Uh, Oh Baby! You did the Twist! (Ankle Sprains)

This article gets a bit technical. I highlighted the key points below to make it easier for the average person, with some more technical points for those who care afterward.

The Journal of Orthopedic and Sports Physical Therapy (JOSPT) recently released it’s new Clinical Practice Guidelines (CPG) for lateral ankle sprains (by far the most common type of ankle sprain-for the rest of this I’ll just refer to them as ankle sprains to type more and use one less acronym). A CPG is created when a group of researchers or experts comb through all the research that has been added to the field on a particular topic (ankle sprains, low back pain, ACL sprains, headaches, frozen shoulder, etc) and then create a synopsis of the results, with evidence and recommendations graded based on the quality and quantity of research produced.

The last ankle sprain CPG was in 2013 so this year’s update takes all that information into account and adds the relevant research for the ~7 years since.

Ankle Sprain: Key Points

• Ankle sprains are the most common foot-ankle and sports-related injury for which individuals seek care (even though only 50% of people who have a sprain seek care).
  

• 40% of people with ankle sprains go on to develop continued symptoms and feelings of instability and “giving way”- termed Chronic Ankle Instability (CAI).
  

• 20% of adolescent athletes and 29% of high school athletes will have CAI at some point.
  

• For patients with an acute or postacute lateral ankle sprain, there is strong to moderate evidence supporting 1) protection and optimal loading 2) manual therapy 3) therapeutic exercises directed at identified impairments (not just randomly chosen or general programs) and 4) occupational and sports-related training.
  

• For patients with CAI strong to moderate evidence supports 1) proprioception and neuromuscular therapeutic exercise and 2) graded joint mobilizations.

....Now for some more information.

Background and statistics:

• Level 1 evidence shows that 11.88% of individuals in the general population will sprain their ankle. 50% of them will seek care. Of those who seek care, only 6.8%-11% are referred to a rehabilitation specialist within 30 days (bummer-see CAI).

• There is mixed research regarding whether males or females sprain ankles at higher or equal rates (some say equal, some say females are higher risk than males).

• Only 40% of lateral ankle sprains occur during sports… meaning most are not sports injuries.

Ankle Sprain: Risk factors

• Ankle Sprains are the most common in indoor court sports such as volleyball and basketball

• There is conflicting evidence regarding previous injury being a risk factor for future sprains.

• Decreased hip strength is a risk factor for ankle sprains.

Post sprain recovery:

• Inability to complete jumping and landing tasks within 2 weeks of injury, poorer dynamic postural control, and lower self-reported function at 6 months after injury were predictors of CAI at 6 months.

• Not using prophylactic bracing and not participating in an exercise program that includes balance training are risk factors for a subsequent sprain following a first time sprain.

• For faster return to sports, a supervised exercise program to address strength, coordination, proprioception and functional deficits that occur after sprain should be performed.

• A systematic review and meta-analysis found the addition of rehabilitation exercises to standard care significantly reduced reinjury in the 7-12 months following injury. While another found that bracing and neuromuscular training were not associated with reduced recurrence at 12 months.

• There is strong evidence supporting the use of exercise for prevention of recurrent sprains, but there is mixed evidence to support the use of prophylactic exercises for the prevention of first time sprains.

Post Injury: CAI

• Moderate evidence supporting a functional treatment program aimed to improve jumping and landing biomechanics which increased self-reported functional status in the treatment vs control group (small study side though, n=14 in each group).

• In those with decreased single limb balance exam performance as well as CAI, joint mobilizations were shown to be a beneficial intervention to improve balance (which then helps decrease pain and risk of reinjury).

(END OF EVIDENCE)

Ankle sprains are common, and they can vary from a week long nuisance to a career altering recurrent issue. A fair amount of people go from the former to the latter. There is good evidence suggesting that there are specific things that can be done to help reduce the risk of this transition. Programs to reduce risk of injury or reinjury should be individually made and implemented, rather than given as general exercise advice- as there isn’t evidence to support this (though it doesn't hurt either).

If you, or someone you care about, has that wonky ankle that has given them recurring trouble in the past- let me know. Send me a comment and let’s start talking about what can specifically be done to help that specific issue. It doesn’t have to be fancy or painful, but it can be effective.

Martin RL, Davenport TE, Fraser JJ, Sawdon-Bea J, Carcia CR, Carroll LA, Kivlan BR, Carreira D. J Orthop Sports Phys Ther. 2021 Apr;51(4):CPG1-CPG80. doi: 10.2519/jospt.2021.0302. PMID: 33789434.