Don't Immobilize Grade I or II Ankle Sprains: Guidelines

July 01, 2013

By Rob Goodier

NEW YORK (Reuters Health) Jul 01 - New guidelines for treating and preventing ankle sprains in athletes call for nonsteroidal anti-inflammatory drugs (NSAIDS) early after the injury, functional rehabilitation rather than immobilization for grade I and II sprains, and prophylactic ankle supports for athletes with a history of previous ankle sprains, among other things.

That advice - all backed by level A or B evidence - appears in guidelines issued by The National Athletic Trainer's Association at its annual conference in Las Vegas June 27.

The guideline panel urges practitioners to put the high-graded procedures into practice.

To prevent injury, athletes, especially those at higher risk, should undergo a three-month or longer balance and neuro-muscular control program, another recommendation with grade A evidence.

Balance training, in which the athlete stands on one foot, stands on soft foam or jumps on one foot on a trampoline, for example, reduces subsequent injuries, a recommendation with grade A evidence.

Other recommendations with level A or B evidence include:

- Special tests such as the anterior drawer and inversion talar tilt tests have more diagnostic accuracy five days after injury than two days after injury (Level B evidence).

- The Ottawa Ankle Rules (OARs) are valid for determining need for x-rays (Level A evidence).

- Magnetic resonance imaging (MRI) reliably detects acute tears of the anterior talofibular ligament and calcaneofibular ligament (Level B evidence). Compared with MRI, diagnostic ultrasound is useful but less accurate and sensitive (Level B evidence).

- Arthrography and tenography are also less accurate than MRI and CT, especially when performed 48 hours after lateral ligamentous injury (Level B evidence).

- After acute trauma, MRI is highly sensitive, specific and accurate for determining the level of injury to the ankle syndesmotic ligaments (Level B evidence).

- Grade III sprains should be immobilized for at least 10 days with a rigid stirrup brace or below-knee cast and then controlled therapeutic exercise instituted (Level B evidence).

-Rehabilitation should include comprehensive range-of-motion, flexibility, and strengthening of the surrounding musculature (Level B evidence).

-Balance training should be performed throughout rehabilitation and follow-up management of ankle sprains to reduce reinjury rates (Level A evidence).

- Before the patient returns to sport-specific tasks, the injured limb's functional performance should measure at least 80% of the uninjured limb (Level B evidence).

"This provides the most comprehensive collection of evidence available," Dr. Phillip Gribble, director of the Athletic Training Research Laboratory at the University of Toledo in Ohio, told Reuters Health by phone.

"What this paper will do for clinicians is give them some solid guidelines on how to manage what is actually the most common injury in all sports. The ankle injuries are a lot more prevalent and more of a healthcare burden than what people think," Dr. Gribble said. He was not involved in writing the guidelines, but he moderated the session at the NATA conference in which the guidelines were presented]

The high frequency of ankle sprains - and advances in treatment over the last two decades - have prompted these guidelines, said Dr. Thomas Kaminski, director of athletic training education at the University of Delaware in Newark, Delaware, who headed the guidelines task force.

"It's amazing how much better we are at treatment, especially prevention," Dr. Kaminski said.

The guidelines are available in their entirety at


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