What is the recommended management for a veteran with chronic left ankle sprain and bilateral foot strains?

Management of Chronic Left Ankle Sprain with Bilateral Foot Strains in Veterans

For veterans with chronic left ankle sprain and bilateral foot strains, functional treatment with exercise therapy and functional support is strongly recommended as the primary treatment approach, as this leads to better outcomes than immobilization or surgery for most patients. 1

Initial Assessment and Treatment Approach

• Evaluate the severity of the chronic ankle sprain and bilateral foot strains, checking for signs of mechanical instability, functional instability, and proprioceptive deficits 1
• Rule out fractures using the Ottawa Ankle Rules if there is suspicion of recent injury or worsening symptoms 1
• Begin with functional treatment consisting of a semi-rigid ankle brace for the chronic left ankle sprain and appropriate functional support for the bilateral foot strains 1, 2
• Functional treatment allows for faster return to work (approximately 7.1 days sooner) compared to immobilization approaches 1, 2

Exercise Therapy Protocol

• Implement supervised exercise therapy focusing on proprioception, strength, coordination, and function for both the chronic ankle sprain and bilateral foot strains 1
• Supervised exercises have been proven superior to non-supervised training for chronic ankle instability 1
• Include balance and coordination training, which has shown a protective effect against recurrent ankle sprains (RR 0.62,95% CI 0.51 to 0.76) 1
• Progress exercises from basic to advanced, incorporating:
  • Range-of-motion exercises and isometric/isotonic strength training initially 3
  • Proprioception training exercises in the intermediate stage 3
  • Sport-specific or activity-specific exercises in the advanced stage 3

Functional Support Recommendations

• Use a semi-rigid ankle brace for the chronic left ankle sprain during weight-bearing activities for 3-6 weeks 1, 2
• Semi-rigid braces are more effective than elastic bandages and are the most cost-effective option compared to taping 1, 2
• For bilateral foot strains, appropriate supportive footwear with potential orthotic inserts should be considered, though evidence on specific shoe types is inconclusive 1

Pain Management

• NSAIDs may be used for short-term pain management if not contraindicated 1
• Consider paracetamol as an alternative if NSAIDs are contraindicated, as it appears to be equally effective with potentially fewer side effects 4

Prevention of Recurrence

• Functional support has shown significant effectiveness in preventing recurrent sprains (RR 0.30,95% CI 0.21 to 0.43) 1
• Exercise therapy has demonstrated effectiveness in preventing recurrent sprains (RR 0.62,95% CI 0.51 to 0.76) 1
• Continue proprioceptive and balance training even after acute symptoms resolve to prevent recurrence 3, 5

Surgical Considerations

• Surgery should be considered only if the patient fails to respond to a comprehensive functional rehabilitation program 1, 6
• While surgery shows better outcomes in terms of preventing recurrent sprains (RR 0.72,95% CI 0.55 to 0.94), 60-70% of individuals respond well to non-surgical treatment 1
• If chronic instability persists despite appropriate rehabilitation, anatomic repair (Brostrom-Gould procedure) may be considered 6

Return to Work/Activities Timeline

• For sedentary work: 2-4 weeks 2
• For physically demanding work: 6-8 weeks for severe cases 2
• Return to activities should be guided by functional milestones rather than strict timelines 1

Common Pitfalls to Avoid

• Avoid complete immobilization as it shows no benefits and delays recovery 1, 2
• Do not rely solely on the RICE protocol (Rest, Ice, Compression, Elevation) as there is insufficient evidence for its effectiveness as a standalone treatment 2, 4
• Avoid continuous 24-hour bracing as this may lead to muscle weakness 2
• Do not delay initiation of exercise therapy, as early movement promotes better healing and functional outcomes 1, 3
• Elastic bandages like Tubigrip provide insufficient support and should not be used as the primary functional support 2

Addressing the Relationship Between Conditions

• The bilateral foot strains may be compensatory due to altered biomechanics from the chronic left ankle sprain 7, 8
• Treatment should address both conditions simultaneously, with particular attention to correcting any gait abnormalities that may be contributing to the bilateral foot strains 3, 8
• Proprioceptive training is particularly important as deficits in this area can lead to both ankle instability and compensatory foot issues 3, 5