But the orthopedic surgeons on duty in the emergency department always encounter some unlucky people with ankle sprains, which are almost the most common orthopedic emergency cases, accounting for about 25% of the skeletal muscular system injuries, the vast majority of which are lateral ligament injuries.
RICE principles
The RICE principle has become a classic for the emergency management of ankle sprains.
Rest (rest): Stop walking and let the injured part rest to reduce further damage;
Ice: lower the temperature of the injured area, reduce the inflammatory response and muscle spasm, relieve pain and inhibit swelling. Each time 10-20 minutes, more than 3 times a day, be careful not to apply ice directly to the affected area, can be wrapped in a wet towel ice to avoid frostbite. Ice should only be applied within 48 hours of the injury.
Compression: Wrap the injured ankle joint with an elastic bandage and apply appropriate pressure to reduce swelling. Be careful not to apply excessive pressure, as this may increase the swelling and ischemia of the limb far from the wrap.
Elevation: Elevate the limb above the heart position to increase venous and lymphatic return, reduce swelling and promote recovery.
But is the RICE principle enough for ankle sprains? Which patients need immobilization? Which patients need surgery? Obviously, RICE is only a principle for the emergency management of ankle sprains (within 24-48 hours), but what is the subsequent management?
Grading of ankle sprains
Ankle sprains are usually graded into 3 levels depending on the severity of the injury.
Grade 1: There is stretching of the ligaments, only microscopic damage to the ligament fibers and mild pain. Weight bearing is possible as long as it is tolerated; splinting is not required; isometric contraction exercises are feasible; full range of joint mobility exercises and muscle strength training can be performed if tolerated.
Grade 2: Partial rupture of ligament fibers, moderate pain and swelling, limited mobility, and possible joint instability. Immobilization with splinting or bracing, physical therapy, and muscle and joint mobility exercises are required.
Grade 3: Complete ligament rupture with significant swelling and pain and joint instability. Braking and rehabilitation are the same as grade 2, but the rehabilitation time is longer and in a few cases surgery is required.
Non-surgical treatment
POLICE principles
In 2012, the British Journal of Sports Medicine recommended replacing the current RICE principles of ankle injury treatment with POLICE: Protect, Optimal loading, Ice, Compression, Elevation, which places a strong emphasis on early activity.
It has been suggested that for grade 1 and 2 ankle sprains, joint mobility exercises and gradual weight bearing after a few days can lead to a faster recovery. In grade 3 ankle sprains (complete ligament tears), evidence supports early braking within 10 days of injury and initiation of ankle motion thereafter. Of course, many scholars still support 2-3 weeks of braking in patients with grade 3 injuries.
General recommendations
Phase 1, 1 week RICE principles of rest, protection of the ankle joint, and reduction of swelling;
Phase 2, weeks 2-3, gradually restore joint mobility, strength and flexibility;
Phase 3, over the next few weeks to months, gradually start to resume sports, starting with sports that do not require twisting of the ankle, and eventually return to sports.
Medication
The available evidence recommends only NSAIDs to control the pain and inflammatory response. It is worth mentioning that there is no clear evidence to support all external medications and manipulative rubbing for revision.
Surgical treatment
Only a very small number of patients with grade 3 injuries require surgical treatment after failure through several months of systematic non-surgical treatment. These patients are typically those with severe injuries, significant instability, and high motor demands.
Ankle instability usually presents with a positive anterior drawer test as well as a positive talar tilt test, which can also be seen on orthogonal inversion stress films of the ankle, and MRI can be helpful in determining ligament tears.
Anterior drawer test
Talar tilt test
Performed at a later stage of the examination, it is more useful to determine the stability of the ankle joint.
Surgical approach can be considered arthroscopic or open reconstruction to repair the ligamentous structures.