The guidelines for Ankle Sprain have been established by the New York State Workers Compensation Board to assist physicians, podiatrists, and other healthcare professionals in delivering suitable treatment.
These guidelines are designed to serve as a valuable resource for healthcare professionals, aiding them in making informed decisions about the appropriate level of care for patients with ankle and foot disorders.
It’s crucial to emphasize that these guidelines are not a replacement for clinical judgment or professional experience. The ultimate decision regarding care should be a collaborative one between the patient and their healthcare provider.
Ankle Sprain
Ankle injuries are common and often necessitate urgent care. In an ankle sprain, one or more ligaments within any of the three ligament groups might be torn. The majority of ankle sprains involve only the lateral ligaments, while about 15% of injuries affect the medial ankle.
The natural course of recovery for a lateral ankle sprain is typically swift. However, between 10% and 20% of acute ankle sprain patients may develop persistent ankle instability.
To determine the severity of lateral ankle sprains based on physical examination results, classification methods are used to specify the level of ligament damage:
– Sprain: A ligament injury that isn’t always permanent.
– Grade I: Overstretching or slight tearing without instability.
– Grade II: Incomplete tearing.
– Grade III: Complete tear or rupture.
It’s crucial to consider red signs, including the possibility of a fracture, in the assessment of ankle injuries.
Diagnostic Studies for Ankle Sprain in workers compensation patients
Checking ligament rupture with routine stress X-rays in acute ankle sprains is not recommended, especially for severe tears.
Similarly, using regular stress X-rays for evaluating ligament rupture in chronic or subacute ankle sprains is not advised, particularly for assessing ongoing ankle pain.
Here’s why: X-rays are not needed to diagnose an acute ankle sprain because they aren’t effective in detecting soft tissue injuries. Instead, plain film X-rays are better suited to check for ankle or foot fractures, assessing factors like the direction of fracture planes and the extent of articular surface involvement. If there’s a strong suspicion of a foot or ankle fracture, X-rays are recommended.
For the evaluation of subacute or chronic ankle sprains, CT scans are recommended for specific cases. These include patients not improving after non-operative treatment, experiencing chronic discomfort with weight-bearing even after four to six weeks of therapy, or dealing with a persistent sense of instability. Signs such as crepitus, catching, ankle injuries, or locking may indicate a displaced chondral bone fragment and warrant a CT scan.
However, when it comes to acute ankle sprains, using CT for assessment is not recommended.
Magnetic Resonance Arthrography (MRA) is not suggested for evaluating subacute or chronic ankle sprains.
Similarly, MRA is not recommended for assessing acute ankle sprains.
However, Magnetic Resonance Imaging (MRI) is recommended for evaluating specific patients with acute or recurring ankle sprains. This includes individuals who don’t improve after non-operative treatment, experience chronic discomfort with weight-bearing even after four to six weeks of therapy, or have a persistent sense of instability. Signs like crepitus, catching, ankle injuries, or locking may suggest a displaced chondral bone fragment.
The reason for this recommendation is to assess ligament and osteochondral damage caused by fractures, ankle sprains, lesions of the talus, and other soft tissue injuries like impingement.
But, when it comes to assessing acute ankle sprains, MRI is not recommended.
Bone scans are recommended for assessing acute ankle sprains in specific cases where there is suspicion of a stress fracture, infection, or malignancy.
However, bone scans are not advised for patients with subacute or chronic ankle sprains.
Similarly, ultrasound is not recommended for diagnosing chronic or subacute ankle sprains.
On the other hand, electrodiagnostic studies of the peroneal nerve are recommended for select patients with recurrent or recalcitrant lateral sprains. This is especially crucial to rule out peroneal neuropathy in patients with clear inversion damage due to lateral sprains.
Medications for Ankle Sprain
Ibuprofen, naproxen, or other earlier-generation NSAIDs are recommended as the primary treatments for most patients experiencing ankle pain. In cases where NSAIDs are not suitable, acetaminophen (or its analog, paracetamol) can be a viable alternative, even though research suggests it is slightly less effective than NSAIDs.
There is evidence supporting the use of NSAIDs as both safer and as effective as opioids, such as tramadol, for pain relief.
Acetaminophen is recommended for the treatment of acute, subacute, or chronic ankle pain, especially for individuals who should avoid NSAIDs.
- Indications: Suitable for acute, subacute, chronic, and postoperative cases of foot/ankle pain.
- Dose/Frequency: Adhere to the manufacturer’s guidelines; use as needed. Caution is advised with doses exceeding 4 g/day due to demonstrated hepatic toxicity.
- Indications for Discontinuation: Discontinue in case of pain relief, adverse effects, or intolerance.
NSAIDs are recommended for the treatment of ankle sprain pain, whether it’s severe, mild, chronic, or post-surgery.
- Indications: Advisable for ankle sprain pain treatment, with over-the-counter (OTC) options being the first choice.
- Frequency/Duration: Use as needed may be appropriate for many patients.
- Indications for Discontinuation: Discontinue when ankle/foot discomfort is resolved, effectiveness is lacking, or adverse effects emerge and necessitate discontinuation.
NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding are recommended, and it’s advisable to simultaneously administer cytoprotective medications such as histamine Type 2 receptor blockers, sucralfate, misoprostol, and proton pump inhibitors. This is particularly crucial for individuals at high risk of gastrointestinal bleeding.
- Indications: Cytoprotective drugs should be considered for patients with a high-risk profile who also require NSAIDs, especially for extended treatment periods. Those with a history of gastrointestinal bleeding, the elderly, diabetics, and smokers are particularly at risk.
- Frequency/Dose/Duration: Usage of misoprostol, proton pump inhibitors, sucralfate, and H2 blockers is recommended, following the manufacturer’s dosage guidelines. Effectiveness in preventing gastrointestinal bleeding may vary.
- Indications for Discontinuation: Discontinue in case of intolerance, the emergence of side effects, or cessation of NSAIDs.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects are recommended, with aspirin or acetaminophen considered the least harmful initial treatment options for cardiovascular concerns. Non-selective NSAIDs are preferred over COX-2-specific medications when administering low-dose aspirin to prevent primary or secondary cardiovascular disease, ensuring the NSAID is taken at least 30 minutes after or eight hours before aspirin.
Opioids for Select Acute or Postoperative Ankle Sprain are recommended for a maximum of one week, specifically for patients with extreme discomfort related to acute ankle sprain or postoperative pain. For those who have undergone surgery to restore ankle ligaments or have surgical complications, the duration may extend beyond one week.
- Indication: Judicious use for acute ankle sprain-related extreme discomfort or post-surgical pain control when NSAIDs are insufficient.
- Frequency/Dose/Duration: Follow the manufacturer’s recommendations for frequency and dosage, usually taken on a scheduled or as-needed basis for short, few-day courses.
- Indications for Discontinuation: Discontinue when pain resolves, adequate pain management is achieved with other treatments like NSAIDs, intolerance arises, negative side effects occur, benefits are lacking, or no progress is made after a few weeks.
- Rationale for Recommendation: Opioids should be sparingly used since most ankle sprains don’t cause enough pain to warrant their use. Nighttime opioid use is primarily for postoperative patients seeking rest after surgery when NSAIDs may be ineffective.
Lidocaine Patches for Acute, Subacute, or Chronic Ankle Sprain are not recommended for treating acute, subacute, or chronic conditions of a sprained ankle.
Topical NSAIDs for Acute Ankle Sprain are recommended for prompt relief.
- Indications: Suitable for individuals with recent ankle sprains or those who prefer not to take oral medications. No evidence supports the superiority of one topical NSAID over another.
- Frequency/Duration: Use as directed by the manufacturer, typically reported for one to three weeks.
- Indications for Discontinuation: Cease usage in case of problem-solving, intolerance, negative impacts, or lack of benefits.
- Rationale for Recommendation: Topical NSAIDs are applied directly to the affected area, providing localized and superficial relief for musculoskeletal conditions, including ankle sprains.
Topical NSAIDs for Subacute or Chronic Ankle Sprain are not recommended for treating chronic or subacute ankle sprains.
Treatments for Ankle Sprain
Immediate Non-weight Bearing (Rest) for Acute Ankle Sprain is recommended as the initial approach for individuals who cannot bear weight.
- Indications: Suitable for acute ankle sprains of varying severity, particularly for patients unable to bear their own weight. The recommended duration is up to 48 hours, with the flexibility to adjust based on tolerance and weight-bearing capacity. Early activation is encouraged.
- Frequency/Duration: Complete non-weight bearing for up to 48 hours, followed by a gradual increase in weight-bearing as tolerated. Early mobilization, including therapeutic exercises at home, is advisable.
- Indications for Discontinuation: Discontinue when the patient is willing and able to tolerate weight on the affected ankle.
Cryotherapy for Acute Ankle Sprain is recommended for prompt treatment.
- Frequency/Duration: Apply for 10 to 20 minutes every two hours, as needed, for up to three days. Discontinue in case of resolution or unfavorable outcomes, or if the patient is non-compliant.
Cryotherapy / Heat for Ankle Sprain
Heat for Acute Ankle Sprain
Heat for Acute Ankle Sprain is not recommended to treat severe ankle pain
Immobilization for Ankle Sprain
Ankle Brace (Orthosis) for Acute Ankle Sprain is recommended for the treatment of severe ankle sprains and can be optionally used for mild and moderate pain based on patient preference.
- Walking Boot for Acute Ankle Sprain: Not recommended for the treatment of acute ankle sprains.
- Walking Boot for Select Cases of Severe Ankle Sprain: Recommended for some severe ankle sprain patients.
- Early Mobilization for Acute Ankle Sprain: Recommended for acute ankle sprains without fractures. Severe sprains should not undergo more than three weeks of immobilization; splints are sufficient for immobilization. Mild or moderate ankle sprains should avoid immobilization.
- Indications: Acute ankle sprains; severe sprains limited to three weeks of immobilization; mild or moderate sprains without immobilization.
- Rationale for Recommendations: Early mobilization is preferred over immobilization for most patients.
- Immobilization for Acute Mild to Moderate Ankle Sprain: Not recommended. Splints are effective for mild to moderate ankle injuries.
- Rationale for Recommendation: Casting is not advisable for acute mild sprains, as they are typically self-limited and respond well to other therapies upon initial exposure.
Immobilization for Severe Ankle Sprain is recommended, involving the use of splints for immobilization.
- Indications: Severe ankle sprain.
- Frequency/Duration: Application of a splint for ten days to three weeks following a 48-hour period spent elevated and not bearing any weight.
- Rationale for Recommendation: Casting has limitations, impairs driving, exercise, and returning to work. Performance is more important than bracing and carries a risk of deep vein thrombosis. Cast-induced immobility is not advised; therefore, the use of splints for incapacitation of a severely sprained ankle is recommended.
Rehabilitation for Ankle Sprain
After a work-related injury, rehabilitation (supervised formal therapy) should be focused on restoring the functional abilities necessary for the patient to fulfill their daily and work responsibilities, aiming to facilitate a return to their pre-injury status as much as practical.
Active therapy involves the patient actively participating in specific activities or tasks, requiring internal effort. On the other hand, passive therapy relies on modalities administered by a therapist without the patient exerting effort.
While passive therapies are often used to expedite an active therapy program and achieve simultaneous functional gains, priority should be given to active initiatives over passive interventions.
To maintain improvement levels, patients are encouraged to continue both active and passive therapies at home, extending the therapeutic process. Additionally, assistive devices may be employed as a supplementary measure in the rehabilitation strategy to enhance functional gains.
Therapy – Active for Ankle Sprain
Therapeutic Exercise is recommended for a specific group of individuals experiencing acute, subacute, or persistent ankle sprain.
Frequency/Dose/Duration: The total number of visits may vary, ranging from as low as two to three for individuals with minor functional deficits to as high as 12 to 15 for those with more severe deficits. Continued objective functional progress will determine the frequency.
For individuals demonstrating evidence of functional improvement towards specific goals, such as increased range of motion or enhanced capacity for work activities, more than 12 to 15 visits may be necessary to address persistent functional impairments. As part of the rehabilitation strategy, a home exercise regimen should be developed and implemented in conjunction with therapy.
Therapy – Passive for Ankle Sprain
Immediate Non-weight Bearing (Rest) for Acute Ankle Sprain is recommended as the initial intervention for patients unable to tolerate weight.
Indications: This includes patients with mild, moderate, and severe ankle sprains who cannot bear weight. Depending on tolerance and the patient’s weight-bearing capacity, a brief period of up to 48 hours may be recommended, followed by early mobilization.
Frequency/Duration: Non-weight-bearing for up to 48 hours, followed by early mobilization and gradual weight-bearing as tolerated. Additionally, rehabilitative activities should be initiated at home.
Indications for Discontinuation: Willingness and tolerance of weight.
Cryotherapy for Acute Ankle Sprain is recommended.
Indications: This is suitable for acute ankle sprains.
Frequency/Duration: Self-application for 10 to 20 minutes every two hours, up to three days, as needed.
Indications for Discontinuation: Resolution of symptoms, avoidance of negative consequences, and adherence to the prescribed treatment plan.
Cryotherapy / Heat for Ankle Sprain
Heat for Acute Ankle Sprain is not recommended as a treatment.
Compression Therapy for Acute Ankle Sprain is not recommended.
Tubigrip for Acute Ankle Sprain is not recommended.
Tape, Elastic Wrap, or Tubular Elastic for Acute Ankle Sprain is not recommended.
Intermittent Elevation for Acute Ankle Sprain is recommended for controlling edema in cases of acute ankle sprains with severe symptoms.
Indications: Acute ankle sprain with severe edema.
Indications for Discontinuation: Resolution of symptoms, avoidance of negative consequences, and compliance with the recommended treatment.
Contrast Bath Therapy for Acute Ankle Sprain is not recommended.
High-Voltage Pulsed Current for Acute Ankle Sprain is not recommended for severely sprained ankles.
Magnets for Acute, Subacute, or Chronic Ankle Sprain are not recommended for the treatment of severe, moderate, or persistent ankle sprain.
Diathermy for Acute, Subacute, or Chronic Ankle Sprain is not recommended.
Low-Frequency Electrical Stimulation for Acute, Subacute, or Chronic Ankle Sprain is not recommended for chronic, acute, or subacute ankle pain.
High-voltage Pulsed Electrical Stimulation for Acute, Subacute, or Chronic Ankle Sprain is not recommended as a treatment for recent or lingering ankle injuries.
Iontophoresis for Ankle Sprain, Acute, Subacute, or Chronic is not recommended for the treatment of acute, subacute, or chronic ankle sprains.
Low-level Laser Therapy for Acute, Subacute, or Chronic Ankle Sprain is not recommended for the treatment of acute, subacute, or chronic ankle sprains.
Phonophoresis for Acute, Subacute, or Chronic Ankle Sprain is not recommended for the treatment of severe, moderate, or long-lasting ankle sprains.
Therapeutic Ultrasound for Acute, Subacute, or Chronic Ankle Sprain is not recommended for the treatment of acute, subacute, or chronic ankle sprains.
Acupuncture for Acute, Subacute, or Chronic Ankle Sprain is not recommended for the treatment of acute, subacute, or chronic ankle sprains.
Hyperbaric Oxygen Therapy for Acute, Subacute, or Chronic Ankle Sprain is not recommended for the treatment of acute, subacute, or chronic ankle sprains.
Manipulation or Mobilization for Acute or Subacute Ankle Sprain is not recommended to treat acute or subacute sprained ankles.
Manipulation or Mobilization for Chronic Recurrent Ankle is not recommended to treat persistent ankle sprains that repeat often.
Injection Therapy Ankle Sprain
Autologous Blood Injection for Ankle Sprain, whether it’s acute, subacute, or chronic, is not recommended as a remedy for the injury.
Glucocorticosteroid Injections for Ankle Sprain, whether it’s acute, subacute, or chronic, are not recommended for the treatment.
Hyaluronic Acid Injections for Ankle Sprain, whether it’s acute, subacute, or chronic, are not recommended.
Prolotherapy Injections for Ankle Sprains, whether they are acute, subacute, chronic, or postoperative, are not recommended for the most severe cases.
Platelet Rich Plasma Injections for Ankle Sprain, whether it’s acute, subacute, or chronic, are not recommended.
Surgery Ankle Sprain
Surgery for the treatment of an acute or subacute ankle ligament tear is not recommended for a common lateral ligament injury resulting from an acute or subacute ankle sprain.
Surgery for the treatment of chronic ankle instability (CAI) is recommended in specific situations of long-term ankle instability.
Indications: Failure of non-operative treatments, such as therapy and the use of an ankle orthosis, along with chronic ankle instability lasting at least three months.
Recommendations are justified by persistent functional issues, and surgical reconstruction of a ligament may be considered for chronic instability.
Postoperative management of ankle instability is recommended, and it can involve short-term cast immobilization, early mobilization, and treatment.
Rationale for Recommendation: Therapy and early motion are listed as common postoperative treatment strategies.
What our office can do if you have Ankle Sprain
We’ve got the know-how to assist you with your workers’ compensation injuries. We truly get the challenges you’re facing and are here to address your medical requirements, adhering to the guidelines outlined by the New York State Workers Compensation Board.
Recognizing the significance of your workers’ compensation cases, we’re here to guide you through the complexities of dealing with both the workers’ compensation insurance company and your employer.
We understand that this period is stressful for you and your family. If you’re interested in setting up an appointment, please reach out to us, and we’ll go the extra mile to ensure it’s as hassle-free for you as possible.
