Ankle Injury

Comprehensive Treatment Program For
Uncomplicated Lateral Ankle Sprains

[su_note note_color=”#d8d8d8″]John G. Aronen, M.D. Consultant, Center for Sports Medicine
Saint Francis Memorial Hospital San Francisco, CA

James G. Garrick, M.D. Director, Center for Sports Medicine
Saint Francis Memorial Hospital San Francisco, CA

Raymond D. Chronister, ATC Department of Sports Medicine/Orthopedic Surgery
United States Naval Academy, Annapolis, MD[/su_note]

Introduction

Studies have shown that roughly 85% of all acute ankle injuries are sprains,4 and some 85% of these are uncomplicated, i.e., involve the lateral ligaments only.1 The anterior talofibular ligament is the most susceptible to injury, and associated sprains of the calcaneofibular ligament often occur as well.

“A grading system is often used in describing lateral ankle sprains based on the level of injury to one or more of the lateral ligaments. The grade of the injury, however, does not influence the treatment program. Additionally, instability tests such as the anterior drawer and talar tilt tests are often emphasized. These tests for clinical instability are fine for gathering esoteric information, but the results do not determine or influence the treatment program either.” 5

Medical studies have clearly shown that the occurrence and persistence of the soft tissue swelling and the associated loss of pain free motion and strength seen in sprained ankles delay a patients return to full activities more than any other factor. 5 Thus, the prevention or elimination of soft tissue swelling should always be of paramount importance in the management of lateral ankle sprains.

Uncomplicated lateral ankle sprains can be expected to respond well to a comprehensive program designed to prevent/eliminate soft tissue swelling, regain full pain free range of motion and normal strength of the muscles that stabilize the ankle. 2, 3

Additionally, these studies have also shown that the high incidence of recurrence of lateral ankle sprains following the initial sprain is due to failure of the patient to: (1) regain full pain free range of motion, (2) regain normal strength and (3) utilize a ankle brace specifically designed to prevent the recurrence of lateral ankle sprains. 5, 6, 7

The desired goals to achieve in the management of lateral ankle sprains are:

[su_accordion] [su_spoiler title=”1. Prevent/eliminate soft tissue swelling with appropriate focal and generalized compression.” style=”fancy”] To appreciate why focal compression around the malleoli in the early stages plays such an important role in the management of uncomplicated lateral ankle sprains, one must recognize that the anatomical makeup of the ankle consists of peaks and valleys, with the lateral and medial malleoli being the peaks and the areas anteriorinferior and posterior to the malleoli being the valleys. As a result of the soft tissue trauma, swelling accumulates in the “areas of least resistance”, i.e., the lateral and medial valleys. In realizing that the failure to prevent and/or eliminate soft tissue swelling has been identified as the key component in delaying a patients return to full activities, emphasis must be placed on “filling the valleys” with focal compression to either prevent swelling from occurring or eliminating it as soon as possible if it has already occurred (See information on focal and generalized compression). For years, 3 the focal compression provided by horseshoes fabricated out of felt and secured in position with an elastic wrap, which also provides generalized compression, has been the gold standard for focal and generalized compression in the athletic trainer community. Realistically, felt is not a common item found in a physicians office, and horseshoes can be fabricated from equipment typically found in the office as 4 x 4 pads gauze pads, ABD pads, etc., i.e., anything that will effectively fill in the valleys. Recently a self-adhesive donut pad was introduced on the market. Proper placement of a donut pad laterally and medially to either retain or recreate the valleys is easily achieved and confirmed by insuring that the malleoli is in the hole of the donut (See information on focal and generalized compression). Too frequently, the importance of focal compression is overlooked as an integral part of the initial management at the time of the injury, and providers will simply apply an elastic wrap for compression. If the anatomical makeup of the ankle was that of a cylinder and not one of peaks and valleys, the use of an elastic wrap by itself would suffice, but the ankle is not a cylinder, although it quickly becomes one if only an elastic wrap is used as the soft tissue swelling fills in the valleys under the elastic wrap. Even if significant soft tissue swelling has occurred in the valleys, the application of fabricated pads to “recreate the valleys” laterally and medially secured by an elastic wrap or tubagrip, coupled with elevation and motion exercises, will significantly expedite the elimination of the swelling. If self-adhesive pads are utilized, the use of an elastic wrap or tubagrip to secure the pads is no required, but the generalized compression provided by the elastic wrap or tubagrip is. Could generalized compression be provided just as effectively by a brace? [/su_spoiler] [su_spoiler title=”2. Support and protect the ankle in the treatment phase.” style=”fancy”] There are a myriad of braces designed to support and protect the ankle in the treatment phase. The selection of which brace to use should be based on what one desires the brace to provide. Some providers prefer to provide support and protection with a brace as part of the initial treatment. This requires a brace that is capable of accommodating the increased girth of the ankle and foot that is the end result of any swelling that has occurred, the focal compression pads and the elastic wrap. Other providers, relying on the compression pads, wrap, patients shoe and “sprained induced” limited activity for support and protection, prefer to wait until the swelling resolves before adding a brace to the treatment program. Regardless of which method of management one chooses, the brace utilized should: (1) be easy to put on, (2) fit comfortably into a shoe, (3) provide the necessary support and protection with ambulation yet allow the patient to perform motion exercises, and (4) continue to provide support and protection to the ankle once the soft tissue swelling has resolved. [/su_spoiler] [su_spoiler title=”3. Regain full pain free motion of the ankle.” style=”fancy”] Some providers, perhaps over their concern of unnecessary stress being placed on the involved ligaments, question the rational of a lateral ankle sprain treatment program that advocates starting pain free motion exercises on the day of the injury. Justification of early pain free motion comes from recognizing that during the normal range of motion of a joint, ligaments are relatively unstressed. Thus, in performing early pain free motion exercises, the ligaments are relatively unstressed, insuring that no harm is being done to the involved ligaments. Motion exercises include plantar and dorsiflexion, eversion and inversion (See information on elevation and motion exercises). If the patient is wearing a brace that has stabilizing straps, these straps should be loosened whenever motion exercises are performed. For plantar and dorsiflexion, the patient is instructed to repeatedly move their foot up and down as if they were pushing on a gas pedal. This motion exercise will regain/retain talar motion of the ankle. For eversion and inversion, there are two exercises that are equally effective if performed properly. For both exercises the patient is instructed to hold their heel still. With the first exercise, the patient repeatedly rotates their forefoot up and in and then up and out like the motion of a windshield wiper. For the second exercise the patient, using their big toe as a pen, writes the letters of the alphabet in capital letters, with the goal to increase the size of the letters each time the exercise is performed. These two motion exercises will regain/retain subtalar motion, but are only effective if the heel is held still. Ideally, the motion exercises would be performed frequently throughout the day. [/su_spoiler] [su_spoiler title=”4. Regain normal strength.” style=”fancy”] Exercises to regain normal strength can be started once the patient has regained pain free motion of their injured ankle equal to that of their non-injured ankle. A variety of techniques have been described to exercise the peroneal and tibialis anterior muscles. Of utmost importance is that the strengthening exercise be performed solely with motion of the talar and subtalar ankle joints (See information on ankle strengthening exercise). The goal of the strengthening exercise is for the patient to be able to balance on the ball of their foot of their injured ankle for as long as they can on the ball of their of their foot of their non-injured ankle, usually 5-10 seconds, i.e., the “single leg balance test”.  [/su_spoiler] [su_spoiler title=”5. Protect the ankle with a brace upon return to functional activities.” style=”fancy”] To determine the efficacy of a lateral sprain treatment program designed by the authors for use by military personnel, a clinical trial was conducted at the United States Naval Academy. Emphasis of the program was placed on: (1) minimizing the amount of equipment required, (2) simplifying the application and securing of appropriate focal compression, (3) selecting a brace that could provide 5 generalized compression, stability and protection to the ankle and at the same time allow the patient to perform motion exercises numerous times throughout the day, plus fit comfortably in a shoe or boot, and (4) expediting the midshipmen’s safe return to unrestricted full athletic activities. Midshipmen included in the clinical trial were members of the men’s junior varsity and varsity soccer teams and each participated in an identical treatment program under the direct supervision of one of the authors (Raymond D. Chronister, ATC)

Self-Adhering Focal Compression Donut Pads, a product of The Recovery Zone, Inc., were selected for providing focal compression based on their ease of accurate placement around the malleoli and their self-adhering capabilities that eliminated the need for an elastic wrap. The ASO brace, a product of Medical Specialties, Inc., was selected for multiple reasons: (1) the ASO is universal, i.e., fits either right or left side thus decreasing the number of the nylon brace kept in stock, (2) the lace up front allows easy pain free application of the brace onto the injured ankle fitted with self-adhering donut pads, (3) the ASO provides the generalized compression once provided by the elastic wrap that is accommodating, i.e., as the swelling resolves, the desired amount of generalized compression can be maintained by tightening the laces, (4) it has medial and lateral stabilizing straps for enhanced stability that can easily be loosened to allow the midshipmen to perform motion exercises throughout the day, (5) once the laces are tied and the medial and lateral stabilizing straps secured, the braced foot comfortably fits into a shoe or boot and (6) the ASO provides the desired protection against recurrent lateral ankle sprains with return to full unrestricted activities. The following treatment program was shown in a clinical trial at the United States Naval Academy to be an “easy to follow, minimal amount of equipment required” treatment program that satisfied all the desired goals of a comprehensive treatment program and expedited the safe return of the midshipmen to full unrestricted athletic activities. [/su_spoiler] [/su_accordion]

Treatment Stages

[su_accordion] [su_spoiler title=”STAGE 1. Treatment during first 24 hours: emphasize compression, elevation and motion.” style=”fancy”] Goals of Stage 1: no swelling of the ankle/foot and full motion of the ankle.

1. FOCAL COMPRESSION: to prevent/eliminate swelling around the malleoli.

  1. Early application of a self-adhering donut pad laterally and medially (Figure 3).  

2. GENERALIZED COMPRESSION: to prevent/eliminate swelling of foot and stabilize ankle.

  1. Put sock on over donut pads.
  2. Put ASO ankle brace on over sock. To determine what size brace to use if significant soft tissue has occurred to the ankle and foot, fit the non-injured side with the appropriate size brace 6 and then use this size for the injured ankle. This will insure that the ASO brace will fit appropriately once the swelling has resolved. Note: The ASO brace is worn continuously until there is no evidence of swelling and full pain free range of motion and normal strength have been regained.
  3. Tighten the laces of the ASO so that the brace fits snug, but pain free, and secure the medial and lateral stabilizing straps.
  4. Put shoe on over ASO brace.

3. CRUTCHES: required if patient cannot walk with a pain free heel to toe gait.

  1. With ambulation on crutches, the patient is instructed to:
    1.Walk with a heel to toe gait to regain plantar and dorsiflexion motion of the ankle.
    2. Use pain as guideline for the amount of weight placed on ankle with heel to toe gait.

4. ELEVATION: combined with motion exercises, enhances prevention/elimination of swelling.

  1. Prior to elevating the ankle, remove the shoe and loosen the medial and lateral stabilizing straps of the ASO brace.
  2. For the elevation to be effective, the ankle must be constantly maintained higher than heart. To insure constant elevation, elevate the foot of the bed by placing a large object between the mattress and box springs. If the injured ankle is simply placed on a pillow for elevation, it is highly likely that the patient’s foot will roll off the pillow as he turns in his sleep, thus negating any elevation.

5. MOTION EXERCISES: enhance prevention/elimination of swelling plus regain ankle motion.

  1. With the medial and lateral stabilizing straps of the ASO brace loosened and the ankle elevated, the patient repeatedly performs the motion exercises to regain/retain talar and subtalar motion.
  2. As the swelling subsides, the ASO brace will become loose. When the patient experiences this, they tighten the laces of the brace so that the brace fits snug at all times to provide maximum generalized compression
[/su_spoiler] [su_spoiler title=”STAGE 2. Treatment after first 24 hours: emphasize motion and strengthening exercises.” style=”fancy”] Goals of Stage 2: DC use of donut pads and crutches ASAP, increase weight bearing activities ASAP.

1. COMPRESSION: after 24 hours, take off the ASO and the sock and evaluate for swelling.

  1. If the swelling is minimal, remove the donut pads. Continue wearing the ASO brace for generalized compression and stability.
  2. If swelling is evident, continue the use of the donut pads, the ASO brace and emphasize elevation and motion exercises (performed with the medial and lateral stabilizing straps loosened) numerous times throughout the day. Remove the donut pads once the swelling is minimal or resolved. Note: During the clinical trial, the supervising author noted a direct correlation between the resolution of the soft tissue swelling and how diligent the midshipmen was in keeping the ankle elevated and performing motion exercises during the first 24 hours following the injury.

2. CRUTCHES: increase the amount of weight placed on the injured ankle with heel to toe gait.

  1. Discontinue the use of crutches as soon as patient can walk with a pain free heel to toe gait.

3. MOTION EXERCISES: continue even if patient has regained full pain free motion.

  1. Loosen the medial and lateral stabilizing straps of the ASO brace and perform motion exercises numerous times throughout the day. This prevents stiffness from recurring in the ankle while the ASO brace is worn continuously.

4. STRENGTHENING EXERCISE: “must do” to prevent recurrent lateral ankle sprains.

5. INCREASED WEIGHT BEARING ACTIVITIES: wearing ASO brace, start when:

  1. No evidence of soft tissue swelling.
  2. Range of motion equal to that of non-injured ankle (plantar and dorsiflexion, eversion and inversion).
  3. Normal strength regained in the muscles responsible for preventing recurrent lateral ankle sprains.
[/su_spoiler] [su_spoiler title=”STAGE 3. Return to unrestricted full athletic activities wearing the ASO ankle brace when:” style=”fancy”]
  1. Able to demonstrate the mobility and agility required of sport.

Ankle sprain compression Stages

FIGURE LEGENDS

Figure 1. Immediate application of a focal compression device that fills in the valleys (darkened area) laterally and medially prevents the swelling from filling in the valleys, thus preserving motion and expediting the athletes return to activities.

Figure 2. Although felt horses applied medially and laterally secured with an elastic wrap are highly advocated, the importance is not what material the compression pads are made of (gauze 4×4 pads shown), but instead that they provide focal compression to the entire area of the valleys.

Figure 3. The standard ankle stirrup fails to fill in the entire area of the valleys (visible darkened area posterior to malleoli identifies area without focal compression) and thus is not a suitable device for providing focal compression.

Figure 4. Proper placement of a self-adhering donut pad laterally and medially is easily achieved and confirmed by insuring that the malleoli (stippled area) is in the hole of the donut.[/su_spoiler][/su_accordion]

REFERENCES

  1. Brostrom, L.: Sprained ankles: I. Anatomical lesions in recent sprains. Acta Chir. Scand., 128:483- 495, 1964.
  2. Brostrom, L.: Sprained ankles: V. Treatment and prognosis in recent ligament ruptures. Acta Chir. Scand., 132:537-550, 1966.
  3. Freeman, M.A.R.: Treatment of ruptures of the lateral ligaments of the ankle. J. Bone Joint Surg., 47B:661-668, 1965.
  4. Garrick, J.G.: The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am. J. Sports Med., 5:241-242, 1977.
  5. Garrick, J.G.: Managing ankle sprains. Phys Sportsmed, 25 (3); 56-68, 1997.
  6. Garrick, J.G.: A practical approach to rehabilitation of the ankle. Am. J. Sports Med., 9:67-68, 1981.
  7. Thonnard, J.L., et al: Stability of the braced ankle. Am. J. Sports Med., 24: 356-361, 1996.