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External support and early mobilisation works best for mild or moderate ankle sprains

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7572.0-e (Published 12 October 2006) Cite this as: BMJ 2006;333:0-e

Research question What is the best method of treating first time ankle sprains?

Answer External support with a combination of an elastic wrap and a stirrup brace and early mobilisation are best for moderately severe injuries.

Why did the authors do the study? There is still debate about the best way to treat ankle sprains of differing severity. External support coupled with controlled, early mobilisation probably works best for mild injuries, but which kind of support? These authors also wanted find out whether a cast works better than support and early mobilisation for people with moderate or severe sprains.

What did they do? Two hundred and twelve young adults who had sprained their ankle for the first time took part in a randomised controlled trial. Doctors at a sports medicine clinic classified their injuries as grade I (partial tear of the lateral ligament complex), II (partial disruption with some loss of function), or III (complete disruption of the ligament complex with instability, severe pain, swelling, and total loss of function).

Participants with grade I injuries were treated with a stirrup brace, an elastic wrap, or both. Those with grade II injuries were treated with a stirrup brace, an elastic wrap, both, or a fibreglass walking cast worn for 10 days followed by the elastic wrap. Those with grade III injuries had either the stirrup brace or the walking cast followed by an elastic wrap. All participants followed the same rehabilitation programme for at least three weeks and completed a daily log of their pain and functional ability. The authors made a final assessment of the movement and function of participants' ankles six months after randomisation, and used intention to treat analysis to compare treatments for the three grades of ankle injury.

What did they find? Combined treatment with a brace and an elastic wrap worked best for grade I injuries, reducing by about half the time it took for participants to walk and climb stairs normally compared with either treatment alone (for walking, >4.6 days v 10.3 days with brace alone and 11.2 with wrap alone, P < 0.05 for both comparisons).

For patients with grade II injuries, any kind of functional treatment (brace, elastic wrap, or both) worked significantly better than an immobilising cast. The combination of wrap and brace, for example, cut the time it took to return to normal walking and climbing stairs by about 60% compared with a cast (10 days v 24 days, P = 0.0001). Patients with grade III injuries did equally well after treatment with a brace or a cast followed by an elastic wrap: they were all walking and climbing stairs normally by 18-21 days after randomisation.

After six months, there were no differences in ankle function or movement between any of the treatment groups for any severity of ankle injury.

What does it mean? Patients with moderately severe injuries of the ankle lateral ligaments get better faster if they are treated with external support and early mobilisation rather than a cast. The best support seems to be a combination of an elastic wrap and a stirrup brace, at least for people with grade I injuries. In this trial, severe injuries responded equally well to functional treatment or immobilisation in a cast for 10 days, but the authors failed to recruit enough severely injured patients to be sure of this result.

Acknowledgments

Beynnon et al. A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. Am J Sports Med 2006;34: 1401-12

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