Everything Ankle: Updated Clinical Practice Guidelines

Thanks for tuning into Ortho Hub! Here goes a run-down from 2 clinical guidelines released this Spring.

Diagnosis, Treatment, and Prevention of Ankle Sprains: Update of an Evidence-Based Clinical Guideline

British Journal of Sports Medicine, March 7th, 2018

Vuurberg Et Al.  The University of Amsterdam

Thanks to the Dutch, we’ve got some updated guidelines for the management of lateral ankle sprains from doing a large meta-analysis from the past couple years. Based on this review, I’ll try and highlight a few of the more clinically relevant factors you can add to your knowledge base and practice.

Some of the most important “intrinsic factors” that could put someone at more risk for having an ankle sprain include limited ankle dorsiflexion ROM, reduced proprioception, and deficiencies in postural control and balance. Consider these modifiable factors with any type of screening you perform. Women, who often have the short end of the stick with regards to higher risk of injury in the orthopedic world, once again appear to sprain their ankles 1.25 times more than men.

The degree to which people experience complication after an ankle sprain at 1-4 years was pretty striking. In some studies, up to 34% of patients had another ankle sprain and up to 55% self-reported ankle instability! It begs us to ask the question if we need to be more robust and thorough with our patient’s treatments prior to discharge? Some predictive factors for chronic ankle instability (CAI) we can look for prior to discharge are the ability to complete jumping and landing within 2 weeks from injury, dynamic postural control, altered hip function, and lack of mechanical stability in the ankle. Perhaps we don’t have that evidence yet, but the numbers for our success in preventing CAI don’t appear to be great. Despite treatment, up to 40% of people will develop CAI at some point following an ankle sprain.

When looking at an ankle sprain, the authors encouraged the utilization of the Ottawa Ankle Rules to rule out ankle fractures (they happen 15% of the time, by the way), which have a sensitivity of 86-99% and specificity of 25-46%. The anterior drawer test is another good test to use to look for rupture of the ATFL with a sensitivity of 84% and specificity of 94%.

Okay, so you want to get your people with ankle sprains better, what’re the latest guidelines? What should you do per the guidelines?

  • Opt away from extensive immobilization. 4-6 weeks of rehab focusing on progressive exercise has better results than 4 weeks of lower leg immobilization. However, <10 days of immobilization can be beneficial for severe cases, provided they aren’t fractured, of course.
  • Get people moving, get people strong! Therapeutic progressive exercise (strengthening and proprioception) has level 1 evidence for treatment and also demonstrates some good protective effect. Manual mobilization also aids with improving ankle dorsiflexion, which we mentioned earlier as a risk factor for an ankle sprain.
  • Ankle braces, available for approx $15 online, and non-elastic ankle taping are both helpful following injury. They also reduce the risk for first-time and recurrent ankle sprains.

The above appears to be what works best, but what does not appear to have any evidence? Some of the following are not as evidence-based for treating ankle sprains:

  • No evidence for any treatment effect for ultrasound, laser therapy, electrotherapy, or shortwave therapy. Evidence for acupuncture is inconclusive and very little evidence for vibration therapy exists. AKA – keep the modalities at home.
  • K-tape did not demonstrate having any effect on ankle stability for treatment, though it may have an effect on postural control for prevention.
  • Platelet-rich plasma injections, hyaluronic acid injections, and topically applied Traumeel was not superior for pain and functional outcomes compared to placebos.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018

Journal of Orthopedic and Sports Physical Therapy, May 2018 Issue

Martin Et Al.  Duquesne University

If you work in any form of orthopedics or sports medicine, it’s inevitable you’ll run into achilles tendinopathy. The annual incidence in runners is between 7-9% and usually strikes people during training, most often in 30-50-year-olds. The injury keeps runners out for 82 days for median recovery time! Tendinopathy in the achilles tendon is caused by excessive mechanical stress such as tensile loading/shearing that can occur during running. This causes some actual physiological changes in our tendons, such as collagen organizational changes and thickening of the tendon, which can lead to less force production and increased stiffness – not good!

Some things that can lead someone to develop achilles tendinopathy include less ankle dorsiflexion and subtalar mobility, less plantar flexion strength, increased foot pronation, and a thickened tendon as seen on ultrasound. Interestingly enough, in a study of over 2,500 soldiers, there was a 50% reduction in achilles tendinopathy in those that wore more shock-absorbing insoles.

When examining someone with possible achilles tendinopathy, look for the report of localized pain and perceived stiffness in the achilles tendon (2-6 cm proximal to insertion is defined as mid portion) following a period of inactivity that lessens with a quick bout of activity, but then once again kicks up afterward.  Other things to look for are achilles tendon tenderness, positive Arc Sign, and positive findings on the Royal London Hospital Test. Don’t forget your outcome measures either, the VISA-A in combination with either the FAAM or the LEFS will give you good data and are validated for this population.

The best evidence we have for treating mid portion achilles tendinopathy are:

  • Mechanical loading of the achilles tendon has grade-A evidence with a wealth of level 1 evidence. This means either eccentric or heavy-load, low-speed exercise done progressively, ala heel raises, calf press. Progressively loading your folks should be your no.1 priority!
  • Conversely, stretching had grade-F evidence, meaning, it is limited to expert opinion only. The lack of evidence there may be a shocker for many who frequently prescribe the slant board for achilles tendinopathy.
  • Complete rest is not recommended for Achilles tendinopathy and you should advise your patients to participate in activity within their pain tolerance. Get em’ moving.
  • Iontophoresis and extracorporeal shockwave therapy appear to have some evidence when combined with a loading program so they can be considered.
  • Laser, dry needling, and taping don’t appear to have too much evidence if any. The promotion of loading and the lack of evidence for these modalities may be beneficial for your supply budget!

Forever Disclaimers:

1): Readers –  If any of these articles peak your interest, please click the link to the original source to read the full text! It’s important to interpret research for yourself and as it pertains to you and your practice. Not to mention, we should support our journals and authors that provide this content.
2): Journals and authors – I do my best job to help promote the message from the research you provide to help clinicians improve. This is not a platform to try and promote my own individual views. I can promise you that I will not always have everything right, so please, if you have any feedback for me or if I misinterpreted anything then let me know!

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