INJURY CLINIC

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

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1145 1. Ankle Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146 2. Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146 3. Multifaceted Prevention Programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1148 4. Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1148 5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1149

Abstract

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,[1] and the estimated percentage of ankle sprains ranges from

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14% to 33% of all sports-related injuries.[2-5] Up to 40% of individuals with a history of an ankle sprain have been found to have symptoms of chronic functional instability,[6,7] and re-injury to the same ankle is common. The frequent nature of ankle sprains and the persistent disability that all too commonly occurs, has lead to considerable medical costs in the US. In a 1983 study conducted by investigators at Harvard, estimates for the annual aggregate dollar expenditures for moderate to severe ankle sprains in the US was approximately $US2 billion.[1] Adjusted for inflation, this figure equals $US3.65 billion in todays economy (Consumer Price Index, 2003). Prevention of disease and injury has become an increasingly important part of the practice of medicine today. Considerable morbidity and unnecessary medical costs may potentially be averted if more effective ankle injury prevention and treatment programmes could be developed. 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. This paper examines the current literature in this regard and provides a review of common treatment methods. 1. Ankle Supports The use of ankle supports and taping is common. 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.[8] As typical of Cochrane reviews, only randomised or quasi-randomised trials were evaluated. The authors included four studies 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. This benefit, however, was principally observed in athletes with a prior history of ankle sprain. In a 1998 comprehensive review, Hume and Gerrard[13] examined the literature regarding the effectiveness of external bracing in reducing ankle sprains. They reported that little information was available delineating the precise mechanisms
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through which ankle supports reduce ankle injury. Conventionally, the ability of a brace to physiologically restrict ankle motion has been the presumed predominant mechanism of action. In their review, rigid and semi-rigid braces were found to be more effective in limiting ankle motion than taping, which was found to lose much of its restrictive support after 20 minutes of exercise. Other mechanisms of effect were postulated for taping such as enhancing proprioceptive function of the injured ankle. External supports were not found to improve athletic performance, and in some situations were found to impair athletic performance. Hume and Gerrard have recommended that where there is a clear history of recurrent ankle injury, the use of an external support should be encouraged.[13] Similarly, following a review of 113 studies, Thacker et al.[14] recommended that athletes who have sustained a moderate or severe ankle sprain should wear an ankle orthosis for at least 6 months following injury. The role of high-top shoes in ankle sprain prevention has also been evaluated.[15] In 1995, Barrett and Bilisko[16] reviewed the literature and found that although biomechanical studies have demonstrated that high-top shoes improve mechanical ankle stability, clinical studies regarding their effectiveness in reducing ankle sprains were inconclusive. 2. Rehabilitation Functional ankle rehabilitation is a vitally important component of acute ankle sprain treatment. In addition, certain components of ankle rehabilitation have also been found to protect the joint from reinjury. The basic tenets of ankle rehabilitation are out lined in table I. In a review of 22 studies, Kerkhoffs et al.[18] found that functional treatment was preferable to immobilisation for initial treatment of acutely injured ankles. Rehabilitation can begin when the pain and swelling of an injury are under control. Care must be taken because aggressive rehabilitative activities during the acute phase of a sprain may increase pain, cause re-injury and inhibit the patients participation in treatment. However, early mobilisation is preferable to prolonged immobilisation.[18]
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Table I. Principal components of a functional ankle rehabilitation programme (reproduced from Osborne,[17] with permission) Rehabilitation mode PRICE Goal Reduce swelling, inflammation and pain Methods Use of ice massage, ice packs, ankle cryo-sleeve, compressive sleeves/elastic ankle wraps, and shortterm use of braces Heel cord stretching with the knee straight (to stretch the gastrocnemius) and flexed 30 (to stretch the soleus), 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. Use a combination of open and closed kinetic chain strengthening Restore dynamic ankle balance and stability Restore dynamic strength, balance and power Use of ankle disks/wobble boards, single leg stance on uneven surface or with eyes closed Jogging, running, double-leg jumping, single-leg hopping, skipping rope, figure-eight drills, lateral cutting drills, and plyometrics

Proprioceptive exercises Functional exercises

PRICE = protection, rest, ice, compression, elevation; ROM = range of motion.

Initial treatment methods include: ice massage, compression, elevation, taping/bracing, nonsteroidal anti-inflammatory drugs (NSAIDs) and/or analgesics. The most common pharmacological approach to treatment of sprains has been to prescribe NSAIDs, and a review of clinical trials supports their use in the first several days (<2 weeks) following acute injury for symptom control.[19] Functional ankle rehabilitation starts by normalising joint range of motion. This involves gentle stretching, taking care to avoid causing further tissue stretch injury. As symptoms allow, the patient begins progressive weight-bearing exercises. Injured muscle, tendon and ligaments heal with stronger and more organised collagen fibril architecture when a gentle load is applied during the healing process. Resistance exercises can begin when there is no pain through the available range of motion, with full weight bearing.[20] Rehabilitation programmes usually start with low-level strengthening such as submaximal isometric exercises and progress in a painfree fashion to isotonic and isokinetic strengthening. Emphasis is placed on strengthening the muscles that serve to provide dynamic stability to the injured joint.[21] Typically, a combination of open and closed kinetic chain strengthening are utilised in the rehabilitation process. Open-chain exercises include
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the use of free weights and resistance tubing. 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. Since eccentric muscle contractions place the greatest force upon the muscle, this mode of strengthening should be reserved for the final stages of the rehabilitation programme.[21] Proprioceptive exercises are an integral part of sprain rehabilitation. Numerous studies have been performed using force plate balance testing as a quantitative measure of postural equilibrium,[22-24] and patients with functional ankle instability following ankle sprain have been found to have significant deficits in balance compared with controls. Ankle disk training has been found to significantly improve balance testing[22,25,26] and decrease symptoms of functional instability.[27] Furthermore, proprioceptive training has been shown to reduce the rate of re-injury in ankle sprains.[28-30] Tropp et al.[28] 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. Wester et al.[29] prospectively evaluated patients with ankle sprain parSports Med 2003; 33 (15)

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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.[31,32] The final phase of acute ankle sprain rehabilitation consists of functional exercises and sport-specific drills. These may begin when the patient has full ankle range of motion, no pain, and about 80% strength compared with contralateral extremity.[33] These exercises facilitate the attainment of dynamic strength and balance. 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, and have no pain or swelling following the training session.[17] 3. 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. Ekstrand et al.[34] studied the effect of an injury protection programme on the frequency of injury in 90 male soccer players. The programme consisted of education on the importance of disciplined play, warm-up/cool-down and flexibility exercises, use of shin guards by all players, and ankle taping for those with prior sprain or instability (48% of players). Special rehabilitation schemes were developed for each injury sustained but were not a part of the prophylactic programme. The authors found a 75% reduction in all injuries and an 82% reduction in ankle sprains compared with controls. This group of soccer players constituted a mix of injured (48%) and uninjured (52%) players. Bahr et al.[35] 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. The programme consisted of an injury awareness educational session, technique training (that included jumping and lateral movement drills), and ankle disk training. The results showed a 47% reduction in the incidence of ankle sprains over 1 year compared with the year prior to
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implementation of the injury prevention programme. This study also utilised individuals both with and without prior ankle sprains. In a randomised, controlled study of 237 female handball players, Wedderkopp et al.[36] investigated the effect of an injury prevention programme that included a warm-up, major muscle group functional exercises, and 1015 minutes use of a wobble board at all practice sessions. Similarly, they reported that significantly fewer ankle sprains occurred during games and practices in the intervention group (n = 6) compared with controls (n = 23). 4. Surgery The role of surgery in the initial treatment of acute ankle sprain is limited. Grade I and II sprains generally recover quickly with non-operative management.[37] Increasingly, grade III sprains are also treated conservatively, although some debate continues. In a 1999 review of conservative versus surgical treatment for acute sprain, Lynch and Renstrom[37] concluded that functional treatment is the treatment of choice. A 2002 Cochrane Systematic Review by Kerkhoffs et al.[38] concludes there is insufficient information from randomised trials to recommend surgery over conservative treatment, or visa versa. In their review of 17 studies, return to work was usually quicker for patients treated with functional rehabilitation, although these patients also demonstrated more evidence of mechanical instability on stress radiography following treatment. Nevertheless, the frequency of recurrent ankle sprain was no different between the two groups. Longer-term swelling was found in the functional treatment group, while complaints of ankle stiffness were greater in surgically-treated patients. Surgery should be considered for patients who sustain recurrent lateral ankle sprains or exhibit significant symptoms of chronic functional instability despite appropriate rehabilitation interventions. The goal of surgery is to restore mechanical stability to the ankle and thereby significantly reduce or eliminate chronic symptoms of instability. Late ankle reconstruction for chronic lateral instability is sucSports Med 2003; 33 (15)

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cessful in approximately 85% of patients regardless of the type of surgical procedure performed.[39] Primary anatomical repair of the anterior talofibular and calcaneal fibular ligament is often preferred.[39] However, in cases where there is excessive joint laxity, peroneal weakness, hindfoot varus, or significant tibiotalar osteoarthritis, reconstructions such as the Chrisman-Snook or Watson-Jones procedures may be preferred.[39,40] 5. Conclusions The frequent nature of ankle sprains and persistent disability that often ensues, consumes considerable monetary medical resources. Ankle braces are an effective means for reducing recurrent ankle sprains, although their role in primary prevention is less evident. Functional rehabilitation of an acute ankle injury is the initial treatment of choice, while surgery for ankle sprain is principally reserved for patients who fail a comprehensive non-operative treatment programme. Surgery for chronic ankle instability is typically successful. Aspects of ankle rehabilitation such as proprioceptive training have been shown to reduce the frequency of recurrent sprain. Likewise, multifaceted ankle sprain prevention programmes are effective in sprain prevention; however, the relative importance of each component of such programmes remains unknown and warrants further research. In particular, the isolated effect of proprioceptive-type exercises in primary ankle sprain prevention has yet to be determined. Acknowledgements
No sources of funding were used to assist in the preparation of this manuscript. The authors have no conflicts of interest that are directly relevant to the content of this manuscript.

References
1. Soboroff SH, Pappius EM, Komaroff AL. Benefits, risks, and costs of alternative approaches to the evaluation and treatment of severe ankle sprain. Clin Orthop 1984; (183): 160-8 2. Garrick JG, Requa RK. The epidemiology of foot and ankle injuries in sports. Clin Sports Med 1988; 7 (1): 29-36 3. Berger-Vachon C, Gabard G, Moyen B. Soccer accidents in the French Rhone-Alpes Soccer Association. Sports Med 1986; 3 (1): 69-77

4. Ekstrand J, Tropp H. The incidence of ankle sprains in soccer. Foot Ankle 1990; 11 (1): 41-4 5. Jackson DW, Ashley RL, Powell JW. Ankle sprains in young athletes: relation of severity and disability. Clin Orthop 1974; 101 (1): 201-15 6. Verhagen RA, de Keizer G, van Dijk CN. Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg 1995; 114 (2): 92-6 7. Gerber JP, Williams GN, Scoville CR, et al. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 1998 Oct; 19 (10): 653-60 8. Handoll HH, Rowe BH, Quinn KM, et al. Interventions for preventing ankle ligament injuries. Available in The Cochrane Library [database on disk and CD ROM]. Updated quarterly. The Cochrane Collaboration; issue 4. Oxford: Update Software, 2002 9. Amoroso PJ, Ryan JB, Bickley B, et al. Braced for impact: reducing military paratroopers ankle sprains using outsidethe-boot braces. J Trauma 1998; 45 (3): 575-80 10. Simon JE. Study of the comparative effectiveness of ankle taping and ankle wrapping on the prevention of ankle injuries. J Athl Train 1969; 4: 6-7 11. Sitler M, Ryan J, Wheeler B, et al. The efficacy of a semirigid ankle stabilizer to reduce acute ankle injuries in basketball: a randomized study at West Point. Am J Sports Med 1994; 22: 454-61 12. Surve I, Schwellnus MP, Noakes T, et al. A fivefold reduction in the incidence of recurrent ankle sprains in soccer players using the Sport-Stirrup orthosis. Am J Sports Med 1994; 22 (5): 601-6 13. Hume PA, Gerrard DF. Effectiveness of external ankle support: bracing and taping in rugby union. Sports Med 1998 May; 25 (5): 285-312 14. Thacker SB, Stroup DF, Branche CM, et al. The prevention of ankle sprains in sports: a systematic review of the literature. Am J Sports Med 1999; 27 (6): 753-60 15. Garrick JG, Requa RK. Role of external support in the prevention of ankle sprains. Med Sci Sports 1973; 5 (3): 200-3 16. Barrett J, Bilisko T. The role of shoes in the prevention of ankle sprains. Sports Med 1995; 20 (4): 277-80 17. Osborne MD. Chronic ankle instability. In: Frontera WR, Silver JK, editors. Essentials of physical medicine and rehabilitation. Philadelphia (PA): Hanley & Belfus Inc, 2002: 409-13 18. Kerkhoffs GM, Rowe BH, Assendelft WJ, et al. Immobilisation for acute ankle sprain: a systematic review. Arch Orthop Trauma Surg 2001 Sep; 121 (8): 462-71 19. Almekinders LC. Anti-inflammatory treatment of muscular injuries in sport: an update of recent studies. Sports Med 1999; 28 (6): 383-8 20. Demaio M, Paine R, Drez D. Chronic lateral ankle instabilityinversion sprains: part II. Orthopedics 1992; 15 (1): 87-96 21. Rizzo TD, Osborne MD. Sprains and sprains. In: Sinaki M, editor. Basic clinical rehabilitation medicine. 3rd ed. St Louis (MO): Mosby Year Book. In press 22. Goldie PA, Evans OM, Bach TM. Postural control following inversion injuries of the ankle. Arch Phys Med Rehabil 1994; 75: 969-75 23. Tropp H, Ekstrand J, Gilquist J. Stabilometry in functional instability of the ankle and its value in predicting injury. Med Sci Sports Exerc 1984; 16: 64-6 24. Tropp H, Odenrick P. Postural control in single-limb stance. J Orthop Res 1988; 6: 833-9

Adis Data Information BV 2003. All rights reserved.

Sports Med 2003; 33 (15)

1150

Osborne & Rizzo

25. Freeman M, Dean M, Hanham I. The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br 1965; 47-B: 678-85 26. Hoffman M, Payne VG. The effects of proprioceptive ankle disk training on healthy subjects. J Orthop Sports Phys Ther 1995; 21: 90-3 27. Gauffin H, Tropp H, Odendrick P. Effect of ankle disk training on postural control in patients with functional instability of the ankle joint. Int J Sports Med 1988; 9: 141-4 28. Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med 1985; 13: 259-62 29. Wester JU, Jespersen SM, Nielsen KD, et al. Wobble board training after partial sprains of the lateral ligament of the ankle: a prospective randomized study. J Orthop Sports Phys Ther 1996; 23: 332-6 30. Holme E, Magnusson SP, Becher K, et al. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports 1999 Apr; 9 (2): 104-9 31. Sheth P, Yu B, Laskowski ER, et al. Ankle disk training influences reaction times of selected muscles in a simulated ankle sprain. Am J Sports Med 1997 Jul-Aug; 25 (4): 538-43 32. Osborne MD, Chou LS, Laskowski ER, et al. The effect of ankle disk training on muscle reaction time in subjects with a history of ankle sprain. Am J Sports Med 2001 Sep-Oct; 29 (5): 627-32 33. Noonan TJ, Garrett Jr WE. Muscle strain injury: diagnosis and treatment. J Am Acad Orthop Surg 1999 Jul-Aug; 7 (4): 262-9 34. Ekstrand J, Gillquist J, Liljedahl SO. Prevention of soccer injuries: supervision by doctor and physiotherapist. Am J Sports Med 1983; 11 (3): 116-20

35. Bahr R, Lian O, Bahr IA. A twofold reduction on the incidence of acute ankle sprains in volleyball after the introduction of an injury prevention program: a prospective cohort study. Scand J Med Sci Sports 1997; 7: 172-7 36. Wedderkopp N, Kaltoft M, Lundgaard B, et al. Prevention of injuries in young female players in European team handball: a prospective intervention study. Scand J Med Sci Sports 1999 Feb; 9 (1): 41-7 37. Lynch SA, Renstrom AFH. Treatment of acute lateral ankle ligament rupture in the athlete. Sports Med 1999 Jan; 27 (1): 67-71 38. Kerkhoffs GMMJ, Handoll HHG, de Bie R, et al. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Available in The Cochrane Library [database on disk and CD ROM]. Updated quarterly. The Cochrane Collaboration; issue 4. Oxford: Update Software, 2002 39. Colville MR. Surgical treatment of the unstable ankle. J Am Acad Orthop Surg 1998; 6 (6): 368-77 40. Peters JW, Trevio SG, Renstrom PA. Chronic lateral ankle instability. Foot Ankle 1991; 12 (3): 182-91

Correspondence and offprints: Dr Michael D. Osborne, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, FL 32224, USA.

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Sports Med 2003; 33 (15)