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Sports Med 2003; 33 (15): 1145-1150 0112-1642/03/0015-1145/$30.00/0 Adis Data Information BV 2003. All rights reserved.
Prevention and Treatment of Ankle Sprain in Athletes
Michael D. Osborne and Thomas D. Rizzo Jr
Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, Florida, USA
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1145 1. Ankle Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146 2. Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146 3. Multifaceted Prevention Programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1148 4. Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1148 5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1149
The frequent nature of ankle sprains and persistent disability that often ensues has lead to considerable medical costs. As prevention of disease and injury becomes an increasingly important part of the practice of medicine today, we strive to understand and identify interventions that optimally reduce the frequency of ankle sprain and re-injury. In doing so, considerable morbidity and unnecessary medical expenditures may potentially be averted. The prophylactic use of ankle braces is fairly common. Recent critical evaluation of their effectiveness supports their use for at least 6 months following injury in athletes who have sustained a moderate or severe sprain; however, their role in primary prevention of ankle sprain is less evident. Functional ankle rehabilitation is the mainstay of acute ankle sprain treatment and in recent reviews has been deemed preferable to immobilisation or early surgery for initial treatment of acutely injured ankles. Furthermore, certain components of ankle rehabilitation, such as proprioceptive exercises, have been found to protect the joint from re-injury. Multifaceted ankle sprain prevention programmes that incorporate a variety of strategies for injury reduction are also effective in sprain prevention, although the relative importance of each component of such programmes warrants further investigation. Surgery for ankle sprain is principally reserved for patients who fail a comprehensive non-operative treatment programme and can be highly successful in treating chronic functional instability. This paper examines the current literature regarding common ankle sprain prevention strategies and provides a review of appropriate treatment schemes.
Ankle sprains are the most frequent injury sustained in sports, and often lead to chronic pain, swelling and functional instability. In 1983, it was
estimated that moderate to severe ankle sprains occur in 2 million persons per year in the US, and the estimated percentage of ankle sprains ranges from
The frequent nature of ankle sprains and the persistent disability that all too commonly occurs. found that functional treatment was preferable to immobilisation for initial treatment of acutely injured ankles. A recent critical evaluation of the effectiveness of ankle supports in reducing the frequency of ankle injury has been published in the Cochrane Database of Systematic Reviews. clinical studies regarding their effectiveness in reducing ankle sprains were inconclusive. estimates for the annual aggregate dollar expenditures for moderate to severe ankle sprains in the US was approximately $US2 billion. Considerable morbidity and unnecessary medical costs may potentially be averted if more effective ankle injury prevention and treatment programmes could be developed. The authors included four studies in their review. Sports Med 2003. was principally observed in athletes with a prior history of ankle sprain. 33 (15) . however. cause re-injury and inhibit the patient’s participation in treatment. Hume and Gerrard examined the literature regarding the effectiveness of external bracing in reducing ankle sprains.65 billion in today’s economy (Consumer Price Index. Kerkhoffs et al. In 1995. This benefit. Rehabilitation Functional ankle rehabilitation is a vitally important component of acute ankle sprain treatment. All rights reserved. the ability of a brace to physiologically restrict ankle motion has been the presumed predominant mechanism of action. and in some situations were found to impair athletic performance.[6. Other mechanisms of effect were postulated for taping such as enhancing proprioceptive function of the injured ankle. 2003). The basic tenets of ankle rehabilitation are out lined in table I. As typical of Cochrane reviews. Conventionally. Thacker et al. Rehabilitation can begin when the pain and swelling of an injury are under control. which was found to lose much of its restrictive support after 20 minutes of exercise. Care must be taken because aggressive rehabilitative activities during the acute phase of a sprain may increase pain. The initial step of such an endeavour is to identify the interventions that optimally reduce the frequency of initial ankle sprain as well as re-injury in athletes. 2. has lead to considerable medical costs in the US. only randomised or quasi-randomised trials were evaluated. In a review of 22 studies. Prevention of disease and injury has become an increasingly important part of the practice of medicine today. In a 1983 study conducted by investigators at Harvard.1146 Osborne & Rizzo 14% to 33% of all sports-related injuries. This paper examines the current literature in this regard and provides a review of common treatment methods. Hume and Gerrard have recommended that where there is a clear history of recurrent ankle injury. The role of high-top shoes in ankle sprain prevention has also been evaluated. In a 1998 comprehensive review. rigid and semi-rigid braces were found to be more effective in limiting ankle motion than taping.[2-5] Up to 40% of individuals with a history of an ankle sprain have been found to have symptoms of chronic functional instability. In addition. Adjusted for inflation. Ankle Supports The use of ankle supports and taping is common. However. In their review.[9-12] Their conclusions were that external support to the ankle yields a significant reduction in the number of ankle sprains compared with controls. External supports were not found to improve athletic performance. this figure equals $US3. the use of an external support should be encouraged.7] and re-injury to the same ankle is common. through which ankle supports reduce ankle injury. certain components of ankle rehabilitation have also been found to protect the joint from reinjury. recommended that athletes who have sustained a moderate or severe ankle sprain should wear an ankle orthosis for at least 6 months following injury. 1. following a review of 113 studies. Barrett and Bilisko reviewed the literature and found that although biomechanical studies have demonstrated that high-top shoes improve mechanical ankle stability. early mobilisation is preferable to prolonged immobilisation. Similarly. They reported that little information was available delineating the precise mechanisms Adis Data Information BV 2003.
this mode of strengthening should be reserved for the final stages of the rehabilitation programme. ice packs. Rehabilitation programmes usually start with low-level strengthening such as submaximal isometric exercises and progress in a painfree fashion to isotonic and isokinetic strengthening. ankle cryo-sleeve. inflammation and pain Methods Use of ice massage. Use a combination of open and closed kinetic chain strengthening Restore dynamic ankle balance and stability Restore dynamic strength.[22-24] and patients with functional ankle instability following ankle sprain have been found to have significant deficits in balance compared with controls. with full weight bearing. double-leg jumping.26] and decrease symptoms of functional instability. as well as eversion (posterior tibialis) stretching. Alphabet ROM exercises ROM Primary emphasis is on early ROM restoring ankle dorsiflexion and eversion Strengthening Primary emphasis on ankle evertor strengthening and Begin with low level strengthening such as restoring appropriate invertor/evertor strength ratios submaximal isometric exercises and progress in a pain-free fashion to isotonic strengthening. running. Closed-chain exercises are more functionally based where the distal extremity is fixed on a stable surface and the patient engages in an activity that requires the co-activation of antagonistic muscles to stabilise the extremity. taping/bracing. This involves gentle stretching.Prevention and Treatment of Ankle Sprain in Athletes 1147 Table I. elevation. All rights reserved. lateral cutting drills. Typically. The most common pharmacological approach to treatment of sprains has been to prescribe NSAIDs. Principal components of a functional ankle rehabilitation programme (reproduced from Osborne. Open-chain exercises include Adis Data Information BV 2003. Wester et al. and shortterm use of braces Heel cord stretching with the knee straight (to stretch the gastrocnemius) and flexed 30° (to stretch the soleus). tendon and ligaments heal with stronger and more organised collagen fibril architecture when a gentle load is applied during the healing process. balance and power Use of ankle disks/wobble boards. Proprioceptive exercises are an integral part of sprain rehabilitation. skipping rope.25. 33 (15) . Resistance exercises can begin when there is no pain through the available range of motion.[28-30] Tropp et al. Initial treatment methods include: ice massage. compressive sleeves/elastic ankle wraps. ice. examined the effects of an ankle disk training programme in 65 male soccer players with previous ankle sprain and found an 80% decrease in the frequency of repeat sprain over a 6-month period compared with controls with a similar history of ankle injury. prospectively evaluated patients with ankle sprain parSports Med 2003. compression. and plyometrics Proprioceptive exercises Functional exercises PRICE = protection. Emphasis is placed on strengthening the muscles that serve to provide dynamic stability to the injured joint. Functional ankle rehabilitation starts by normalising joint range of motion. single leg stance on uneven surface or with eyes closed Jogging. As symptoms allow. ROM = range of motion. Since eccentric muscle contractions place the greatest force upon the muscle. Ankle disk training has been found to significantly improve balance testing[22. nonsteroidal anti-inflammatory drugs (NSAIDs) and/or analgesics. the patient begins progressive weight-bearing exercises. elevation. Injured muscle. figure-eight drills. the use of free weights and resistance tubing. Furthermore. rest. compression. taking care to avoid causing further tissue stretch injury. Numerous studies have been performed using force plate balance testing as a quantitative measure of postural equilibrium. single-leg hopping. a combination of open and closed kinetic chain strengthening are utilised in the rehabilitation process. and a review of clinical trials supports their use in the first several days (<2 weeks) following acute injury for symptom control. with permission) Rehabilitation mode PRICE Goal Reduce swelling. proprioceptive training has been shown to reduce the rate of re-injury in ankle sprains.
 3. while complaints of ankle stiffness were greater in surgically-treated patients. Ekstrand et al. grade III sprains are also treated conservatively. technique training (that included jumping and lateral movement drills). These exercises facilitate the attainment of dynamic strength and balance. and ankle disk training. Bahr et al. warm-up/cool-down and flexibility exercises. In a randomised. and have no pain or swelling following the training session. and about 80% strength compared with contralateral extremity. studied the effect of an injury protection programme on the frequency of injury in 90 male soccer players. Surgery The role of surgery in the initial treatment of acute ankle sprain is limited. In a 1999 review of conservative versus surgical treatment for acute sprain. This study also utilised individuals both with and without prior ankle sprains. and 10–15 minutes use of a wobble board at all practice sessions. Surgery should be considered for patients who sustain recurrent lateral ankle sprains or exhibit significant symptoms of chronic functional instability despite appropriate rehabilitation interventions. Increasingly. The results showed a 47% reduction in the incidence of ankle sprains over 1 year compared with the year prior to Adis Data Information BV 2003. or visa versa. All rights reserved. In their review of 17 studies. Grade I and II sprains generally recover quickly with non-operative management. Multifaceted Prevention Programmes Multifaceted ankle sprain prevention programmes that incorporate a variety of strategies for prevention of ankle sprains have also been found to be effective. 4. investigated the effect of an injury prevention programme that included a warm-up. The authors found a 75% reduction in all injuries and an 82% reduction in ankle sprains compared with controls. the frequency of recurrent ankle sprain was no different between the two groups. no pain.[31. Lynch and Renstrom concluded that functional treatment is the treatment of choice. The programme consisted of an injury awareness educational session. although these patients also demonstrated more evidence of mechanical instability on stress radiography following treatment. Wedderkopp et al. although some debate continues. they reported that significantly fewer ankle sprains occurred during games and practices in the intervention group (n = 6) compared with controls (n = 23).32] The final phase of acute ankle sprain rehabilitation consists of functional exercises and sport-specific drills. use of shin guards by all players. A 2002 Cochrane Systematic Review by Kerkhoffs et al. prospectively studied the effects of an injury prevention programme on the rate of ankle sprain in 719 men and women in the Norwegian Volleyball Federation. implementation of the injury prevention programme. This group of soccer players constituted a mix of injured (48%) and uninjured (52%) players. return to work was usually quicker for patients treated with functional rehabilitation. The goal of surgery is to restore mechanical stability to the ankle and thereby significantly reduce or eliminate chronic symptoms of instability. and ankle taping for those with prior sprain or instability (48% of players). Longer-term swelling was found in the functional treatment group.1148 Osborne & Rizzo ticipating in 12 weeks of proprioceptive training and observed a 50% reduction in re-injury rates compared with controls. Eight weeks of ankle disk training has also been found to alter ankle muscle onset latencies that may act to improve dynamic ankle stability. The patient should start at a low level of intensity and progress with increased intensity and difficulty provided they remain pain free while performing the exercise. The programme consisted of education on ‘the importance of disciplined play’. Similarly. ‘Special rehabilitation schemes’ were developed for each injury sustained but were not a part of the prophylactic programme. Nevertheless. 33 (15) . Late ankle reconstruction for chronic lateral instability is sucSports Med 2003. These may begin when the patient has full ankle range of motion. concludes there is insufficient information from randomised trials to recommend surgery over conservative treatment. controlled study of 237 female handball players. major muscle group functional exercises.
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