Ankle Sprain Final Version.pdf

R1 OnjiraWondontri
19 June 2018 6th Topic
Ankle sprain

Reference
• Donald A. Neumann. Kinesiology of the musculoskeletal system foundations for physical
rehabilitation. St.Louis.1 st edition
• Miller,Mark D,Thomson,Stephen R.Delee&Drez’s Orthopaedic Sports Medicine. 4 th
edition:Saunder;2015
• David R Richardson.Campbell’s operative Orthopaedic.edition 4
• Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative
treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane
Database Syst Rev. 2007
• Robroy L,Todd E,Stephen P,Dane K,Joseph J. Clinical Practice Guidelines Linked to the
International Classification of Functioning, Disability and Health From the Orthopaedic
Section of the American Physical Therapy Association. J Orthop Sports Phys Ther.
2013;43(9):1-40
• Vuurberg G, Hoorntje A,Wink LM, et al.Diagnosis, treatment and prevention of ankle sprains:
update of an evidence-based clinical guideline.Br J Sports Med Published Online First: 07
March 2018

Outline
• Introduction
• Type of ankle ligament injury
• Physical exam
• Investigation
• Treatment

Outline
• Introduction
• Type of ankle ligament injury
• Clinical manifestation
• Physical exam
• Treatment
Vuurberg G, Hoorntje A,Wink LM, et al.Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline.Br J Sports Med Published Online First: 07 March 2018

• Ankle joint Transmits 1.5 times the body weight when walking
4 times the body weight when running
• Ankle sprain: Injury to the ligamentous structures that support the ankle joint
• Most common soft tissue injuries affecting athletes
• Nearly 40% of sports injuries
Ankle sprain
181 prospective epidemiology
studies incidence of lateral,
medial and syndesmotic ankle
sprains
• Lateral ankle sprain 0.93 per 1,000
athlets
• Syndesmotic injury athlets 0.38 per
1,000 athlets
• Medial ankle sprain 0.06 per 1,000
athlets
B,Hertel J,Ryan J,Bleakley C.The Incidence and Prevalence of Ankle Sprain Injury:A Systematic Review and Meta-Analysis of Prospective Epidemiological StudiesSport medicine.2014:123-40

Medial ankle
ligament injury
Syndesmosis
ligament injury
Type of ankle ligament injury
https://www.uofmhealth.org/health-library/zm2754#zm2754-sec
Lateral ankle
ligament injury

Lateral ankle ligament injury
Lateral
• Anterior talofibular
ligament(ATFL)
• Calcaneofibular ligament(CFL)
• Posterior talofibular ligament
(PTFL)
Primary function : Limit Inversion
Hansen J.Netter’s clinical anatomy.3 edition.Philadelphia:Saunder,an imprint of Elsevier Inc;2014 https://www.uofmhealth.org/health-library/zm2754#zm2754-sec
Mechanism of injury :
Inverted, plantar-flexed foot
• Common injured structure is the
ATFL
• CFL 2nd injured
ATFL
PTFL
CFL

Inferior Talo-Fibula syndesmosis
- Anterior tibiofibular ligament
- Posterior tibiofibular ligament
- Transverse tibiofibular ligament
- Interosseous ligament
Primary Function : maintain stability
between distal Tibia and distal Fibula
Hansen J.Netter’s clinical anatomy.3 edition.Philadelphia:Saunder,an imprint of Elsevier Inc;2014
Mechanism of injury:
externally rotated and dorsiflexed
foot
• Anterior tibiofibular ligament is
the most common injured
• PosteriorTibiofibular ligament is the last
ligament
Inferior Talo-Fibula syndesmosis injury

Deltoid ligament
• Tibionavicular ligament
• Tibiocalcaneal ligament
• Anterior tibiotalar ligament
• Posterior tibiotalar ligament
Primary function : Limit Inversion
Mechanism of injury:
Force eversion of ankle
• Strongest ankle ligament
Medial ankle ligament injury
Hansen J.Netter’s clinical anatomy.3 edition.Philadelphia:Saunder,an imprint of Elsevier Inc;2014
Posterior tibiotalar ligament
Tibiocalcaneal ligament
Tibionavicular ligament
Anterior tibiotalar ligament

Risk factor

Risk factor
External
Risk Factor
Internal
Risk Factor

Intrinsic risk factor Level of evidence
Limited dorsiflexion ROM Level 1
Reduced proprioception
(passive inversion position sense)
Level 1
Deficiency in postural control/balance
(Positive single-leg balance test)
Level 1
Lower BMI Level 2
Others: Reduce strength of peroneus muscle , limited
over all ankle joint ROM and decreased peroneal action
time
Level 3
Previous history of ankle sprain Level 2
Female Level 3
Greater height, abnormalities of ankle and
knee alignment
Level 3
Internal Risk Factor
Modifiable
Risk factor
Non-modifiable
Risk factor

External risk factors Level of evidence
Athletes with previous ankle sprain not participate
in balance proprioceptive and stretching program
prevention programs
Level 1
Type of sport practice
(Basketball,indoor volleyball,field sports and
climbing)
and level of participation
Level 2
High heel shoe (9.5 vs 1.3 cm) Level 3
External Risk Factor

Ankle ligament injury
Physical exam
Swelling Bruising Range of motion Neurovascular
Status
Tenderness

Lateral ankle
ligament injury
Ankle ligament injury
Medial ankle
ligament injury
Syndesmosis
ligament injury
Tender at
antero-lateral ankle
Tender over the anterior
and posterior tibiofibular
ligaments
or
proximally to the
anteromedial part of
the fibula
medial-sided pain

Special tests
Anterior drawer stress test
Anterior talofibular ligament
Talar tilt test
(Inversion stress test)
Calcaneofibular ligament injury
External rotation stress test
Syndesmotic injury
Squeeze test
Syndesmotic injury

Anterior drawer test
(anterior talofibular ligament)
Sensitivity 84%
Specificity 96%
Delay 4-5 days post injury
Special tests
Talar tilt test
Calcaneofibular ligament injury
Sensitivity 50%
Specificity 88 %
Schwieterman, Braun et al.“DIAGNOSTIC ACCURACY OF PHYSICAL EXAMINATION TESTS OF THE ANKLE/FOOT COMPLEX:A SYSTEMATIC REVIEW.” International Journal of Sports
PhysicalTherapy 8.4 (2013): 416–426. Print.
https://clinicalgate.com/83-ankle-sprain/

Syndesmosis squeeze test.
syndesmotic injury
Sensitivity: 30%,Specificity: 93
Special tests
Dorsiflexion + ER stress test
syndesmotic injury
Sensitivity 71 specificity 61
External rotation stress test :Sensitivity: 20%,
Specificity: 84.5%
Schwieterman, Braun et al.“DIAGNOSTIC ACCURACY OF PHYSICAL EXAMINATION TESTS OF THE ANKLE/FOOT COMPLEX:A SYSTEMATIC REVIEW.” International Journal of Sports
PhysicalTherapy 8.4 (2013): 416–426. Print.

Diagnostic study
• Pain film X-ray
• Stress film radiography
• CT
• MRI
• Ultrasound
• MR arthrography

Ottawa Ankle Rule
• Reduce the number of unnecessary radiographs by 30- 40%.1
• Patients age 2 years and older with ankle or midfoot
pain/tenderness in the setting of trauma.
• Sensitivity 86-99 % , Specificity 25- 46 %
• Negative likelihood ratio of less than 1.4%
• Very few fractures are missed2
(Level of evidence I)
1.Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G.Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ : British Medical Journal.
2003;326(7386):417.

Ottawa ankle rule
1.Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G.Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ : British Medical Journal.
2003;326(7386):417.
Inability to bear weight

The Bernese ankle rules
Consists of 3 consecutive steps: any of these clinical examination causes pain, the
radiographic examination is required
• Indirect fibular stress applied 10 cm proximal to the fibular tip
• Direct medial malleolar stress
• Simultaneous compression of the midfoot and hindfoot.
Eggli S, Sclabas GM, Eggli S, Zimmermann H, Exadaktylos AK.The Bernese ankle rules: a fast, reliable test after low-energy, supination-typemalleolar and midfoot trauma. J Trauma. 2005;59:1268-71.

Xray
Weight-bearing
anteroposterior
A
C
B Mortise views
Lateral

• Positive:
• Anterior translation of talus inside ankle mortise
(shortest distance between posterior lip of tibial
plafond and talar dome) is more than 5mm or 3
mm more than normal side
Talar tilt stress test
• Line draw across talar dome and tibia vault
• Normal is less than 5 degree
• More than 10 degree indicate ligament injury
• Compare to the other side
http://www.fisiokinesiterapia.biz/download/Rays
Not recommend in acute setting due to pain
Stress film radiography

Investigation
Investigation
CT
Ultrasound sensitivity 92%, specificity 64%
Advantage in dynamic diagnostic study, Cheaper
price
Operating dependent , Difficult in high
subcutaneous fat patient,swelling
Ultrasound
MRI
MR
Arthrography
CT Requires if fracture is questionable
• Evaluate the extend and location of
intraaarticular fracture (preoperative
planning)
• Cystic osteochrondral defect of talus

MR arthrography
Evaluate intra-articular pathology of ankle
sensitivity and specificity are equal to delay physical exam
Mildly invasive one (risk of intra-articular needle placement)
Not recommend as diagnostic tool in acute setting
(Level of evidence 2)
Investigation
Investigation
CT
Ultrasound
MRI
MR
Arthrography
MRI sensitivity 93-96%, specificity 100 %
•R/O partial tear of ligament, high grade ligament
injuries, osteochrondral defect, syndesmotic injury
•Poor availability, expensive + high prevalence of
ankle sprain  persisiting symptoms
•No routine use in acute setting
Vuurberg G, Hoorntje A, Wink LM, et al.Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline.Br J Sports Med Published Online First: 07 March 2018

Signs/symptoms Grade I
Mild
Grade II
Moderate sprain/
Microligament lesion
Grade III
Severe sprain/
Full ligament lesion
Loss of function No/minimal Partial Near total
Ligament laxity
Talar tilt test
Negative
Negative
Positive
Negative
Positive
Positive
Ecchymosis Little or none Some Extreme
Ankle motion Decrease
Less than 5 degree
Decrease
5-10 degree
Decrease
More than 10 degree
Swelling Less than 0.5 cm 0.5-2 cm More than 2 cm
cGovern, Ryan P, and RobRoy L Martin.“Managing Ankle Ligament Sprains andTears: Current Opinion.” Open Access Journal of Sports Medicine 7 (2016): 33–42.
Grading

• Fibularis (peroneal)
tendon tendinitis/tendinopathy
• Lisfranc fracture/dislocation
• Ankle impingement
• Sinus tarsi syndrome
Differential Diagnosis
Robroy L,Todd E,Stephen P,Dane K,Joseph J. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the
American PhysicalTherapy Association. J Orthop Sports Phys Ther. 2013;43(9):1-40

• Rapid dorsiflexion of an inverted foot inversion
• Injury to the superior peroneal retinaculum
Physical exam
• Swelling posterior to the lateral malleolus
(Pseudotumor over the peroneal tendons)
• Tenderness over the tendons
• Apprehension test & Compression test
PeronealTendon Subluxation & Dislocation
https://www.painfreephysiotherapy.com/peroneal-tendon-subluxation-rupture/
Special tests

Lisfranc fracture • Fracture.dislocation of tarsometatarsal
joint (Lisfranc joint)
• Hyperflexion of forefoot,vagus foot
• Severe pain, Inability to bear
weight,Swelling at dorsum of foot
• Piano key" test
https://orthoinfo.aaos.org/en/diseases--conditions/lisfranc-midfoot-injury/
Miller,Mark D,Thomson,Stephen R.Delee&Drez’s Orthopaedic Sports Medicine. 4 th edition:Saunder;2015
David R Richardson.Campbell’s operative Orthopaedic.edition 4

• Ankle impringement

Ankle impingement
• Leading causes of impingement lesions
are posttraumatic ankle aprain
• Cause of chronic ankle sprain
• Involving both osseous and soft tissue
abnormalities ex. Hypertrophied of
synovial tissue and fibrosis
• Symptom
- Pain
- Limit ROM due to pain
• Imaging for evaluate exosthosis,
osteophytes
• MR imaging and MR arthrography
Vaseenon,Tanawat, and Annunziato Amendola.“Update on Anterior Ankle Impingement.” Current Reviews in Musculoskeletal Medicine 5.2 (2012): 145–150

Vuurberg G, HorntjeA,Wink ML,et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline.Br J Sports Med.2017

• Small bony canal between talus and
calcaneous
• Cause: traumatic event result in
significant injuries to the talocrural
interosseous and cervical ligaments
• Symptom: swelling, ecchymosis,
tenderness 2 cm anterior and distal
of the tip of the lateral malleolus (on
sinus tarsi)
• Magnetic resonance imaging
is the best method
Stability test
Sinus tarsi syndrome
https://www.epainassist.com/sports-injuries/ankle-injuries/sinus-tarsi-syndrome-sts

• Improvement in pain and function
Grade I injury: 7 to 14 days
Grade 2 injury: 2 to 6 weeks of activity
Grade 3 injury: 4 weeks to 26 weeks from full activity
• Long term follow up > 1 year with out physical treatment
- Pain (5-46%)
- Recurrent sprain (3-34%),
- Ankle instability (33-55%)
Clinical Course

Ankle instability
• Long-term symptoms and signs ex. Pain, weakness, giving way,
repetitive ankle sprain after acute lateral ankle injuries
• Mechanical or functional instability
Mechanical instability
Excessive joint motion following anatomical defects
Functional instability
Recurrent ankle instability and the sensation of joint
instability due to the contributions of two factors: proprioceptive
and neuromuscular deficits but seem to have normal joint motion

• Chronic Ankle instability
Residual symptoms
(‘giving way’ and feelings of ankle joint instability)
should be present for a minimum of 1 year after initial sprain
Fibularis (peroneal) tendon disorders, chondral damage,
posttraumatic ankle arthritis
Ankle instability

• Evaluate the severity of functional ankle
instability (level of evidence I)
• 9 items ask individuals to describe their
instability
• Scores range from 0 (worst) to 30 (best).
• The test-retest intraclass correlation coefficient
(ICC) was 0.96
• 28 or higher as having a sensitivity specificity of
85.5 and 82.6, respectively
• Other tool:The Ankle Instability Instrument,
The Functional Ankle Instability Questionnaire
The Cumberland Ankle Instability Tool

Treatment
Acute phase /
Protected motion phase
of rehabilitation
Progressive loading /
Sensorimotor training
phase
• Acute phase
- 72 hours following injury
- Or subjects with significant
edema, pain, limited weight
bearing, and overt gait deviations
(ie, limited stance time)
• Progressive loading and
sensorimotor training phase
- Postacute period with primary
concerns of weakness, balance
responses and intermittent edema
- Includes studies that enrolled
subjects with mechanical and/or
functional ankle instability
Robroy L,Todd E,Stephen P,Dane K,Joseph J. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of
the American Physical Therapy Association. J Orthop Sports PhysTher. 2013;43(9):1-40
Vuurberg G, HoorntjeA,Wink ML,et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline.Br J Sports Med.2017

Treatment
Acute phase
Non phamacological
Phamacological Surgery

Use of NSAIDs may delay the natural healing process as the inflammation suppressed by NSAIDs is a
necessary component of tissue recovery
Phamacological
Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Oral orTropical NSAIDsVS. Placebo (F/U <14 days)
- Oral or Tropical NSAIDs : Less pain without significant increase risk of adverse effect
• Selective NSAIDs (celecoxib 200 mg two times daily) Vs.non-selective NSAIDs
(ibuprofen, naproxen or diclofenac)
- Celecoxib was non-inferior to non-selective NSAIDs for the primary outcome of
pain (Level of evidence 1)
• Naproxen fixed dosage (500 mg two times daily) Vs. as needed naproxen
dosage
- No different in effect in pain,swelling (Level of evidence 3 )
• Paracetamol VS.NSAID
- Equally effective as NSAID usage for pain swelling and ROM (Level of evidence 2)

• Platelet-rich plasma injections
- Not superior for pain and functional outcomes compared with placebo injections
• Periarticular hyaluronic acid injections
- Not show a positive effect on pain, nor did they result in a quicker time to return to sport
or reduced prevalence of recurrent sprains (Level of evidence 2)
Phamacological

• Therapeutic exercise
• Immobilization
• Functional support
• Manual therapy
• Other therapies
Acute phase
Non phamacological
Treatment

Non pharmacological (Acute phase)
 Reduce the prevalence of
recurrent injuries and
functional ankle instability
 Quicker time to return to
work
 Level of evidence1
American Academy of Orthopaedic Surgeons 2017
American Orthopaedic Foot & Ankle Society 2018
Therapeutic Exercises (Acute phase)
Restore functional range ex.AROM of ankle and foot
Strengthening
peroneal muscle
Isometric exercise Early Neuro muscular and proprioceptive
training

Immobilization
• ImmobilizationVs. functional support and exercise
- Less optimal outcomes
- For severe pain: maximum of 10 days of immobilization
level of evidence 2

Non pharmacological(Acute phase)
Functional support/Early weight bearing with support
• Ankle brace ( Air-stirrup ,Aircast standard brace,semi-rigid))
- Better functional outcome compared with other types of functional
treatment such as sports tape (non-elastic) or kinesiotape (elastic) (level of
evidence 2)
• kinesiotape
Unlikely to provide sufficient mechanical support in unstable ankles (level of
evidence1/small systamatic review)
• Compression stockings: not helpful (level of evidence 3)
Use of functional brace 4–6 weeks is preferred
Vuurberg G, Hoorntje A,Wink LM, et al.Diagnosis, treatment and prevention of ankle sprains: update of an evidence-
based clinical guideline.Br J Sports Med Published Online First: 07 March 2018
Kemler E, van de Port I, Backx F, et al.A systematic review on the treatment of acute ankle sprain: brace versus other
functional treatment type

ManualTherapy
• Active and passive soft tissue and joint mobilization
Anterior-to-posterior talar mobilization procedures within
pain-free movement
Increase ankle ROM (level of evidence 1)
Decrease pain (level of evidence 1)
Manual therapy combined with exercise therapy resulted in
better outcomes compared with exercise therapy alone (level of
evidence 3)

Physical agent
Cryotherapy
No role for RICE alone in the treatment of acute LAS
(level of evidence 2)
• Cryotherapy reduce LAS associate symptom :Unclear
Cryotherapy + exerciseVs standard treatment
Cryotherapy + exercise
- Improve ankle function
- Increase loading during weight bearing

Other therapies
• Ultrasound,Laser therapy,Electrotherapy shortwave
therapy : no effect on pain, edema, function and return to play
(level of evidence 1 )
• Acupuncture: Inconclusive (level of evidence 1 )
• Local vibration therapy
Increasing dorsiflexion and eversion and decreasing perceived
ankle stiffness(level of evidence 3 )
No strong evidence exists on the effectiveness of these
treatment modalities, they are not advised in the treatment of acute
LAS (level 2).

Treatment
Acute phase
Non phamacological

Surgery (Acute phase)
 Conservative treatment provides equal effects(Level of evidence1)
 Superior at decreasing the prevalence of recurrent LAS(Level of evidence2)
Complications: longer recovery times, higher incidences of ankle stiffness, impaired
ankle mobility and surgical complication(wound healing, infection) (Level of evidence1)
Higher cost
Functional treatment is preferred (level of evidence1)
- Avoid unnecessary exposure to invasive (over) treatment
- Unnecessary risk of complication

Treatment
Progressive loading &
phase
Non phamacological
• Therapeutic exercise
• Functional support
• Modality

Therapeutic Exercise and Activities
Functional exercises and activities, Balance training
program, proprioceptive exercise ,sport-related activity
training
Exercise therapy had a protective effect compared with
usual care
Start exercise therapy as soon as possible after the initial
sprain to prevent recurrent LAS
Non pharmacological treatment : Progressive loading phase

Promote improvement in dynamic postural control
Level of evidence : I
Therapeutic Exercise and Activities: functional exercises and activities,
especially utilizing unstable surfaces
4 wks; 12 sessions; 20 min

Significant improvement in stability index measures of postural sway in
individuals with functional ankle instability (level of evidence 2)
Therapeutic Exercise and Activities: Balance training program
Wobble and tilt board
single-leg balance retraining program
(ankle disc and mini-trampoline activities)
ElasticTubing

Multi-station proprioceptive exercise
1.exercise mats 2.swinging platform 3.ankle disk
4.Pedalo 5.exercise bands 6.air squab
7.wooden inversion-eversion boards 8.mini trampoline
9.aerobic step
10.uneven walkway (customized)
11.swinging and hanging platform 12.Biodex®
Eils & Rosenbaum, 2001
once per week(20mins) × 6 weeks

External support
• Brace or tape reduces the risk recurrent and first
time sprain (Level of evidence 1)
- semi-rigid orthoses or air-cast braces
- Kinesiotape have a preventive effect due to its effects on
postural control (Level of evidence 1)
 No differences in prevention of recurrent sprains
were found between different types of brace
The use of a brace or tape is a personal choice
and based on practical usability and costs
Vuurberg G, Hoorntje A,Wink LM, et al.Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline.Br J Sports
Med Published Online First: 07 March 2018
BiciciS,KaratasN,BaltaciG.Effect of athletic taping and kinesiotaping on measurements of cuntional performance in basketball players with chronic inversion
anklesprains.IntJSportsPhysTherap.2012;7:154–166
Handoll HH, Rowe BH, Quinn KM, et al. Interventions for preventing ankle ligament injuries.The Cochrane database of systematic reviews 2001
KinesioTex®
- Peroneus longus in pink
colored tape
- Peroneus brevis in black
colored tape
- Anterior tibiofibular
ligament in flesh colored tape

Foot wear
• No evident conclusions (level of evidence 2)
• Wearing low-fitted or high-fitted shoes did not show any difference in
preventive effect (level of evidence 1)
No recommendations can be made concerning shoe wear
(level of evidence 1)

Modality and acupuncture
None of included review evaluated efficacy of electrophysical
agent, and acupuncture in progressive loading phase

Treatment
Progressive loading &
phase
Non phamacological

Surgery : Progressive loading phase
• Conservative group : higher incidence of instability
• Surgical treatment group:
- Longer recovery times, and higher incidences of ankle
stiffness, impaired ankle mobility, osteoarthritis was observed
Surgical treatment may be preferred
- Professional athletes: ensure quicker return to play
- Patients chronic instability after a LAS and not responded exercise-based
physiotherapy program
Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries
of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. 2007

• Full range of motion and nearly full strength compared to the uninjured side.
• Standing on the uninjured side only,hop 8-10 times without pain
• Before returning to sport, the athlete must be able to sprint and change directions off
the injured ankle comfortably
• Sport-related tasks is also helpful in determining readiness for return to play.
- Starting out with jogging and gradually progressing in speed, and finally to sprints.
- Must stop if there is significant pain or limp.
Return to play

1.Kunkel M, Miller SD. Return to work after foot and ankle injury. Foot Ankle Clin 2002;7:421–8.
2.Abidi NA. Sprains about the foot and ankle encountered in the workmans’ compensation patient. Foot Ankle Clin 2002;7:305–22.
Return to work
Distortion : Depending on degree of pain/subjective limitation/severity

Return to work
Partial or total rupture of ligament

Return to work
Surgery

• Diagnosis of ankle sprain: type and grading
• Acute phase
- Pharmacological treatment
- Non pharmacological treatment: therapeutic exercise,
Functional support, Manual therapy
• Progressive loading / Sensorimotor training phase
- Clinical course
- Non pharmacological treatment: therapeutic exercise,
Functional support
• Surgery: Fail exercise base therapy program, Professional athletes
Take Home Message

Appendix
Vuurberg G, HoorntjeA,Wink ML,et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline.Br J Sports Med.2017

Ankle Sprain Final Version.pdf

Ankle Sprain Final Version.pdf

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