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There is no such thing as a simple ankle sprain: clinical commentary on the 2016 International Ankle Consortium position statement
  1. C Niek van Dijk1,2,3,
  2. Gwendolyn Vuurberg1,2,3
  1. 1Department of Orthopedic Surgery, Academic Medical Center, Amsterdam, The Netherlands
  2. 2Academic Center for Evidence based Sports Medicine (ACES), Amsterdam, The Netherlands
  3. 3Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands
  1. Correspondence to Professor C Niek van Dijk, Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Centre, PO Box 22660, Amsterdam 1100 DD, The Netherlands; c.n.vandijk{at}amc.uva.nl

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Lateral ankle sprains (LAS) have a high incidence and prevalence among a relatively young population. It is the most commonly incurred musculoskeletal trauma among athletes. The prevalence of LAS among the general population is also high. LAS is associated with a wide range of negative sequelae leading to a substantial healthcare burden and by consequence high societal costs. As such, LAS has a high socioeconomic impact.1 In the previous issue, the Executive Committee of the International Ankle Consortium presents a position paper with recommendations based on a consensus statement on the prevalence, impact and long-term consequences of LAS.2 ,3

Epidemiology and complications

The authors state that following a LAS injury, most patients do not receive ongoing supervised professional treatment for their injury.4 Acute injury-associated symptoms typically resolve in a short period of time. However, after an acute ankle sprain, as many as 70% of patients can develop long-lasting symptoms. These symptoms may include persistent ‘giving way’ of the ankle joint, a feeling of ankle joint instability, pain and recurrent injury; ultimately resulting in functional limitations. These persistent symptoms are the characteristic features of chronic ankle instability (CAI). In up to 89% of ankle sprains, osteochondral lesions are present which combined with chronic instability (CAI) eventually may lead to osteoarthritis (OA).5 This leads to one of the authors' recommendations that LAS warrants treatment by a trained medical professional. Lingering ankle instability contributes to ongoing disability and sensorimotor control deficits, which contribute to functional impairment and decreased quality of life. Historically, a differentiation is made between functional ankle instability and mechanical ankle instability or a combination of these.6 Mechanical ankle instability has been linked to subsequent degenerative changes of the ankle.7 It is not surprising that patients with a history of LAS and CAI make up for the majority of post-traumatic OA (PTOA) surgical cases.5

Owing to the high rate of injury recurrence and the risk of developing CAI, proper progressive treatment guided by a healthcare professional is essential following acute LAS. No consensus exists regarding the optimal treatment for acute LAS. Considering the multifactorial nature, one might assume that even with adequate conservative treatment, patients may still progress to CAI after a LAS.6 An evidence-based consensus on prevention and early management are needed to reduce the prevalence of CAI and associated sequelae, which in turn increase public healthcare burden in terms of decreased physical activity and early onset of ankle joint PTOA.

Management tips

Most LAS can be treated conservatively; initially, we would advocate a structured functional rehabilitation programme with the aim of addressing sensorimotor deficits. A short initial period of immobilisation leads to a faster recovery compared with treatment without a short period of immobilisation.8 Athletes participating in high-risk sports for LAS and the subsequent development of CAI may opt for surgical treatment, as in such circumstances, it may offer better outcomes compared with functional rehabilitation.9 It is currently not a common practice to treat non-athletes with an acute ankle sprain with or without ligament involvement (eg, rupture), by means of surgery. In patients who eventually develop chronic instability, a secondary ligament reconstruction can be performed with excellent reported outcome.

In the decision on treatment, recognition of the severity of the trauma is important. After a knee trauma, differentiation is made between patients with and without a ligament rupture. Patients with a ligament rupture are treated with mechanical support or surgery, depending on the severity and number of ligaments which are torn. The goal of treatment is to prevent chronic instability and its consequences such as functional limitations. The same accounts for the ankle joint. The anterior talofibular ligament (ATFL) is the main stabiliser of the ankle joint and the first ligament to rupture during a sprain. An unhealed rupture of the ATFL creates a rotational unstable ankle comparable to a chronic ACL rupture. In the case of a LAS, proper assessment is therefore needed to detect an ATFL rupture. Delayed physical examination has demonstrated excellent sensitivity and specificity.10 Adequate initial treatment should be based on the correct diagnosis.

To gain control over the high prevalence and healthcare burden of LAS, prevention and implementation of current knowledge and proven solutions is important. Additionally, LAS should be identified as a noteworthy musculoskeletal injury that requires diagnosis and treatment by a trained professional. Knowledge is needed on the optimal dosage and intensity of initial management of LAS, not only to encourage return to activity, but also to lessen chances of reinjury. Finally, to allow optimal tissue restoration and reduce the high LAS recurrence rates and progression to CAI, a standardised immobilisation and rehabilitation programme should be used that addresses sensorimotor and arthrokinematic deficits simultaneously. Future research is needed to further improve care after a LAS. There is no such thing as a simple sprain.

References

Footnotes

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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