Differential Diagnoses which can be treated using this pathway.

Lateral Ligament Sprain (Sub acute)

Sub acute : Approximately between 4 days and 4 weeks

Significant History/Physical symptoms

A lateral ankle sprain is one of the most common musculoskeletal injuries. Patients typically describe an inversion injury, which can result in damage to the ligaments on the lateral aspect of the ankle. It usually occurs when the ankle is inverted and plantarflexed with the forefoot bearing weight. Patients may present with significant pain and swelling. However, they are quite often able to weight bear unlike an ankle fracture where weight bearing is extremely difficult.

75% of ankle injuries involve the lateral ligamentous complex, comprised of the ATFL, the CFL and the PTFL.

Videos:

Testing ATFL

Testing peroneal strength

Testing syndesmosis

Ligament sprain classification

• Grade 1 - Mechanically stable / mild damage to ligament
• Grade 2 - Some joint laxity / partial tear to ligament to cause laxity
• Grade 3 – Clinical and/or radiological evidence of instability / complete tear to ligament

Less Common Differential Diagnoses not included in this pathway:

• Osteochondral Defect
• Syndesmosis damage
• Sinus Tarsi Syndrome
• Missed Fractures- Osteochondral, Lateral Talar process
• Fracture of the lateral malleolus or anterior calcaneal process
• Peroneal tubercle hypertrophy or peroneal tendon dislocation
• Osteochondritis Dessicans
• Os Peroneum Syndrome

Ottowa Ankle Rules: Apply Ottawa rules for foot and ankle fracture. If positive refer to A&E.

The first line intervention should focus on educating the patient about the condition, and prescribing therapies that can be self-administered by the patient.

Leaflets should be given to patients to reinforce verbal advice and links to NHS website resources where available.

• NHSGGC ankle sprain leaflet
• NHSGGC ankle sprain leaflet (printable)

Guidance for treatment duration and escalation

For the treatment of the acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function.

Evidence suggests that incorporating balance / proprioception / neuromuscular exercises is effective at increasing functionality as well as prevention of recurrent injury.
Neuromuscular reprogramming will retrain damaged proprioceptive nerves and strengthen muscles around the ankle.

Factors that may be associated with poor recovery of grade I and II injuries at short term review (< 8 weeks) include:

• Pain intensity
• Difficulty bearing weight
• Restricted joint motion
• Functional ability

If a patient is not improving as expected they should be referred on to another AHP who can deliver an escalated evidenced intervention or referred to orthopaedics as per the escalation guidance on the pathway.

Evidence suggests that bracing/taping are effective in reducing reinjury incidence in a sporting population (Doherty et al, 2017). There is moderate evidence suggesting that bracing may be superior for self reported function in comparison to taping.

Initial Patient Directed Treatment Options

• Advise weight loss if appropriate
  • Signposting to activities which may promote weight loss link exit/parallel pathways
  • Referral to Weight Management Service if BMI greater than 30.
  • NHS Choices - Lose weight
  • Leisure Pathway 
• Activity modification and management advice
• Analgesia & Non-Steroidal Anti Inflammatory Drugs as appropriate.
  • See guidance on good practice for Analgesia Advice
• PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
• Footwear Advice
  • Increased width of heel sole / increase support around ankle, with low but not flat heel height.
  • Give leaflet to reinforce verbal advice - NHSGGC Footwear Advice Leaflet
  • Alternative Shoe Lacing Options

Non evidenced treatments

The following treatments are not supported by high quality evidence therefore they should not be considered as a treatment option for patients unless all other evidenced treatments have been tried unsuccessfully and there is clear clinical justification as to why these treatments are being used.

• There is no evidence for the addition of supervised exercise to unsupervised home based exercises for simple ankle sprains
• Acupuncture - insufficient evidence to support use in this condition
• Low Level Laser Therapy LLLT - some limited evidence but more research needed to determine optimum dosage to provide a significant effect
• Therapeutic Ultrasound - not clinically beneficial for acute ankle sprains
• Corticosteroid Injection

If no longer sub acute but the symptoms persist without improvement then follow the persistent lateral ankle guidance.

The majority of the papers included here are level 1 or level 2 evidence, however other papers have been included to allow for further reading around the subject. Articles are listed in Harvard format.

1. Delahunt, E., Bleakley, C.M., Bossard, D.S., Caulfield, B.M., Docherty, C.L., Doherty, C., Fourchet, F., Fong, D.T., Hertel, J., Hiller, C.E. and Kaminski, T.W., 2018. Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. British journal of sports medicine, 52(20), pp.1304-1310.
   Click here for Article
2. Fatoye, F. and Haigh, C., 2016. The cost‐effectiveness of semi‐rigid ankle brace to facilitate return to work following first‐time acute ankle sprains. Journal of Clinical Nursing, 25(9-10), pp.1435-1443.
   Click here for Article
3. Kerkhoffs, G., Struijs, P., Marti, R., Blankevoort, L., Assendelft, W. and van Dijk, C., 2003. Functional treatments for acute ruptures of the lateral ankle ligament. Acta orthopaedica Scandinavica, 74(1), pp.69-77.
   Click here for Article
4. Thompson, C., Schabrun, S., Romero, R., Bialocerkowski, A., van Dieen, J. and Marshall, P., 2018. Factors contributing to chronic ankle instability: a systematic review and meta-analysis of systematic reviews. Sports Medicine, 48(1), pp.189-205.
   Click here for Article

Reference still to be edited:

Doherty C, Bleakley C, Delahunt E, Holden S. Treatment and prevention of acute andrecurrent ankle sprain: an overview ofsystematic reviews with meta-analysisBr J Sports Med 2017;51:113–125. doi:10.1136/bjsports-2016-096178.  Available at: http://www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/4084354/03dbc9f5-bc4a-4859-b842-03e0ea9cb2be.pdf

Clinical Benefits of passive mobilisation on ankle sprains. http://www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/4086965/1790a355-ffcc-448d-87fd-b6d010ca969d.pdf

Weerasekara, I., Osmotherly, P., Snodgrass, S., de Zoete, R. and Rivett, D., 2017. Clinical benefits of passive joint mobilisation on ankle sprains. Journal of Science and Medicine in Sport, 20, p.e49.

Lateral ankle sprain - An Update available at: http://www.worldscientific.com/doi/abs/10.1142/S0218957713300032

Nuhmani, S. and Khan, M.H., 2013. LATERAL ANKLE SPRAIN—AN UPDATE. Journal of musculoskeletal research, 16(04), p.1330003.

Therapeutic ultrasound. Available at: http://bjsm.bmj.com/content/46/4/241

Swain, M. and Henschke, N., 2012. Therapeutic ultrasound is not clinically beneficial for acute ankle sprains. Br J Sports Med, pp.bjsports-2011.

Neuromuscular Training for rehabilitation of sports injuries. Availbale at: http://scholar.google.co.uk/scholar_url?url=http%3A%2F%2Fxa.yimg.com%2Fkq%2Fgroups%2F19520777%2F336902774%2Fname%2FMedicine%2Band%2Bscience%2Bin%2Bsports%2Band%2Bexercise%2B2009%2BZech.pdf&hl=en&sa=T&oi=ggp&ct=res&cd=0&ei=OIgeWo-IKImMmAHdvLu4DA&scisig=AAGBfm1O63SRbRNTU323vN_EiyVMXx3sEQ&nossl=1&ws=1280x929
Zech, A., Hübscher, M., Vogt, L., Banzer, W., Hänsel, F. and Pfeifer, K., 2009. Neuromuscular training for rehabilitation of sports injuries: a systematic review. Medicine & Science in Sports & Exercise, 41(10), pp.1831-1841.

Effect of early supervised physiotherapy on recovery from acute ankle sprain. Available at: http://www.bmj.com/content/355/bmj.i5650.long

Brison, R.J., Day, A.G., Pelland, L., Pickett, W., Johnson, A.P., Aiken, A., Pichora, D.R. and Brouwer, B., 2016. Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. bmj, 355, p.i5650.

Prognostic factors for recovery following acute lateral ankle ligament sprain. Available at: https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-017-1777-9

Thompson, J.Y., Byrne, C., Williams, M.A., Keene, D.J., Schlussel, M.M. and Lamb, S.E., 2017. Prognostic factors for recovery following acute lateral ankle ligament sprain: a systematic review. BMC musculoskeletal disorders, 18(1), p.421.

Brukner, P. & Khan, K. 2012, Clinical Sports Medicine. 4th ed. McGraw-Hill, Australia

Clinical Knowledge Summaries (CKS) 2012, Sprains and Strains, available from: http://cks.nice.org.uk/sprains-and-strains#!scenariobasis:2 NICE, accessed 23.09.2013

Denegar, C.R., Hertel, J., Olmsted, L.C., & Vela, L. I. 2004, “Prophylactic Ankle Taping and Bracing: A Numbers-Needed-to-Treat and Cost-Benefit Analysis.” Journal of Athletic Training, Vol. 39, no. 1, pp.95–100

Dombek MF, Lamm BM, Satrick K, Mendicino RW, Catanzariti AR. Peroneal Tendon Tears: a retrospective review. J Foot Ankle Surg 2003; 42: 250-258.

Guskiewicz KM, Perrin DH. Effect of orthotics on postural sway following inversion ankle sprain. J Orthop Sports PhysTher 1996; 23: 326-31

Hertel J: Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train 37:364. 2002

Heckman DS, Gluck GS, Parekh SG. Tendon Disorders if the Foot and Ankle: Peroneal Tendon Disorders. The American Journal of Sports Medicine 2009; 37(3): 614-625.

Hupperets, M.D., Verhagen, E.A. & Van Mechelen, W. 2009, “Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial”, British Medical Journal, Vol.9, no. 3394

Klammer G, Benninger E. Espinosa N. The varus ankle and instability. Foot Ankle Clin N Am. 17 (2012).

Loudon, J.K., Reiman, M. P., & Sylvain, J. 2013, “The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review”, British Journal of Sports Medicine, Vol.48, no.5, pp.365-70

Maffulli N, Ferran NA, Oliva F, Testa V. Recurrent Subluxation of the Peroneal Tendons. Am J Sports Med 2006; 34: 986-992.

Manoli A, Graham B. The subtle cavus foot, ‘underpronator’ A review. Foot and Ankle International. 2005.

Mansour R, Jibri Z, Kamath S, Mukherjee K, Ostlere S. Persistent ankle pain following a sprain: a review of imaging. EmergRadiol. 18 (2011)

Mattacola, C. G. & Dwyer, M. K. 2002, “Rehabilitation of the Ankle After Acute Sprain or Chronic Instability” Journal of Athletic Training, Vol. 37, no.4, pp.413-429

Mills, K., Blanch,P.,Chapman, A. R. ,McPoil, Vicenzino, T. Foot orthoses and gait: a systematic review and meta-analysis of literature pertaining to potential mechanisms Br J Sports Med 2010;44:1035–1046

Orteza LC, Vogelbach WD, Denegar CR. The effect of molded orthotics on balance and pain while jogging following inversion ankle sprain. J Athletic Training 1992; 27: 80-4

Peroneal Tendonitis. Physioadvisor.com. Accessed 01/10/2012. Available at: http://www.physioadvisor.com.au/8071750/peroneal-tendonitis-peroneal-tendinopathy-phys.htm

Philbin TM, Landis GS, Smith B. Peroneal Tendon Injuries. J Am AcadOrthopSurg 2009; 17: 306-317.

Richie D. H. (2007) Effects of Foot Orthoses on Patients with Chronic Ankle Instability. Journal of the American Podiatric Medical Association: January 2007, Vol. 97, No. 1, pp. 19-30

Sammarco GJ, Mangone PG. Diagnosis and Treatment of Peroneal Injuries. Foot and Ankle Surgery 2000; 6: 197-205

Stiell, I., Wells, G., Laupacis, A., et al. 1995. “Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Study Group”, British Medical Journal, Vol. 311, no. 7005, pp. 594–7

Tanaka H, Mason L. Chronic Ankle Instability. Orthopaedic and Trauma. 24(5) 2011.

Douglas R. Functional Instability of the Ankle and the Role of Neuromuscular Control: A Comprehensive Review. The Journal of foot and ankle surgery. 40(4) 2001.

Tourne Y, Besse J, Mabit C, Sofcot. Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options? Orthopaedics & Traumatology: Surgery and Research. 96 (2010).

Van den Bekerom, M.P.J., Van derWindt, D.A.W.M, Van der Heijden, G.J., &Bouter L.M. 2011, “Therapeutic ultrasound for acute ankle sprains”, Cochrane Database of Systematic Reviews, Issue 6 available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001250.pub2/pdf

Van Mechelen, W., Verhagen, E. A. L. M., & de Ventre, W. 2000. “The Effect of Critical Review: Preventative Measures on the Incidence of Ankle Sprains”. Clinical Journal of Sport Medicine. Vol 10, no.10, pp. 291-296

Verhagen, E.A.L.M., Van Tulder, M., Van der Beek, A.J., Bouter, L., & Van Mechelen, W. 2005, “An economical evaluation of a proprioceptive balance board training program for the prevention of ankle sprains in volleyball”, British Journal of Sports Medicine, Vol.39. pp.1115

Watson A. Ankle Instability and Impingement. Foot and Ankle Clinics of North America. 12 (2007)

Wolfe, M.W., Uhi, T.L., Mattacola, C.G., &McCluskey, L. 2001, “Management of Ankle Sprains” American Family Physician, Vol. 63, pp.93-104