Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline
A lateral ankle sprain (LAS) is a frequently incurred musculoskeletal injury. A large proportion of individuals who sustain a LAS will develop chronic ankle instability (CAI). CAI may be defined as persistent complaints of pain, swelling and/or giving way in combination with recurrent sprains for at least 12 months after the initial ankle sprain.
Inclusion and exclusion criteria
- Inclusion if they included individuals aged at least 16 years with acute LAS. Studies published in Dutch, English, German, French, Spanish, Danish or Swedish were all eligible for inclusion.
- Narrative reviews, case reports and cadaveric analyses were excluded. Additional exclusion criteria were reported medial ankle involvement, fractures or other concomitant injuries/pathology and CAI.
- What’s new: No new statements could be made based on the newly identified studies. The increased evidence indicates that the individual aspects of RICE are not effective, apart from cryotherapy, if provided in combination with exercise therapy.
- Recommendation (modified): There is no evidence that RICE alone, or cryotherapy, or compression therapy alone has any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE alone in the treatment of acute LAS (level 2)
- (based on 33 randomized controlled trials (RCTs), n=2337)
- What’s new: Based on the search results concerning treatment, the committee agreed on implementing a topic on NSAIDs. Over the past years much research has been undertaken on NSAIDs in relation to musculoskeletal injuries, and in many countries they are available without prescription. However, before recommending NSAIDs, their effect in the specific context of an ankle sprain had to be assessed.
- Recommendation (new): NSAIDs may be used by patients who have incurred an acute LAS for the primary purpose of reducing pain and swelling. However, care should be taken in NSAID usage as it is associated with complications (level 2) and may suppress or delay the natural healing process.
- What’s new: Despite the inclusion of new recent studies, there were no new findings. Recommendation (not changed):
- Use of functional support and exercise therapy is preferred as it provides better outcomes compared with immobilisation. If immobilisation is applied to treat pain or oedema, it should be for a maximum of 10 days after which functional treatment should be commenced (level 2).
- What’s new: New evidence emphasizes that the use of external supports (ie, braces) is preferred over immobilization. Additionally, the preferred time frame during which the use of external support is advised is outlined. Overall, the core message of this section remains unchanged.
- Recommendation (modified): Use of functional support for 4–6 weeks is preferred over immobilisation. The use of an ankle brace shows the greatest effects compared with other types of functional support (level 2).
- What’s new: New evidence has become available on the specific effects of different types of exercise/rehabilitation programmes; especially the beneficial effect of exercise therapy on preventing recurrent sprains, reducing the risk of functional instability and expediting the recovery of ankle joint function.
- Recommendation (modified): Exercise therapy should be commenced after LAS to optimise recovery of joint functionality. Whether exercise therapy should be supervised or not remains unclear due to contradictory evidence and requires further research (level 1).
- What’s new: Despite findings by the previous version of this guideline that manual mobilisation only results in short-term treatment effects, current evidence shows added value of manual mobilisation when used in combination with exercise therapy.
- Recommendation (modified): A combination with other treatment modalities, such as exercise therapy, enhances the efficacy of manual joint mobilisation and is therefore advised (level 3).
- What’s new: Acupuncture, vibration therapy and Bioptron light therapy were added to the present update. Concerning the other identified therapies, new evidence did not change previous statements.
- Recommendation (not changed): As no strong evidence exists on the effectiveness of these treatment modalities, they are not advised in the treatment of acute LAS (level 2).
Communication between professionals
- What’s new: The checklist and statements from the previous version of this guideline were not subject to change. The most important factor remains communication.
- Recommendation (not changed): To refine communication between healthcare professionals involved in the treatment of patients with LAS, a communication check list is recommended
- What’s new: In addition to updating the risk ratios by including new studies, a risk ratio is provided for the preventive effect of tape and brace for first-time ankle sprains. Additionally information on the effect on proprioception and adverse events was included. This new evidence did not change the previous recommendation.
- Recommendation (not changed): Both tape and brace have a role in the prevention of recurrent LAS despite limited evidence on mechanisms that leads to these beneficial effects (level 1). The choice of usage should depend on personal preferences.
- What’s new: More positive effects of different training programmes have become available, strengthening the recommendation of the previous guideline.
- Recommendation (not changed): For this reason, it is advised to start exercise therapy, especially in athletes, as soon as possible after the initial sprain to prevent recurrent LAS. Exercise therapy should be included into regular training activities as much as possible as home-based exercise (level 1). The preventive effect of exercise therapy for first-time LAS lacks evidence (table 6).