Management Of Acute Grade II Lateral Ankle Sprains With An Emphasis On Ligament Protection: A Descriptive Case Series
Wells B, Allen C, Deyle GD, Croy T. MANAGEMENT OF ACUTE GRADE II LATERAL ANKLE SPRAINS WITH AN EMPHASIS ON LIGAMENT PROTECTION: a DESCRIPTIVE CASE SERIES. The International Journal of Sports Physical Therapy. 2019;14(3):445-458. doi:10.26603/ijspt20190445Link to Original Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816301/
Key Points
1. Lateral ankle sprains (LAS) are common and individuals who sustain an acute lateral ankle sprain may not receive timely formal rehabilitation, leading to an increased risk of subsequent sprains and chronic pain.
2. A comprehensive rehabilitation strategy for managing acute first episode grade II lateral ankle sprains was implemented, focusing on protecting the injured ligament, preventing impairments to movement, restoring strength and proprioception, and progressing to full function.
3. Ten patients with acute grade II lateral ankle sprain were treated with an approach resulting in rapid improvement in self-reported function, ankle range of motion, and pain within the first four weeks of care. Meaningful improvements were also noted at eight and 12 weeks, and all patients returned to desired physical activity, with only one re-sprain event within one year after injury.
4. The strategy involved careful clinical decisions to provide activity limitations and bracing to protect the injured ankle from further injury while providing the balance of rehabilitation stimuli to maintain normal ankle motion, restore the required strength and balance for higher levels of sport and activity.
5. The intervention strategies had overlapping effects that helped to simultaneously address multiple goals, such as maintaining and regaining ankle movement, normalizing gait, and reducing ankle swelling.
6. The results indicate that a treatment approach designed to protect the injured ligament, maintain and restore normal ankle motion, and provide a tailored functional pathway to return to run and sport demonstrated resolution of symptoms and improvement in reported functional outcomes in patients following grade II acute primary ankle sprain.
Background And Purpose
The paper discusses the common occurrence of lateral ankle sprains (LAS) among teenagers and young adults during sports and exercise. It highlights the lack of supervised rehabilitation for LAS, the significant costs of physician evaluations, and the high percentage of subsequent ankle sprains and incomplete recovery after the initial injury. The paper points out athletes return to sport within 3 to 21 days after LAS, resulting in incomplete ligament healing and recovery. Early return to sport results in 30 to 70% chance of reinjuring the same ligament with 45% reporting incomplete recovery 3 years after initial injury. The most current Clinical Practice Guidelines (CPG) for ankle sprains highlight the usages of ankle sprain grading scale based on clinical findings of loss of function, ligamentous laxity, hematoma, tenderness to touch, decreased range of motion, and presence of swelling. The relationship between prognosis and injury extent is emphasized, as well as the importance of appropriately grading LAS for injury management. The potential long-term consequences of repeated ankle sprains, including chronic ankle instability, osteochondral defects, and ankle osteoarthritis, are also addressed.
The paper emphasize the importance of prioritizing ligament protection for the acute stage of the first stage of grade II LAS through functional support using a brace, manual therapy, exercises for strength and range of motion, and proprioceptive training. The authors note the progression of the repair and remodeling of an injured ligament is much slower than the patient’s functional progress, which is often fueled by the desire to return to the field. The study by Brison et al. is mentioned, which found no difference between physical therapy and usual medical care in the management of acute ankle sprains when specific ligament protection and healing measures were not utilized.
The paper highlights the predictable healing process following ligamentous injury and emphasizes the importance of adopting a conservative approach to protect the injured ligament and restore normal motion. This is crucial in enabling a customized return to running and sports activities. The authors also point out that the treatment guidelines for acute ankle sprains should be managed similar to general ligamentous injuries. They provide an example of a patient who sustains an MCL injury in the knee joint and protects the ligament through the use of a brace, controlling range of motion. Conversely, a patient with an ATFL injury is given exercises that do not control ankle inversion, leading to excessive stress and stretching of the healing ligament. Injured ligament requires 6 to 12 weeks of protection from excessive strain for moderate healing and >1 year for complete healing. Despite the evidence of ligamentous healing process, an athlete who suffers LAS are allowed to return to activity much earlier.
The purpose of the case series was to describe the treatment strategies and outcomes associated with the first episode of grade II LAS using conservative approach to prioritize protection of the injured ligament, restore and maintain normal motion, and improve functional movements to return to run and sports.
Case Description
The study was conducted at Brooke Army Medical Center in Fort Sam Houston, TX, with the approval of the Institutional Review Board and informed consent obtained from participants. The research focused on patients with acute primary grade II lateral ankle sprains. Inclusion criteria comprised of presence of acute grade II ankle sprain with no previous ankle sprain on the affected side, negative Ottawa Ankle rules or negative radiography, and able to understand English, while exclusion criteria included other types of ankle sprains, fractures, subacute or chronic conditions, inability to commit to treatment, and pregnancy. Twelve patients were screened for eligibility, with ten agreeing to participate, primarily female and with a mean age of 26.7 years. Evaluation and treatment were provided by a physical therapist who is board-certified in sports physical therapy and included patient interviews, comprehensive examinations (lower quarter screen, palpation of injured site, assessment of swelling, ligamentous special tests, active/passive ROM, gait, balance, and strength), and specific management strategies (RICE, brace wear, and HEP).
All patients who enrolled in the study were requested to avoid active ankle inversion for the first 6 weeks to prevent placing excessive stress on the injured ligament. From week 6 to 12, patients were encouraged to add active ankle inversions in various ankle PF and DR positions as long as they remained pain free. In addition, patient wore a lace up ankle brace every night for 12 weeks and wore ankle brace for activities such as sports, running, and walking on uneven surface during the day.
Self-reported outcomes including Foot and Ankle Ability Measure (FAAM) ADL and Sports subscales and Numeric Pain Rating Scale (NPRS) were used. Performance based tests included Ankle Lunge Test (ALT) for ankle DF ROM and Y-balance Test (YBT) for balance and neuromuscular control. All self-reported outcomes and ALT were measured at baseline, 4 weeks, 8 weeks, and 12 weeks. YBT was not completed at baseline, but measured at 4 weeks, 8 weeks, and 12 weeks. Patients also had telephone follow up at 6 months and 12 months to measure injury recurrence.
Outcomes
Patients started treatment within an average of 2.3 days after injury, with an average of eight clinical visits over 6-9 weeks. Patient compliance with treatment recommendations, including brace use and range of motion limitations was assessed and showed full compliance with restricting ankle inversion until after 6 weeks. The study found that the intervention strategies resulted in clinically meaningful improvements in pain, range of motion, and balance, and 9 patients reported no recurrence of injury at the one-year follow-up. One of the patient who re-strained his/her ankle while sprinting on an uneven surface without donning ankle brace before 6 month follow was able to self-manage the injury using the education provided through the course of care. Additionally, those who were highly compliant with their home exercise program and brace wear achieved better outcomes. All patients achieved clinically meaningful improvement at 4 weeks based on FAAM ADL score and these changes persisted through the end of care at 12 weeks. The average NPRS score improved from mean of 5 at baseline to 0 at 4 weeks. Two patients who showed poor compliance reported 3 out 10 NPRS score at 4 weeks, indicating less than full compliance still resulted in improvement in pain score but less than those who were full compliant. Mean ALT also improved from 2.3 cm at baseline to 8.8 cm at 4 weeks and YBT at baseline (4 weeks) improved from 48.5 cm to 55.1 cm. Both ALT and YBT achieved clinically meaningful improvement.
Discussion
The study investigated a treatment approach for grade II acute primary ankle sprains and found that it led to resolution of symptoms, improved functional outcomes, and near full levels of self-reported function without activity-limiting pain in patients. All patients returned to their pre-injury level of activity with no re-injuries, subjective instability or giving way, and only one patient reported an additional minor ankle sprain at one year post-injury. The short period from injury to initiating physical therapy care (mean of 2.3 days) was noted as important, allowing for early management during the inflammatory phase of healing and guidance when transitioning into the proliferative phase. Early instruction on protecting the injured ligament, controlling swelling, normalizing gait, and promoting range of motion (ROM) without straining injured tissue was emphasized to facilitate early healing without further impairments. After ligament protection, normalization of ankle ROM and gait was the primary treatment priority, with limited dorsiflexion following an ankle sprain recognized as a risk factor for recurrent injury and pain. The study acknowledged limitations in drawing cause-effect conclusions but highlighted the importance of early intervention and tailored functional pathways in the management of acute ankle sprains.
Conclusion
The study suggests treatment strategies for acute grade II ankle sprain that centers around protection of injured ligament, maintaining and restoring ankle ROM, and providing individualized functional sports training results in resolution of symptoms and improvement in functional outcome.
