Article: Brison RJ, Day AG, Pelland L, et al. Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. BMJ 2016;355:i5650
Lateral ankle sprains are one of, if not the most common musculoskeletal injuries and account for approximately 14% of sports injuries. Resulting from inversion of the ankle after quick changes in direction or awkward landings, most ankle sprains are grade 1 (mechanically stable) or grade 2 (some joint laxity) ligament sprains of the anterior talo-fibular ligament (ATFL). These can be graded by performing the anterior drawer test and comparing side to side, with the optimal time to test at day 5 post injury. If there is any pain in the malleolar zone, bone tenderness at the posterior edge or tip of either malleolus, or inability to bear weight for four steps immediately after the trauma and in the ED, then radiographs are indicated as per the Ottawa ankle rules.
Like everything MSK related, physical therapy is recommended for the rehabilitation process, however the evidence for supervised physiotherapy (PT) is limited in terms of breadth and quality. Principles of PT in ankle sprains include early weightbearing as tolerated, range of motion exercises (drawing out the alphabet with the foot), strengthening of lateral stabilizers (peroneals) using resistance bands, and proprioceptive training (standing on one leg/BOSU ball/mini trampoline/wobble board). It takes 8-12 weeks for complete neuromuscular retraining so bracing or taping for at least this period of time is recommended.
Recently, an article was published out of Kingston which is the largest randomised controlled trial (RCT) to have evaluated the therapeutic benefits of supervised physiotherapy in the treatment of acute ankle sprains. In this study, patients who presented to the ED in Kingston were randomized to either the usual care or physiotherapy arms. The usual care arm included medical assessment and a one-page written summary of instruction for basic management of the injury at home, including ankle protection, rest, ice, compression, elevation, use of analgesics as necessary, graduated weight bearing activities, and information about expected recovery. Participants assigned to the physiotherapy arm were provided with usual care (as above) plus a regimen of supervised physiotherapy. They received a maximum of 7 treatment sessions of 30 minutes in length (maximum 210-minute dose) and treatment was augmented by standardised home exercise programs. Ankle function reported by patients, re-injury, clinical measures, and laboratory based assessments of ankle strength were recorded at one, three, and six months.
Groups were similar at baseline and showed that ~40% of sprains were sport-related and ~60% had previous sprains, highlighting the recurrent nature of these injuries. Except for seeing a benefit for physiotherapy at three months in the subgroup of patients aged <30yo, there were no significant differences between groups. These results are in contrast to a recent meta-analysis which indicated rehabilitative exercises were associated with significant improvements in self reported function and reduced risk of recurrent injury, which was lowest with a cumulative dose of >900min of therapeutic exercise. Compliance of with appointments and home exercises in the Kingston study was recorded but unfortunately not included in the results, which hinders our ability to judge the dose of exercise received.
In summary, this trial can be interpreted in a couple of ways. First, it suggests that supervised physiotherapy may not reliably improve clinical outcomes post low-grade ankle sprain within 6 months, and therefore maybe we don’t need to push supervised PT as much in the general population given that it also comes with significant financial cost. Secondly, it could also suggest that a dose of greater than 210 min of therapeutic exercise may be required to see improved clinical outcomes, so if you’re going to do PT, you might need to err on the side of being more aggressive with the volume of rehab. And considering that less than half of participants had excellent outcomes by 6 months, further investigation to reduce morbidity would be prudent.
- Brukner & Khan’s Clinical Sports Medicine, 4th ed. Peter Brukner, Karim Khan Sydney: McGraw-Hill Australia; 2012.
- Doherty C, Bleakley C, Delahunt E, Holden S. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. Br J Sports Med 2016 doi:10.1136/bjsports-2016-096178
Ryan Shields, MD, MSc, CCFP
PGY-3 Sport and Exercise Medicine
Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (SEM), Dip SPort & Exercise Medicine