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Am Fam Physician. 2011;83(11):1340-1343

Background: Ankle sprains are a common musculoskeletal injury, causing acute pain and loss of function. They result in 302,000 visits to emergency departments in the United Kingdom annually. Of patients presenting with ankle sprains, 25 percent miss school or work for more than seven days, and long-term risks include a propensity for reinjury and residual deficits. Classic treatment of sprains includes protection, rest, ice, compression, elevation, and sometimes non–weight-bearing with crutches or immobilization with a cast. Meta-analyses have shown that functional treatment, such as early active use of the injured soft tissue, may be more effective for improving recovery from an ankle sprain. Bleakley and colleagues conducted a randomized controlled trial to compare early functional rehabilitation with current treatments for acute ankle sprains.

The Study: Patients 16 to 65 years of age who presented to an emergency department or a sports medicine clinic in Northern Ireland with a grade 1 or 2 ankle sprain that had occurred within the previous six days were eligible for the study. Patients with a grade 3 sprain (complete ligament rupture), a bony ankle injury, multiple injuries, or a contraindication to ice therapy; who did not speak English; who were under the influence of drugs or alcohol; or who had an unclear address for follow-up were excluded. Patients were randomized to an early exercise group or a standard treatment group. At the study onset, both groups were given written instructions for applying ice and compression (two 10-minute ice and compression sessions with 10 minutes of rest in between, done three times a day for the first week after injury). Also in the first week, the exercise group engaged in therapeutic exercises. This group received written and verbal instructions and a DVD that showed how to perform the exercises. Participants turned in a treatment diary at the first of four weekly follow-up visits that included treatment and analgesic use, and was used to assess compliance. External ankle support (i.e., bracing, taping, and bandaging) and analgesics were not routinely provided to either group.

During weeks 1 through 4 after injury, both groups had standardized ankle rehabilitation, which included muscle strengthening, proprioception training, and sports-specific exercises. This rehabilitation was supervised once per week by the research physiotherapist and done four times per week at home without supervision. Outcomes were assessed weekly for the first four weeks after injury and again at 16 weeks. The primary outcome was subjective ankle function (using the Lower Extremity Functional Scale, a self-completed questionnaire). Secondary outcomes included pain at rest and with activity, swelling, physical activity, and reinjury rates.

Results: Between July 2007 and August 2008, the authors randomized 50 participants to each group. From baseline to week 2 of follow-up, patients in the exercise group reported significantly better ankle function. Patients in the exercise group were more active, with increases in time spent walking, step count, and time spent in light physical activities compared with those in standard treatment. There was no difference between groups in the amount of swelling or pain at rest or with activities, and the study was not adequately powered to detect differences in the secondary outcomes. More participants dropped out of the exercise group (11 in the exercise group, four in the standard group). The reinjury rate was low (two injuries in each group). There were no statistically significant differences between groups at the end of 16 weeks for any measure.

Conclusion: The authors conclude that performing active ankle exercises in the first week after a mild to moderate ankle sprain results in improved short-term function.

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