Lateral Ankle Sprains CPG: Interventions

Today we wrap up the 2021 Lateral Ankle Sprains CPG by covering the interventions section.

Chapters

• 0:51 Injury Prevention
• 3:03 Acute and Post-Acute Sprain
• 14:58 Chronic Ankle Instability
• 21:42 Practice Question

Transcript

Hello and welcome back to OCS Field Guide. Today we will be the much more exciting part 2 on the 2021 Lateral Ankle sprain CPG where we will be focusing on intervention recommendations.

Remember we are distinguishing between two main treatment groups, the acute and subacute lateral ankle sprain group, and the chronic ankle instability group which is going to be defined as having pain or instability symptoms over 12 months from one or more lateral ankle sprains. This CPG is especially cool to me because it is one of the few that actually has pretty strong recommendations for injury prevention.

For primary prevention, that is preventing a first-time ankle sprain, the authors give an A-level recommendation FOR the use of prophylactic bracing and/or taping to reduce the risk of first-time lateral ankle sprain. They note that this is particularly for individuals with intrinsic risk factors, or those engaging in a high-risk activity such as a court sport. Remember, those intrinsic risk factors include female sex, hip abductor and extensor weakness, and poor performance on balance and hopping tests. The evidence regarding balance and exercise training for prevention of a first-time ankle sprain just does not exist yet, but there is strong evidence for its use in secondary prevention. We also know that poor balance and hop testing and hip weakness are risk factors. So, they go ahead and give a C-level recommendation that clinicians may recommend use of prophylactic balance training exercise in individuals who have not experienced a lateral ankle sprain.

For secondary prevention, They give a strong A-level recommendation for the use prophylactic bracing and/or taping AND the use of proprioceptive and balance-focused exercise programs directed at addressing a patient’s specific impairments to reduce risk of subsequent ankle sprains after a first time injury. There is also a note that specific footwear modifications and orthotic prescription are not helpful in preventing a second ankle sprain—so recommending high tops and off the shelf orthotics is not going to help. So for prevention, we can strongly recommend bracing in individuals who have or have not had an ankle sprain, especially if they have risk factors or play a court sport. We aren’t sure yet on balance exercise for preventing a first time injury, but we know that we want to do if for secondary prevention. 

Now we’ll move on to interventions for acute and post-acute lateral ankle sprain, beginning with protection and optimal loading. There is A-level recommendation FOR early progressive weight bearing and for clinicians to use external supports such as bracing or taping and potentially assistive device. The type of brace or assistive device should be based on the severity of the injury, phase of tissue healing, level of protection indicated, extent of pain, and patient preference. A good way to think about this is that early weight bearing is good and we should give the amount of support needed to allow for comfortable, threat-free weight bearing with as little gait deviation as possible. Now, in general the research has shown that early mobilization as opposed to immobilization is best in most cases, but they recognize that for more severe injuries a period of immobilization may be indicated. They give an A-level recommendation that in more severe injuries, immobilization ranging from semi-rigid bracing to below-knee casting may be indicated for up to 10 days post injury. And I think that’s the key there: 10 days, not 2-4 weeks in a boot like I often see from orthopedists in my area. 10 days maximum, and really just as long as they need to bear weight comfortably without. And if they can’t bear weight after that, remember you should probably be wanting to make sure they don’t have a fracture. So again, early weight bearing and loading is good, use bracing or taping to allow for progressive weight bearing; boot immobilization only for severe injuries and only for up to 10-days.

Now for therapeutic exercise. There is strong evidence for ther-ex consisting of neuromuscular training, postural re-education, and balance training to improve both subjective and objective talocrural stability and time to return to pre-injury activity level. So they give A-level recommendation for a structured there-ex program including: protected active ROM, stretching exercises, neuromuscular training, postural re-education, and balance training, both in clinic and at home—as indicated by injury severity, identified impairments, preferences, learning, needs, and social barriers in those with LAS.

Then there is a D-level or conflicting evidence recommendation stating that the research is mixed on what is the best method for the unsupervised portion, but that it can be written instruction, exercise-based video games, or app-based instruction. So, the method of the home portion of rehab can be selected based on individual’s specific learning needs and technology access.

The next recommendation is about occupational and sport-related activity training. The research synthesized here is mostly about minimizing re-injury in return-to-work or sport. They give a B-level recommendation that clinicians should implement a return-to-work or sport schedule and use a brace early in rehabilitation, occupational, or sport-related training, and/or work-hardening program to mitigate activity limitation and participation restriction following LAS. What kind of schedule you may ask? Well, they give an example from a systematic review and multi-disciplinary guideline by Vuurberg and colleagues which is based on injury severity, how active the individual’s work or sport is, and their response to rehabilitation. They give three different timelines depending on if the injury is just a distortion (think more mild injury, grade 1 sprain, that kind of thing), partial/total rupture of ligaments, and then a timeline if surgery is performed. 

For a distortion, they recommend returning to sedentary work by two weeks which they define as mostly sitting work, not exceeding 10-kg of lifting (which is 22lb. for us here in the states), and to limit standing and walking on uneven surfaces. Then they expect full return to work and sport in the 3-4 week range depending on the the patient’s status and the task requirements. 

For the partial/total rupture timeline, they recommend return to sedentary work and activities more in the 3-6 week range which again is mostly sitting work, no more than 10kg lifting, and limiting standing and walking on uneven surfaces. Then full return to work and sport in the 6-8 week range depending on task requirements and result of physical therapy.

Finally, in case of surgery they give this expected guideline: around 2 weeks non-weight bearing in cast or boot with crutches; then in the 3-6 week range weight bearing as tolerated with resuming sedentary work depending on weight bearing status; then at the 6 week mark cast or boot replaced by brace; then at 12-16 weeks is the projected return to physically demanding job tasks and sports—and I’ll add depending on response to rehab and return to sport testing.

The next recommendation is for manual therapy. In case you keep up with too many PT influencers that tear down old-school straw-man representations of what manual therapy is and should be, you may need to hear that the recommendation for manual therapy has strengthened from a B to an A-level recommendation. They highlight the importance of manual therapy especially in the acute period for reducing pain and increasing dorsiflexion ROM in the short term. As always, combining manual therapy with exercise is key, and the combination outperforms either treatment alone or no treatment. The A-level recommendation reads, “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 ther-ex to reduce swelling, improve pain-free ankle and foot mobility, and normalize gait parameters in individuals with a lateral ankle sprain.”

The next intervention recommendation for acute and post-acute lateral ankle sprain is regarding acupuncture, for which they give a D-level recommendation that there is conflicting evidence for the use of acupuncture and so no recommendation for or against can be given. 

The next few recommendations are all regarding physical agents for acute and post-acute lateral ankle sprain:

The first is cryotherapy. Pay attention to this section as there has been a significant change in the recommendation. The 2013 CPG gave an A-level recommendation for repeated intermittent ice, but this 2021 update downgrades this to a C-level recommendation that clinicians may use repeated intermittent ice only in association with a therapeutic exercise program. They state that since the initial CPG strong evidence has emerged that rest, ice, compression, and elevation are insufficient to improve self-reported function and injury recurrence (side note, not sure how anyone expected it to impact injury recurrence) in individuals with an acute LAS. Use of ice ONLY in a combined approach with exercise may improve load tolerance during weight bearing. The previously mentioned review by Vuurberg and colleagues reviewed 27 trials and concluded that there was NO evidence to support the isolated use of ice to increase function and decrease swelling and pain at rest. So, the takeaway is that ice is only useful in combination with exercise for acute cases. They did note that ice and exercise was significantly better than heat and exercise on reducing swelling. So, if you have a case that describes an acute ankle sprain and treatment is indicated, you should be prioritizing things like protected active range of motion exercise and stretching with early weight bearing, and only pick ice if it is combined with that kind of exercise and/or if the patient values it. 

The next physical agent is diathermy. Now, go ahead and raise your hand if your clinic still has a diathermy unit? … Aaand for the two of you that do, do you know how to turn it on? K good just curious. Well, there is actually a C-level recommendation that clinicians can utilize pulsating shortwave diathermy for reducing edema and gait deviations associated with acute ankle sprains. This is the same recommendation as the 2013 recommendation–not surprised no one has been funding diathermy research. 

Moving right along, electrotherapy. There is a D-level recommendation that there is moderate evidence both for and against the use of electrotherapy in management of acute ankle sprains. Again, this is the same as the 2013 recommendation. There’s no new evidence here. 

Now for a more popular modality: low-level laser. Previously there was a conflicting evidence recommendation, but there have been a couple RCTs that have strengthened this recommendation. We now have a C-level recommendation that clinicians may use low-level laser therapy to reduce pain specifically in the initial phase of an acute LAS. 

And the moment you’ve been waiting for: ultrasound. There is an A-level recommendation that clinicians should NOT use ultrasound for the management of acute ankle sprains. Real shocker there. 

The next is a new recommendation regarding NSAIDs. They give a C-level recommendation that clinicians may prescribe NSAIDs (as practice acts allow) to reduce pain and swelling in those with an acute lateral ankle sprain. This is not expected to have any effect on ROM or injury recurrence, and should only be recommended within the first 14 days following a lateral ankle sprain.

Before we move on the Chronic ankle instability interventions lets recap:

For acute lateral ankle sprains, clinicians SHOULD use: early weight bearing with support, therapeutic exercise in clinic and at home, and manual therapy procedures–all of which have A-level recommendation. Clinicians should also do occupational and sport-related activity training, though this is just a B-level recommendation. Clinicians MAY use: cryotherapy (only along with exercise), diathermy, low-level laser, NSAIDs –all of which are C-level recommendations. And finally, clinicians should NOT use ultrasound, against which there is A-level recommendation. 

Now let’s cover the recommendations specific to chronic ankle instability. 

First we have external support, such as bracing, taping, and/or insoles. They give a B-level recommendation that braces, taping, insoles, and any combination of these should not be used as a stand-alone intervention to improve balance and postural stability. This is a little confusing because we know that we do want to recommend bracing or taping in individuals with a history of ankle sprain to help prevent re-injury. This is not disagreeing with that, but rather saying in these individuals with continued instability or pain over a year out from injury, recommending insoles, bracing, and/or taping alone is not going to have any benefit on their balance and postural-control. I think a practical application of this, and maybe the reason it is included, is the common situation where somebody has chronic ankle pain or instability after a sprain and they are just referred for or sold on custom orthotics or some special brace by their podiatrist or PT or ortho. Still, I want to be clear that this recommendation says nothing about whether external supports could help with pain, just that they do not improve balance performance or postural stability. 

Next we have the good stuff: therapeutic exercise. They give A-level recommendation for the prescription of proprioceptive and neuromuscular ther-ex to improve dynamic postural stability and patient-perceived stability during function in individuals with CAI. I will add, there is a ton of research synthesized here with a wide range of exercise focuses. So I would say the key for answering questions on the exam is that you pick exercise interventions that specifically address deficits listed in the case described, but especially those related to proprioceptive and neuromuscular exercise. 

And now more good stuff: manual therapy. Again we have an A-level recommendation for the use of manual therapy procedures such as graded joint mobilizations and manipulations, and both non-weightbearing and weight-bearing mobilization with movement in order to improve weight-bearing ankle dorsiflexion and dynamic balance in the short term for these chronic ankle instability folks. Remember from last episode, they are really big on the weight-bearing measure of ankle dorsiflexion as your measure of choice for assessing ankle dorsiflexion. 

Next is a new recommendation for Dry needling. There is a C-level recommendation that clinicians may use dry needling of the fibularis muscle group in conjunction with a proprioceptive training program to reduce pain and improve function. 

The last recommendation specific to chronic ankle instability is for combined treatments, where they give a B-level recommendation that clinicians may supplement balance training with a combination of various types of therapeutic exercise and manual therapy procedures as guided by patient’s values and goals, clinician’s judgment, and evidence-based clinical recommendations. The studies that make up the basis of this recommendation included various forms of exercise including stretching, strength training, balance, vestibular training, soft tissue mobilization, dry needling, strain/counterstrain techniques, and functional tasks. I think if the exam where to ask a question based of this recommendation, it would be highlighting the patient values piece of the evidence based practice model and would be looking for you to incorporate the patient’s values on including treatments that may not have as strong of a recommendation, like dry needling, or that does not have a specific recommendation at all such as vestibular training or selecting one manual therapy technique over another if the case indicates that the patient values a specific type of treatment. But obviously, only in combination with treatments that have a strong recommendation. They highlight the need for individualization and caution specifically against a one-size-fits-all approach. So look out for them to try to get you on that. 

The final recommendation applies to both ankle sprain and chronic ankle instability groups and is for interventions to address psychological factors during the course of rehabilitation. Although this is only an expert opinion recommendation, I think it’s worth keeping an eye out for on the exam since it’s such a hot button topic. They give an E-level recommendation that clinicians may use psychologically informed techniques, such as motivational interviewing, to maximize patients’ self-efficacy and address uncomplicated psychological correlates and mediators of injury adjustment and recovery, to maximize the effects of treatment. Remember from our first episode that they recommend considering pain coping strategies as a factor that can influence a patient’s course of care, and then they give a C-level recommendation for using pain self-efficacy questionnaire to assess pain coping strategies and the TSK-11 for kinesiophobia and the FABQ for fear avoidance. So watch out for them to include something like low pain self-efficacy or high kinesiophobia or fear avoidance in case they are looking for you to address this along with their treatment. 

To recap, for chronic ankle instability, based on A-level recommendation clinicians should use proprioceptive and neuromuscular therapeutic exercise to improve dynamic postural stability and perceived stability, and should use manual therapy including joint mobilization, manipulation, and weight-bearing and non-weight-bearing mobilization with movement to improve dorsiflexion, proprioception, and weight-bearing tolerance. There’s C-level recommendation that you may use dry needling to the fibularis muscle group. Don’t use bracing taping or orthotics as a stand-alone treatment. Finally, for everyone, consider addressing psychological factors that may impact care. 

Let’s do a quick practice question to wrap this all up: 

You are tasked with educating a group of girl’s highschool basketball coaches on evidence-based guidelines for preventing lateral ankle sprains. Which of the following guidelines would be best for reducing risk of ankle sprain for their athletes?

A. Require athletes with a history of ankle sprain to engage in a pre-season balance program and wear lace-up ankle brace for all game-play. Make ankle braces and balance training optional for athletes without a history of ankle sprain. 

B. Require all athletes to engage in a pre-season balance program. Ankle braces should be optional due to the risk of weakening lower leg muscles. 

C.  Require all athletes to engage in a pre-season balance program and wear lace-up braces for all game-play regardless of injury history.

D. Require all athletes to engage in a pre-season balance program. Require athletes with history of ankle sprain to wear lace-up ankle braces for all game-play

The correct answer here is C, require all athletes to engage in a pre-season balance program and wear lace-up braces for all game play. Remember, there is A-level recommendation for the use of braces or taping for primary prevention of lateral ankle sprain. Not only that but they specifically say, “especially for those with risk factors.” Remember, female sex and participating in a court sport are both risk factors for lateral ankle sprain, so this is a high risk group that for which we should be recommending braces or taping. Now, there is only C-level recommendation for prophylactic balance training in individuals without ankle sprain history, but C is still the best option because it includes prophylactic bracing for all athletes in this high risk group.

That’s it for today! I hope this has been helpful. If you are getting stressed with the test looming near, head over to our patreon account where you can find lots of resources to help make sure you are strong in the most important areas of the exam.