What is the recommended treatment for chronic ankle sprain?

Treatment of Chronic Ankle Sprain

Exercise therapy is the most effective treatment for chronic ankle sprain, particularly supervised exercises focusing on proprioception, strength, coordination, and function to prevent recurrent sprains and restore stability. 1, 2

Initial Assessment

• Evaluate for severity of chronic instability using:
  • Anterior drawer test (detects excessive anterior displacement of talus)
  • Varus stress test
  • Assessment for swelling, hematoma, and pain on palpation
  • Evaluate for subtalar instability (often overlooked) 3

Treatment Algorithm

Step 1: Functional Support

• Use semi-rigid ankle brace or lace-up support rather than tape or elastic bandages 1, 2
  • Provides better functional outcomes
  • Facilitates faster return to activities
  • Decreases risk of recurrent injury, especially in patients with history of recurrent sprains

Step 2: Exercise Therapy (Core Treatment)

• Implement supervised exercise program focusing on:
  • Proprioception training: Balance exercises progressing from stable to unstable surfaces, single-leg stance with eyes open then closed, ankle disk or balance board exercises 1, 2
  • Strength training: Resistance band exercises in all directions, heel raises (progressing from bilateral to unilateral) 2
  • Range of motion exercises: Ankle circles, alphabet drawing with toes, towel stretches for dorsiflexion 2
  • Neuromuscular control exercises: Sport-specific movements without pain or instability 2

Step 3: Pain Management

• NSAIDs (oral or topical) for short-term pain relief
• Paracetamol (acetaminophen) as an alternative with fewer side effects 2

Step 4: Return to Activity Planning

• Implement graded return to work/sports schedule based on:
  • Pain-free walking
  • Full range of motion
  • Restored strength
  • Ability to perform sport-specific movements without pain or instability 1, 2

Timeline for Return to Work/Sports

For chronic cases with partial or total ligament rupture 1:

• 3-6 weeks: Limited work (mostly sitting, <10kg lifting, limited standing/walking on uneven surfaces)
• 6-8 weeks: Return to full work depending on task requirements and physiotherapy results

Special Considerations

For Persistent Instability

If conservative treatment fails after 4-6 months of appropriate management:

• Consider surgical intervention, especially for:
  • Grade III sprains with significant instability
  • Professional athletes requiring quicker recovery 2
• Surgical options include:
  • Anatomical repair
  • Tendon augmentation
  • Arthroscopic intervention 1, 3

Prevention of Recurrence

• Continue proprioceptive training long-term
• Consider semi-rigid or lace-up ankle supports during high-risk activities 1, 2
• Exercise therapy has been shown to reduce risk of recurrent sprains (RR 0.62,95% CI 0.51 to 0.76) 1
• Effect is even greater in athletes (RR 0.38,95% CI 0.23 to 0.62) 1

Common Pitfalls to Avoid

1. Inadequate rehabilitation: 20% of acute ankle sprains develop chronic instability without proper rehabilitation 2
2. Overlooking subtalar instability: Often bypassed during assessment of chronic ankle instability 3
3. Premature return to full activity: Can lead to recurrent sprains and worsening instability
4. Relying solely on passive treatments: Active exercise therapy is essential for recovery
5. Neglecting proprioceptive training: Critical for preventing recurrent sprains 1, 2

By implementing this comprehensive approach focused on exercise therapy and functional support, most patients with chronic ankle sprains can achieve significant improvement in stability, function, and prevention of recurrent injuries.