In the recent few years, there have been recommendations that the immobilization of ankle in ankle sprain can result in delayed fitness of the player for the sports. But traditionally, most of us have been managing the ankle sprains with significant soft tissue injury (gazed on the basis of initial soft tissue swelling and pain) with immobilization in plaster for 3-6 weeks.
Hi Ravi,
Anytime we immobilize an injury, I think we run the risk of negatively impacting fitness relative to a functional rehabilitation. Even if the athlete is out for the same amount of time, it is harder for that athlete to complete any sort of cardio exercise within the given constraints of the injury (e.g. swimming or cycling while partial weight bearing). Another important factor is that athletes completing a functional rehabilitation can work on ROM, isometric strength, etc while non or partial weight-bearing compared to those in a plaster cast who have to wait. Based on the existing research, this delays return to play and thus would have a greater negative impact on fitness.
Having that said, the existing research has only looked at functional vs cast techniques as an exclusive treatment. In other words, we know that ankle joint mobilizations are safe to use on acute ankle sprains, are very effective at restoring dorsiflexion range of motion, and appear to have a positive impact on the sensorimotor system as well. But no study has determined if plaster immobilization followed by aggressive treatments are comparable to functional rehabilitation.
My research focuses on the long term consequences of ankle sprains, so I may be a bit biased but I believe that we are not conservative enough with ankle sprains. The highest quality investigations in the literature would suggest that from mild to moderate sprains functional rehabilitation appears to be the most effective while immobilization is the most effective for severe lateral ankle sprains. In my opinion, giving the damaged ligaments more time to heal should be the priority, particularly given the fact that we have effective interventions to quickly restore ROM, strength, and neuromuscular control.
I have attached a recent review paper that we put out and the articles I mentioned above are summarized in section 5.1. I hope this helps
Erik
Erik,
This is a very good post on the modern treatment of ankle sprains. I am wondering if in your treatment arsenal there still exists the option of surgical ligament repair in severe injuries.
Some 30-40 years ago this option came to the podium as a very effective treatment for severe ankle sprains. I belong to the generation that was witness of the excellent recovery after surgical ligament suture also in elite athletes. Why did this treatment fall in oblivion ?
Excellent post Dr Wikstrom.
Rehabilitation of an athlete with ankle sprain I reckon has to be different from the normal population and that includes consideration of the use of anti-inflammatories in acute stages and psychological (motivation) factors. Unless there's a grade III injury that may require surgical intervention, I would recommend the athlete to bear permissible weight early on. I would also consider newer adjuncts e.g. kinesiology taping over the rigid zinc oxide ones
Panayot- I still think surgical repair for severe sprains has a role and should be considered on a patient by patient basis. It is probably more appropriate to consider within elite athletic populations but that is speculative on my part. Unfortunately, we just dont have enough quality studies on the long-term (i.e. >12-months) effectiveness (rates of ankle instability development, rates of OA development, quality of life [including physical activity levels, etc]) for most treatments for ankle sprains, let alone comparative effectiveness.
Since in most cases lateral stabilitiy is obtained by conservative methods, surgical interventions are therefore out of favor. We differentiate syndesmotic injuries form lateral ankle ligament innjury. In serve injuries wih instability and a bad outcome for stability the surgical intervention is of course given.
The topic is ankle sprain in professional player. Functional treatment vs. casting. I prefer a cast for a week and start after with functional treatment.
Thanks Erik for an excellent paper. It is indeed very informative. Thanks Panayot, Gourav and Jean for sharing your thoughts.
Ankle injuries of Grade I do not need immobilization since they can be treated well by using a flexible or elastic wrap for a few days. However, Grade II ankle injuries are likely to require support by using a flexible wrap and a splint for the first few days until they are pain-free. In Grade III, controlling the range of the patient’s motion is recommended. Patients are also recommended to use an ankle rigid sup-port or a plaster cast to reduce pain and injury during a short period (1 week) of immobilization. Conversely, casting is recommended using a below-knee cast, air-cast brace, tubular compression bandage or ‘Bledsoe’ immobilization boot. Casting, however, has been shown to yield inferior functional results by many authors compared with orthosis and early weight-bearing. Though many patients prefer cast immobilisation, we suggest starting physiotherapy as early as possible for the following reasons: to give time for the ice application to control pain and swelling; to improve and maintain the range of motion; and to minimize the risk of stiffness and muscle wasting, two factors which can delay the patient from returning to their usual activities.
Acute ankle sprain: Conservative or surgical approach?. Available from: https://www.researchgate.net/publication/296330557_Acute_ankle_sprain_Conservative_or_surgical_approach [accessed Feb 2, 2017].
Article Acute ankle sprain: Conservative or surgical approach?
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