Interview: Lateral Ankle Sprains + CAI with Dr. Todd Davenport
Here I’ll be summarizing findings from interviews with experts through our podcast, JOSPT Insights, available on Spotify or wherever you listen to podcasts.
So the last time we had a clinical update on lateral ankle sprains was 2013. This week, we sat down with Dr. Todd Davenport to discuss his work on the latest clinical practice guideline for management of lateral ankle sprains and chronic ankle instability.
In this CPG, the authors not only looked at management but also looked at prevention and how we, as movement specialists, can help our patients not only rehabilitate their injuries but help prevent them in the future. Furthermore, how do we help athletes prevent ankle sprains to begin with?
So what are the recommendations for primary prevention?
Prevention:
First off - prophylactic bracing and taping to reduce the first ankle sprain is actually effective. Exercise and shoewear currently inconclusive (evidence exists on both sides.) This is a big change. In the 2013 edition, there was only evidence to demonstrate the efficacy of prophylactic bracing for secondary prevention, not primary. Currently, no evidence tells us whether bracing is better or worse than taping, but bracing is certainly easier for the patient as opposed to taping.
-Risk factors for lateral ankle sprain that may push you to recommend someone wear a brace prophylactically:
Low (that’s right, low, not high) BMI.
The older an athlete is if they are playing basketball or American football (age 15-40, each 5 year interval increased the odds ratio by 1.5 for LAS.) Age was not a factor for soccer (sorry Euros) players :)
College athletes with navicular-medial-malleolus distance >4.65cms were >4x more likely to sprain their ankle
Soldiers with a Beighton hypermobility scorre >4
Asymetric dorsiflexion range >2.5cms as measured by weightbearing lunge test was predictive in firefighters and inconclusive in collegiate athletes. I interpret this as highly trained athletes may be able to overcome and account for asymmetric dorsiflexion, however, your weekend warrior types, or those who may have spurts of being very active (firefighters) interspersed with long periods of inactivity, may be less able to compensate for asymmetric ROM. Just my interpretation, not the CPG’s.
Hip abductor strength <33% of bodyweight in male soccer players.
Decreased hip extensor strength in youth soccer players.
Poor or decreased performance on single leg balance tests such as STAR excursion balance test, or hopping tests (e.g. >15.4” on a 10 repetition over 30cm distance.)
If they play court sports as opposed to field sports. However, anyone who engages in a lot of cutting/pivoting etc. will likely benefit from prophylactic bracing.
Being female, sorry ladies :/
Secondary Prevention:
If they have had a first sprain already, bracing has been shown to help prevent the second.
Here, neuromuscular reeduction and therapeutic exercise that is focused on balance and proprioception has more evidence.
Exam: Make sure it’s actually a lateral ankle sprain and not something else.
Remember your ottowa ankle rules and apply accordingly.
Anterior impingement can delay healing and prolong rehabilitation
Make sure you look at pain with dorsiflexion and range of dorsiflexion and treat accordingly, lacking that dorsiflexion is going to not only leave them more prone to LAS in the future but without good tibial progresison they’re going to have to rely on transverse motion to GET that forward movement, essentially recreating (on a micro level) that injury pattern.
Knee to wall dorsiflexion measurement (composite measurement of the talo-crural, mid and rearfoot ROM that is all involved in pronation.)
Dynamic postural control….STAR excursion balance test, hopping (if appropriate based on pain etc.)
Exam modifications / considerations for Chronic Ankle Instability:
You need to ascertain whether this is a structural/mechanical instability issue (e.g. + lateral tilt test, talar inversion/inversion motion) or is this more of a dynamic/proprioceptive impairment using tests such as single limb balance tests and hop tests.
Cumberland Ankle Instability tool can be used to help differentiate between patients with and without CAI (as well as a few others included in the CPG.)
The FABQ (while not exactly validated for the foot/ankle) may also be helpful in understanding any potential fear/threat related issues related to their pain.
Evidence exists for electromyographic changes up the ‘kinetic chain’ even to contralateral hip in those with CAI. Train the entire lower extremity, not just the ankle.
Treatment:
Avoid rest. We should know this but seriously, get them moving sooner rather than later. If they must be immobilized such in the case of a grade 3 strain, keep it under 10 days.
Therapeutic exercise/neuromuscular reeducation is great, make sure you’re focusing on balance/proprioceptive training programs. The literature is mixed on whether supervision is absolutely necessary. As always, it probably depends on the patient in front of you…their self-efficacy, motivation, level of independence etc.
Manual therapy is encouraged in those with acute lateral ankle sprains….e.g. lymphatic drainage to address swelling, low velocity mobilizations to help regain mobility/range of motion.
Cryotherapy lost big time. Evidence is showing it may actually be harmful by reducing nerve conduction velocity. If patient’s really like it, sure, it’s probably not a big deal to ice a little here and there but it shouldn’t be a staple recommendation as it has been in the past.
All of the above applies to CAI as well. Make sure they have dorsiflexion ROM, strengthen, focus on balance/proprioception and tailor your program towards their specific goals.
Some evidence for trigger point dry needling, especially the fibularis muscle group. However, this was performed in conjunction with therapeutic exericse so take that as you will. If you needle, great - make sure they exercise too.
The Wrap Up:
The CPG is not a cookbook. The patient in front of you is most important. This CPG will get you most of the way for your average bell curve patient and help make sure you’re not missing anything important in your plan of care. It’s not a script. Get to know your patient and have fun.
