies, this algorithm is safe and effective for diagnosing and treating acute ankle injuries. The algorithm is currently being validated in our department. Development of the algorithm is transparent and, therefore, helps in the decision process when choosing the most appropriate diagnostic procedure and treatment.

Thanks also to Birgit Lansherr for acquisition of all eligible articles from various libraries. National Center for Biotechnology Information , U. Journal List Orthop Rev Pavia v. Orthop Rev Pavia. Published online Dec Author information Article notes Copyright and License information Disclaimer. Munich University Hospital, Dept. Contributed by Contributions: HP, study conceiving, data collection, analysis and interpretation, manuscript writing; KGK, study conceiving, designing and coordinating, manuscript drafting; WCP, data analysis and interpretation, manuscript revising; FH, data acquisition, manuscript drafting; BO, manuscript drafting; WM, study designing, data interpretation, manuscript revising; SG, study conceiving and designing, data analysis and interpretation, manuscript revising.

Contributed by Conflict of interest: no sources of funding were used in the preparation of this article. Received Oct 4; Accepted Nov Polzer et al. This article has been cited by other articles in PMC. Abstract Acute ankle injuries are among the most common injuries in emergency departments. Key words: ankle injury, ankle sprain, evidence based algorithm, diagnosis, treatment. Introduction Acute injuries of the ankle are among the most common injuries of the musculo-skeletal system. Open in a separate window.

Figure 1. Flow chart for selecting articles to be included in the study. Grade of scientific evidence Class I Prospective randomized controlled trials - may be poorly designed, have inadequate numbers, or suffer from other methodological inadequacies Class II Prospective clinical studies and retrospective analyses based on clearly reliable data observational studies, cohort studies, prevalence studies and case control studies Class III Retrospective studies clinical series, database or registry review, large series of case reviews, expert opinion.

Level of recommendation Level 1 Convincingly justifiable based on the available scientific information, usualli Class I data or strong Class II evidence, especially if the issue does not lend itself to testing in a randomized format.

Conversely, low quality or contradictory Class I data may not be able to support a level 1 recommendation. Level 2 Reasonably justifiable by available scientific evidence and strongly supported by experts opinion. Level 3 Supported by available data but adequate scientific evidence is lacking, generally Class III data.

Useful for educational purposes and in guiding future clinical research. Results Which diagnostic tools are required to identify fractures of the ankle and ligament injuries? Medical history Questioning should identify the exact mechanism of injury, previous injuries or operative intervention, as well as congenital or acquired instability of the ankle joint.

X-rays Before extended physical examination, fractures must be excluded. Figure 2. Figure 3. Algorithm for diagnosis and treatment of acute ankle injuries. Ligament testing After a fracture has been ruled out, a careful physical examination should be carried out starting with observation of swelling, deformity and ecchymosis, as they are indicative of acute injury. Figure 4.

Figure 5. Sonography Sonography is a valuable tool for examining the tendons of the ankle joint such as the Achilles or the peroneal tendons for rupture or displacement.

How should injuries of the lateral complex be classified? Table 2 Classification of lateral sprains of the ankle according to the stability of the joint. Swelling and signs of hematoma should be present over the site of the ligament. Should injuries to the lateral ligament complex be treated by surgery, immobilization or functional treatment? Surgery compared with conservative treatment Kerhoffs et al.

Functional treatment compared with immobilization The two approaches to conservative treatment are: i immobilization, usually using a cast, and ii functional treatment, with a short period of protection using tape, a bandage, or a brace, followed by early weight-bearing, including exercises and neuromuscular training of the ankle. Which functional treatment is most beneficial? What other treatments can positively influence the course of acute ankle ligament injuries?

Cryotherapy Cryotherapy has been proved to be effective in the treatment of soft tissue injuries. Drug treatment Ogilvie-Harris et al. Other treatments Laser therapy, , ultrasound, , — electrotherapy, homeopathic therapy, hyperbaric oxygen therapy, prolotherapy, platelet rich plasma, hyaluronic acid or topical nitroglycerin injection were not effective, or available data were insufficient to prove their benefit in the treatment of acute ankle injuries.

Conclusions Although current literature concerning acute ankle sprains is partly inconclusive and difficult to compare we extracted distinct trends in diagnosing and treatment of such injuries, and evaluated the level of evidence of the current literature. References 1. Acute lateral ankle ligament injuries: a literature review.

Foot Ankle. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. Br Med J. The value of mobilisation and non-steroidal anti-inflammatory analgesia in the management of inversion injuries of the ankle. Br J Clin Pract.

Kannus P, Renstrom P. Heterogeneity between trials was tested using a standard chi-square test. A total of 22 studies met the inclusion criteria. Statistically significant differences were found for six outcome measures, all in favour of functional treatment compared with immobilisation: return to sports RR: 1.