Too many choices: Ankle sprain treatment - ace wrap, brace, or boot?

Clinical Scenario:
A 22 year old was running in the park when she accidentally rolls her ankle on the uneven ground.  There is significant swelling over the lateral malleolus that is tender to palpation.  She is unable to bear weight on her ankle so you obtain x-rays, which are normal.  As you are about to send her home, you debate what is the best treatment for her ankle.

Clinical Question:
In a severe ankle sprain, what is the preferred treatment – ace wrap, aircast brace, or air walker boot?

Literature Review:
Grade I injury is a mild stretching of the ligament without joint instability, Grade II injury is a partial rupture of the ligament with mild instability, Grade III is a complete rupture of the ligament with joint instability.   Generally grade II or III are considered severe sprains.

A study released in the Lancet in 2009 compared 584 participants with severe sprains who received a below-knee cast for 10 days, ace wrap, aircast brace, or an air walker boot.  The patients were followed up at 3 months and assessed for quality of ankle function, pain, symptoms, and activity.  The superior method of treatment was the 10 day below-knee cast (when compared to the ace wrap) for overall quality of ankle function (mean difference 9%; 95% CI 2.4-15.0).  The aircast brace was also found to improve quality of ankle function compared to ace wrap and air walker boot, but was not superior with regard to pain, symptom, or activity.  The air walker boot was not superior to the ace wrap.  Another study from 2005 compared ace wraps to the aircast brace for lateral ankle sprains and also found that the aircast ankle brace was superior to an ace wrap at 10 days and one month. In a systematic review published in Sports Med in 2011, they too concluded the superiority of an ankle brace over an ace wrap with regard to functional outcome.

The British Medical Bulletin in a systematic review concluded that for mild to moderate ankle sprains, functional treatment options (ace wrap, aircast brace) where found to be statistically better than immobilization.  For severe ankle sprains, a short period of immobilization in a below-knee cast resulted in a quicker recovery than other functional treatments

Take home points:

-The most practical approach is to offer an aircast brace, which has been shown to offer better functional outcome compared to ace wrap and air walker boot.
-In severe ankle sprains, short below-knee cast immobilization resulted in the best functional outcome

References:

1. Boyce SH, Quigley MA, Campbell S. Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med. 2005 Feb;39(2):91-6.

2. Lamb SE, Marsh JL, Hutton JL, Nakash R, Cooke MW; Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Lancet. 2009 Feb 14;373(9663):575-81.

3. Kemler E, van de Port I, Backx F, van Dijk CN. A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med. 2011 Mar 1;41(3):185-97.

4. Seah R, Mani-Babu S. Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-35.

Images from: www.1staidsupplies.com, www.betterbraces.com, orthotape.com.

Submitted by Lydia Luangruangrong, PGY-3.

Edited by  Steven Hung (@DocHungER), PGY-2

Faculty reviewed by Chris Brooks