Diagnosis, treatment, and prevention of ankle sprains: update of an evidence-based clinical guideline

Key points

1. 01Delayed physical examination (4-5 days post-injury) optimises sensitivity (84%) and specificity (96%) of the anterior drawer test for ligament rupture
2. 02RICE alone is not recommended; exercise therapy combined with functional support (brace or tape) provides the best outcomes
3. 03Immobilisation should be limited to a maximum of 10 days if used at all, after which functional treatment must begin
4. 04NSAIDs reduce short-term pain but may suppress the natural healing process and carry complication risk
5. 05Exercise therapy reduces recurrent sprain risk (RR 0.62, 95% CI 0.51 to 0.76) and ankle braces reduce recurrent sprains (RR 0.30, 95% CI 0.21 to 0.43)

How it was conducted

Design

Updated evidence-based clinical practice guideline with systematic literature search and meta-analyses

Search period

January 2009 to September 2016, combined with articles from the original guideline

Databases

Embase, MEDLINE, Cochrane, PEDro

Studies screened

10,067 identified; 194 articles included after screening

Population

Individuals aged 16 years or older with acute lateral ankle sprain; medial involvement, fractures, and chronic ankle instability excluded

Evidence grading

Dutch evidence classification system (A1 to D) with four levels of conclusion strength; AGREE II criteria applied

What they found

• Ottawa ankle rules sensitivity 86%-99%, specificity 25%-46% for fracture exclusion (level 1 evidence)
• Delayed physical examination at 4-5 days post-injury: anterior drawer test sensitivity 84%, specificity 96% (level 2)
• Ultrasonography sensitivity 92%, specificity 64%; MRI sensitivity 93%-96%, specificity 100% for high-grade ligament and osteochondral injuries
• NSAIDs versus placebo for pain: RR 0.51 (95% CI 0.38 to 0.68) at less than 14 days; no significant increase in complications RR 1.17 (95% CI 0.79 to 1.74) (26 RCTs, n=4225, level 1)
• Paracetamol equivalent to NSAIDs for pain (3 RCTs, n=450): MD 1.80 (95% CI -1.42 to 5.02), swelling MD -0.07 (95% CI -0.29 to 0.14)
• Functional support versus immobilisation - patient satisfaction: RR 1.83 (95% CI 1.09 to 3.07) favouring functional support; days to return to work: MD 7.80 (95% CI 3.07 to 12.52) faster with functional support (10 RCTs)
• Lace-up or semi-rigid brace superior to elastic bandage (meta-analysis, n=892, level 1)
• Exercise therapy reduces recurrent sprains: RR 0.62 (95% CI 0.51 to 0.76) (10 RCTs, n=1284); effect larger in athletes RR 0.38 (95% CI 0.23 to 0.62) (level 1)
• Exercise therapy reduces objective instability: RR 0.68 (95% CI 0.49 to 0.95) (4 RCTs, level 1)
• Manual mobilisation increases dorsiflexion ROM: MD 5.14 (95% CI 5.01 to 5.26) (5 RCTs) and reduces pain: MD -1.20 (95% CI -1.68 to 0.72) (3 RCTs)
• Surgery versus conservative treatment - complications: RR 5.01 (95% CI 2.33 to 10.77) favouring conservative; recurrent sprains: RR 0.72 (95% CI 0.55 to 0.94) favouring surgery (12 RCTs, n=1437)
• Brace or tape prevents recurrent sprains: RR 0.30 (95% CI 0.21 to 0.43) (6 RCTs, n=2307); prevents first-time sprains: RR 0.69 (95% CI 0.49 to 0.96) (4 RCTs, n=2933)
• Positive single-leg balance test increases LAS risk: RR 2.54 (95% CI 1.02 to 6.03); female sex increases risk RR 1.25 (95% CI 1.17 to 1.34)
• Playing soccer on natural grass versus artificial turf increases LAS risk: RR 0.53 (95% CI 0.48 to 0.59) for artificial turf (protective)

Limitations

• Publication bias likely present as negative or null treatment results are under-reported in the included studies
• Selection bias: most included patients sought medical care, so the natural course without intervention is unknown
• GRADE quality assessment was not feasible due to the large number of included studies; a simpler internal evidence-level system was used instead
• Most preventive exercise therapy trials enrolled already-injured athletes, limiting conclusions about prevention of first-time sprains in uninjured populations

Why it matters

For patients

After a lateral ankle sprain, wearing a brace and starting supervised balance and strengthening exercises as soon as possible gives the best chance of full recovery and reduces the risk of re-injury.

For clinicians

Functional treatment with a semi-rigid brace for 4-6 weeks plus early exercise therapy is first-line; reserve surgery for patients who fail comprehensive rehabilitation, and use NSAIDs cautiously given their potential to delay healing.

For readers

This guideline synthesises 194 studies and provides level 1-2 evidence supporting exercise-based functional rehabilitation over immobilisation or surgery for most lateral ankle sprain patients.