What is the preferred initial treatment option between a walking boot and a posterior short leg splint for ankle injuries?

Walking Boot vs. Posterior Short Leg Splint for Ankle Injuries

A walking boot is the preferred initial treatment option over a posterior short leg splint for ankle injuries due to better functional outcomes and prevention of future ankle sprains. 1

Evidence-Based Comparison

Functional Support vs. Immobilization

• The British Journal of Sports Medicine guidelines strongly recommend functional support over immobilization for ankle injuries 1
• Functional treatment leads to:
  • Faster resumption of work and daily activities
  • Better long-term outcomes
  • Lower risk of recurrent sprains

Walking Boot Benefits

• Provides better functional outcomes than immobilization or compression wraps 2
• Allows for early weight-bearing while protecting the injured ankle
• Can be made non-removable if needed for better compliance
• Semi-rigid braces are more cost-effective than taping 1

Posterior Splint Limitations

• Complete immobilization can lead to:
  • Delayed recovery
  • Muscle atrophy
  • Prolonged rehabilitation time
• Higher risk of reduction loss (25% vs 4%) compared to more stable fixation methods 3
• Higher risk of skin complications (22% vs 6%) 3

Treatment Algorithm for Ankle Injuries

1. Initial Assessment:

   • Rule out fractures using Ottawa Ankle Rules 1
   • Assess severity of ligament damage through physical examination
   • Grade the sprain (I-III) based on swelling, hematoma, pain on palpation, and anterior drawer test

2. For Mild to Moderate Sprains (Grade I-II):

   • First choice: Walking boot or ankle brace
   • Allow for early weight-bearing as tolerated
   • Begin exercise therapy as soon as possible 1

3. For Severe Sprains (Grade III):

   • First choice: Walking boot (can be made non-removable for better compliance)
   • Consider short period (<10 days) of more rigid immobilization if pain and swelling are severe 1
   • Transition to functional support with exercise therapy

4. Follow-up Care:

   • Re-evaluate after 3-5 days to distinguish partial tears from frank ligament ruptures 1
   • Begin progressive exercise therapy to prevent recurrent sprains
   • Transition to less restrictive support as healing progresses

Important Clinical Considerations

• Patient Education: Explain the benefits of functional treatment over immobilization to improve compliance 1
• Pain Management: NSAIDs have been shown to improve pain control, decrease swelling, and allow quicker return to activity 1
• Early Mobilization: Exercise therapy should begin as soon as possible to recover joint functionality 1
• Prevention: Both functional support and exercise therapy help prevent recurrent sprains, with bracing being particularly effective 1

Potential Pitfalls to Avoid

• Prolonged Immobilization: Avoid immobilization beyond 10 days as it leads to worse outcomes compared to functional support 1
• Inadequate Pain Control: Insufficient pain management can delay rehabilitation and functional recovery
• Neglecting Exercise Therapy: Exercise is crucial for preventing recurrent sprains and should be incorporated early 1
• Heel Pressure: When using posterior splints, ensure the heel is suspended to prevent pressure ulcers 4

By following this evidence-based approach, patients with ankle injuries will experience better functional outcomes, faster return to activities, and reduced risk of recurrent sprains with a walking boot compared to a posterior short leg splint.