The Academy of Orthopaedic Physical Therapy has just published the 2021 revision of the ankle sprains clinical guidelines in JOSPT @josptofficial .
Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021
Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association
J Orthop Sports Phys Ther. 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302
Summary of Recommendations
Clinical Course – Acute Lateral Ankle Sprain
Clinicians should include patient age, body mass index, pain coping strategies, report of instability, history of previous sprain, ability to bear weight, pain with weight bearing, ankle dorsiflexion range of motion (ROM), medial jointline tenderness, balance, and ability to jump and land (as safely tolerated) in their initial assessment, because of their role in influencing the clinical course and estimation of time to accomplish the goals of an individual with an acute lateral ankle sprain (LAS).
Clinical Course – Chronic Ankle Instability
Clinicians may include previous treatment, number of sprains, pain level, and self-report of function in their evaluation, as well as an assessment of the sensorimotor movement systems of the foot, ankle, knee, and hip during dynamic postural control and functional movements, because of their role in influencing the clinical course and estimation of time to accomplish the goals of an individual with chronic ankle instability (CAI).
Diagnosis/Classification – Acute Lateral Ankle Sprain
Clinicians should use special tests, including the reverse anterolateral drawer test and anterolateral talar palpation in addition to the traditional anterior drawer test, and a thorough history and physical examination to aid in the diagnosis of a LAS.
Diagnosis/Classification – Chronic Ankle Instability
When determining whether an individual has CAI, clinicians should use a reliable and valid discriminative instrument, such as the Cumberland Ankle Instability Tool or the Identification of Functional Ankle Instability, as well as a battery of functional performance tests that have established validity to differentiate between healthy controls and individuals with CAI.
Examination – Outcome Measures
Clinicians should use validated patient-reported outcome measures, such as the Patient-Reported Outcomes Measurement Information System physical function and pain interference scales, the Foot and Ankle Ability Measure, and the Lower Extremity Functional Scale, as part of a standard clinical examination. Clinicians should utilize these before and 1 or more times after the application of interventions intended to alleviate the impairments of body function and structure, activity limitations, and participation restrictions associated with an acute LAS or CAI.
Clinicians may use the Pain Self-Efficacy Questionnaire in the acute and postacute periods after a LAS to assess effective coping strategies for pain, and the 11-item Tampa Scale of Kinesiophobia and the Fear-Avoidance Beliefs Questionnaire to assess fear of movement and reinjury and fear-avoidance beliefs in those with CAI.
Examination – Physical Impairment Measures
Clinicians should assess and document ankle swelling, ROM, talar translation, talar inversion, and single-leg balance in patients with an acute LAS, postacute LAS, or CAI at baseline and 2 or more times over an episode of care. Clinicians should specifically include measures of dorsiflexion, using the weight-bearing lunge test, static single-limb balance on a firm surface with eyes closed, and dynamic balance with the Star Excursion Balance Test anterior, anteromedial, posteromedial, and posterolateral reach directions.
In patients with CAI, clinicians may also assess and document hip abduction, extension, and external rotation strength 2 or more times over an episode of care.
Examination – Activity Limitation/Physical Performance Measures
Clinicians should assess and document objective and reliable measures of activity limitation, participation restriction, and symptom reproduction at baseline and 2 or more times over an episode of care when evaluating a patient with a LAS or CAI, and specifically include measures of single-limb hopping under timed conditions when appropriate.
Interventions – Primary Prevention of First-Time Lateral Ankle Sprain
Clinicians should recommend the use of prophylactic bracing to reduce the risk of a first-time LAS, particularly for those with risk factors for LAS.
Clinicians may recommend the use of prophylactic balance training exercises to individuals who have not experienced a first-time LAS.
Interventions – Secondary Prevention of Recurrent Lateral Ankle Sprains Following an Initial Sprain
Clinicians should prescribe prophylactic bracing and use proprioceptive and balance-focused therapeutic exercise training programs to address impairments identified on physical examination to reduce the risk of a subsequent injury in patients with a first-time LAS.
Interventions – Acute and Postacute Lateral Ankle Sprains: Protection and Optimal Loading
Clinicians should advise patients with an acute LAS to use external supports, such as braces or taping, and to progressively bear weight on the affected limb. The type of external support and gait assistive device recommended should be based on the severity of the injury, phase of tissue healing, level of protection indicated, extent of pain, and patient preference.
In more severe injuries, immobilization ranging from semi-rigid bracing to below-knee casting may be indicated for up to 10 days post injury.
Interventions – Acute and Postacute Lateral Ankle Sprains: Therapeutic Exercise
Clinicians should implement rehabilitation programs with a structured therapeutic exercise component that can include protected active ROM, stretching exercises, neuromuscular training, postural re-education, and balance training, both in clinic and at home, as determined by injury severity, identified impairments, preferences, learning needs, and social barriers in those with a LAS.
There is conflicting evidence as to the best way to augment the unsupervised components of a home program in those with a LAS, for example, by written instructions, exercise-based video games, or app-based instruction. Therefore, this can be determined by the individual’s specific learning needs and access to relevant technology.
Interventions – Acute and Postacute Lateral Ankle Sprains: Occupational And Sports-Related Training
Clinicians should implement a return-to-work schedule and use a brace early in rehabilitation, occupational or sport-related training, and/or a work-hardening program to mitigate activity limitation and participation restriction following a LAS.
Interventions – Acute and Postacute Lateral Ankle Sprains: Manual Therapy
Clinicians should use manual therapy procedures, such as lymphatic drainage, active and passive soft tissue and joint mobilization, and anterior-to-posterior talar mobilization procedures within pain-free movement, alongside therapeutic exercise to reduce swelling, improve pain-free ankle and foot mobility, and normalize gait parameters in individuals with a LAS.
Interventions – Acute and Postacute Lateral Ankle Sprains: Acupuncture
There is conflicting evidence regarding the use of acupuncture to reduce symptoms associated with an acute LAS.
Interventions – Acute and Postacute Lateral Ankle Sprains: Physical Agents
Clinicians may use repeated intermittent applications of ice in association with a therapeutic exercise program to address symptoms and functioning following an acute LAS.
Clinicians can utilize pulsating shortwave diathermy for reducing edema and gait deviations associated with acute ankle sprains.
There is moderate evidence both for and against the use of electrotherapy for the management of acute ankle sprains.
Low-Level Laser Therapy
Clinicians may use low-level laser therapy to reduce pain in the initial phase of an acute LAS.
Clinicians should not use ultrasound for the management of acute ankle sprains.
Interventions – Acute and Postacute Lateral Ankle Sprains: Nonsteroidal Anti-Inflammatory Medication
Clinicians may prescribe nonsteroidal anti-inflammatory medications (as physical therapy practice acts allow) to reduce pain and swelling in those with an acute LAS.
Interventions – Chronic Ankle Instability: External Support
Clinicians should not use external support, including braces or taping, as a stand-alone intervention to improve balance and postural stability in individuals with CAI.
Interventions – Chronic Ankle Instability: Therapeutic Exercise and Activity
Clinicians should prescribe proprioceptive and neuromuscular therapeutic exercise to improve dynamic postural stability and patient-perceived stability during function in individuals with CAI.
Interventions – Chronic Ankle Instability: Manual Therapy
Clinicians should use manual therapy procedures, such as graded joint mobilizations, manipulations, and non–weight-bearing and weight-bearing mobilization with movement, to improve weight-bearing ankle dorsiflexion and dynamic balance in the short term for individuals with CAI.
Interventions – Chronic Ankle Instability: Dry Needling
Clinicians may use dry needling of the fibularis muscle group, in conjunction with a proprioceptive training program, to reduce pain and improve function in individuals with CAI.
Interventions – Chronic Ankle Instability: Combined Treatments
Clinicians may use multiple interventions to supplement balance training over an episode of care for individuals with CAI, to include a combination of exercise and manual therapy procedures as guided by the patient’s values and goals, the clinician’s judgment, and evidence-based clinical recommendations.
Interventions to Address Psychological Factors During the Course of Rehabilitation
Clinicians may use psychologically informed techniques, such as motivational interviewing, to maximize patients’ self-efficacy and to address uncomplicated psychological correlates and mediators of injury adjustment and recovery in order to maximize the effects of treatment in a positive manner for individuals with a LAS and CAI.