What is the current best evidence-based treatment plan for a contusion below the medial malleolus and a distorted ankle joint with a sprained deltoid ligament, using physical therapy and physical medicine and rehabilitation (Physical Medicine and Rehabilitation, PM&R) protocols?

From the Guidelines

The evidence-based treatment plan for a medial malleolus contusion and ankle sprain with deltoid ligament involvement should prioritize functional treatment over immobilization, as it has been shown to be superior in terms of return to sports and work, as well as reducing the risk of recurrent sprains and chronic ankle instability 1.

Initial Treatment

The treatment plan should start with the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for 48-72 hours post-injury, as recommended by the British Journal of Sports Medicine guideline 1. This includes applying ice for 15-20 minutes every 2-3 hours, using a compression bandage, and elevating the ankle above heart level. Pain management should include NSAIDs such as ibuprofen (400-600mg three times daily with food) or naproxen (500mg twice daily) for 5-7 days.

Rehabilitation Phase

After the acute phase, the focus should shift to gentle range of motion exercises and progressive strengthening exercises. This may include ankle circles, toe curls, and ankle pumps, advancing to resistance band exercises in all directions (10-15 repetitions, 2-3 sets) 1. Balance training is crucial and should include single-leg stance exercises, progressing to unstable surfaces like balance pads. Proprioceptive training using wobble boards or BAPS boards helps restore neuromuscular control.

Support and Progressive Weight-Bearing

A functional ankle brace or taping provides support during the rehabilitation phase and when returning to activities. Progressive weight-bearing should be implemented as tolerated, with full weight-bearing typically achieved within 1-2 weeks depending on injury severity. Gait training with appropriate assistive devices (crutches initially, then transitioning to normal gait) is essential.

Return to Activity

Return to sport or full activity should follow functional testing demonstrating symmetrical strength, balance, and agility. This comprehensive approach addresses both the contusion and ligament sprain by controlling inflammation, restoring mobility and strength, and reestablishing proprioception and functional stability, as supported by the evidence-based clinical guideline update 1.

Key considerations include:

• Early mobilization and exercise to prevent chronic ankle instability 1
• Addressing prognostic factors such as pain, workload, and sports participation to reduce the risk of future injury recurrence 1
• The use of tape or a brace in combination with an exercise program for optimal recovery 1

From the Research

Diagnosis and Assessment

• The diagnosis of a contusion below the medial malleolus and a distorted ankle joint with a sprained deltoid ligament requires a comprehensive clinical assessment, including conventional radiological and MR imaging 2.
• The Lauge-Hansen classification system can be helpful in predicting the involvement of the deltoid ligament, but its reliability in terms of sensitivity and specificity is unknown 3.
• Various diagnostic methods, such as clinical examination, stress radiography, magnetic resonance imaging, arthroscopy, and ultrasonography, have been used to investigate medial collateral integrity in cases of ankle fractures, but none have shown to possess the combination of being cost-effective, reliable, and easy to use 3.

Treatment Options

• The treatment of a sprained deltoid ligament in combination with a lateral malleolar fracture is debated, with some studies suggesting that open reduction and internal fixation is the best treatment option 4, 3.
• The use of gravity stress radiography is currently favored for assessing medial collateral integrity, and arthroscopy may be of value in cases of doubt 3.
• There is no evidence found for suturing the deltoid ligament in cases of an acute rupture in combination with a lateral malleolar fracture, but exploration is thought to be beneficial in case of interposition of medial structures 3.

Rehabilitation and Physical Therapy

• The rehabilitation exercise for a patient with a trimalleolar fracture accompanying ankle dislocation and a sprained deltoid ligament should be carefully planned to avoid further injury or complications 4.
• The patient may experience medial arthralgia in the affected ankle during rehabilitation, which should be addressed through appropriate physical therapy and pain management strategies 4.
• The competence of the deltoid ligament in patients with a bimalleolar ankle fracture can be evaluated through radiographs made with application of an external rotation load to the joint, and restoration of the competence of the deltoid ligament is crucial for ankle stability 5.

Physical Medicine and Rehabilitation (PM&R) Protocols

• The medial malleolar osteoligamentous complex (MMOLC) plays a crucial role in ankle stability, and its injury can lead to ankle fractures 6.
• The treatment of MMOLC injuries requires a comprehensive approach, including surgical and nonsurgical options, and various presentations of medial sided injuries in ankle fractures should be considered 6.
• Current recommendations for fixation of MMOLC injuries emphasize the importance of restoring ankle stability and promoting optimal healing 6.