Lateral ankle sprains are common musculoskeletal injuries.
The objective of this study was to perform a systematic literature review of the last 10 years regarding evidence for the treatment and prevention of lateral ankle sprains.
Pubmed central, Google scholar.
Study eligibility criteria
Meta-analysis, prospective randomized trials, English language articles.
Surgical and non-surgical treatment, immobilization versus functional treatment, different external supports, balance training for rehabilitation, balance training for prevention, braces for prevention.
A systematic search for articles about the treatment of lateral ankle sprains that were published between January 2002 and December 2012.
Three meta-analysis and 19 articles reporting 16 prospective randomized trials could be identified. The main advantage of surgical ankle ligament repair is that objective instability and recurrence rate is less common when compared with non-operative treatment. Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. For non-surgical treatment, long-term immobilization should be avoided. For grade III injuries, however, a short period of immobilization (max. 10 days) in a below knee cast was shown to be advantageous. After this phase, the ankle is most effectively protected against inversion by a semi-rigid ankle brace. Even grades I and II injuries are most effectively treated with a semi-rigid ankle brace. There is evidence that treatment of acute ankle sprains should be supported by a neuromuscular training. Balance training is also effective for the prevention of ankle sprains in athletes with the previous sprains. There is good evidence from high level randomized trials in the literature that the use of a brace is effective for the prevention of ankle sprains.
Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. The indication for surgical repair should be always made on an individual basis. This systematic review supports a phase adapted non-surgical treatment of acute ankle sprains with a short-term immobilization for grade III injuries followed by a semi-rigid brace. More prospective randomized studies with a longer follow-up are needed to find out what type of non-surgical treatment has the lowest re-sprain rate.
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The most common injury mechanism is a combination of inversion and adduction of the foot in plantar flexion (supination). This injury mechanism can cause damage to the lateral ankle ligaments . Injury of the anterior talofibular ligament with intact medial ligaments leads to anterolateral rotary instability . Additional transection of the calcaneofibular ligament adds a tilting of the talus (talar tilt) .
Ankle ligament sprains are usually graded on the basis of severity . Grade I is a mild stretching of the ligaments without macroscopic rupture or joint instability. Grade II (moderate) is a partial rupture of the ligament with moderate pain and swelling. There are functional limitations and a slight to moderate instability. Typically, patients present with problems in weight bearing . Grade III (severe) is a complete ligament rupture with marked pain, swelling, hematoma and pain. In grade III injuries, there is a marked impairment of function with instability.
Biological ligament healing can be divided into three different phases : (1) inflammatory phase (until 10 days after trauma), (2) the proliferation phase (4th–8th week) and (3) the remodelling or maturation phase (until 1 year after trauma). The duration of the different phases may individually vary.
Many treatment options have been suggested: surgery, immobilization, functional treatment with bandages, tape or different braces, balance training. Today, most authors recommend non-surgical treatment for lateral ankle sprains.
Nevertheless, many studies have shown that ankle sprains are more serious than commonly believed since many patients develop chronic problems after injury [17, 55, 57]. The symptoms, include chronic pain, recurrent swelling, and chronic instability [17, 55]. In addition, there is strong evidence that within 1 year after injury, athletes have twice the risk of a recurrent ankle sprain [1, 12, 34]. Interestingly, Malliaropoulos  found that low-grade acute lateral ankle sprains result in a higher risk of reinjury than high-grade acute lateral ankle sprains.
The high rate of failure after ankle sprain treatment might be explained by overlooked associated lesions, such as syndesmosis or cartilage injuries . Another cause may be inappropriate treatment with regard of the different injury grades and healing phases.
To find out which treatment option is the most appropriate one, we have performed a systematic review of the literature published the last 10 years. This review should answer the following research questions:
Is there evidence for surgical or non-surgical treatment of acute ankle sprains?
Is there evidence for functional treatment or immobilization?
What is the most effective type of external stabilization for the treatment of acute ankle sprain?
Is there any evidence for neuromuscular training for rehabilitation of acute ankle sprains?
Is there any evidence for neuromuscular training for the prevention of ankle sprains?
Is there any role for prophylactic bracing?
We conducted a comprehensive literature search using the MEDLINE database and Google scholar to identify peer reviewed articles about the treatment of lateral ankle sprains according to the PRISMA statement .
For the systematic review, different combinations of keywords were utilized: (1) ankle sprain, (2) ankle ligament injury, (3) ankle sprain and rehabilitation, (4) ankle sprain and surgical treatment, (5) ankle sprain and functional treatment, (6) ankle sprain and external support, (7) ankle sprain and neuromuscular training.
After each article identified in Pubmed, the “see all” button for related article was activated. Furthermore, the reference lists of the identified articles were screened for relevant publications.
Only contemporary articles published within the last 10 years (first January 2002 to December 2012) were considered for review. The reason for this approach is that many earlier than 2002 published studies were already included in the meta-analyzes. The search was restricted to English language articles. We excluded articles which considered management of ankle fractures, syndesmosis lesions or dislocations. If a prospective randomized trial was already included in a meta-analysis, this trial was also excluded.
The patient selection was limited to adults equal to or greater than 16 years of age. We only considered articles of level I evidence according to the Agency for Healthcare Research and Quality : meta-analysis and randomized controlled trial (RCT). Data from studies of lower evidence levels were only considered when these were included in meta-analysis. Cohort studies, case series, retrospective studies, case reports, expert opinion and anecdotal evidence were not considered.
If a study of interest was found the abstract was studied to find out if any of the exclusion criteria applied. If the study was eligible the full text article was studied. The article should be suited to answer one of the six research questions stated at the end of the introduction.
One hundred fifty-eight articles could be identified and 136 articles had to be excluded (Fig. 1). Three meta-analyzes and 17 RCTs were included in the analysis.
Meta-analysis about treatment options for acute ankle sprains published between 2002 and 2012
We identified three different meta-analysis about the treatment of ankle sprains. These three meta-analysis are summarized in Table 1.
Kerkhoff et al.  analyzed trials comparing surgical and non-operative treatment. This meta-analysis showed statistically significant differences in favour of the surgical treatment for return to pre-injury level of sports; ankle sprain recurrence; long-term pain; subjective or functional instability when using the fixed-effect model. These differences were not robust when using the random-effects model, nor on the removal of one low quality (quasi-randomized) trial that had more extreme results.
The functional implications of the statistically significantly higher incidence of objective instability in conservatively treated trial participants are uncertain. There was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications in surgically treated patients.
In another meta-analysis, Kerkhoffs et al.  compared studies about functional treatment and immobilization. This study showed statistically significant differences in favour of functional treatment when compared with immobilization for seven outcome parameters: return to sports rate, time to return to sports, return to work rate, time to return to work, swelling, and satisfaction with treatment.
In a third meta-analysis, Kerkhoffs et al.  compared the effect of different types of external support for non-operative treatment of ankle sprains. This study showed that lace-up ankle support had significantly better results for persistent swelling at short-term follow-up when compared with semi-rigid ankle support; elastic bandage; and to tape. The use of a semi-rigid ankle support resulted in a significantly lower rate of instability, shorter time to return to work and return to sports when compared with an elastic bandage. Tape treatment resulted in significantly more complications, the majority being skin irritations, when compared with treatment with an elastic bandage.
Randomized controlled trials about surgical versus non-surgical treatment
We found two randomized controlled trials analyzing the effect of surgical versus non-surgical treatment for acute ankle sprain. These trials are summarized in Table 2.
Pihlajamäki et al.  examined suture repair followed by 6 weeks cast treatment vs. functional treatment in patients with a grade III injury. Functional treatment consisted of the use of an Aircast ankle brace for 3 weeks. In this study, the prevalence of reinjury was 1 of 15 in the surgical group and 7 of 18 in the functional treatment group. There was no difference in the ankle score and in anterior drawer and talar tilt as measured by stress radiography. The rate of grade II osteoarthritis detected on MRI was higher in surgically treated patients when compared with functional treatment.
Takao et al.  examined patients after suture repair of the lateral ankle ligaments followed by functional treatment and functional treatment alone. In this study, there was also no difference could be detected in the mean results of the clinical score and ankle stability examined with stress radiography. However, in the group with functional treatment alone 8 of 132 patients suffered from instability after 2 years follow-up in contrast to none in the surgical group. Patients after surgical repair returned significantly quicker to full athletic than patients after functional treatment alone.
Randomized controlled trials about external support
We found 6 articles reporting 5 randomized controlled trials analyzing the effect of different types of external support for the treatment of acute ankle sprain. These studies are summarized in Table 3. Two of these studies reported results from one single trial (CAST trial).
Boyce et al.  showed that Karlsson score was significantly higher in the Aircast ankle brace group than in the elastic bandage group at 10 days and 1 month.
The results of the CAST trial [9, 27] showed that a short period of immobilization in a below-knee cast or treatment with a semi-rigid orthosis results in faster recovery than if the patient is only given tubular compression bandage. There was no difference between below knee cast, semi-rigid orthosis and tubular compression bandage at 9 month follow-up.
Lardenoye et al.  compared tape versus a semi-rigid orthosis. Functional outcome and pain was similar between the two treatment groups. Patient-reported comfort and satisfaction during treatment was significantly increased and the rate of skin complication was significantly lower in the brace group.
Bennyon et al.  examined patients of grades I, II, and III injuries. For grades I and II injuries, a semi-rigid ankle brace (Air-Stirrup®) combined with an elastic wrap returned patients quicker to normal walking and stair climbing than a semi-rigid brace alone. For grade III sprains, the Air-Stirrup brace or a walking cast for 10 days followed by bracing returned subjects to normal walking and stair climbing in the same time intervals. The 6-month follow-up of each sprain severity group revealed no difference between the treatments for frequency of reinjury, ankle motion, and function.
Sultan et al.  compared elastic stockings with a Tubigrip bandage. These authors found that elastic compression improves recovery following ankle sprain.
Randomized controlled trials about the effect of training for treatment of acute ankle sprains
We found four publications about three randomized controlled trials analyzing the effect of neuromuscular training for the treatment of acute ankle sprains [6, 22, 56, 61]. These studies are summarized in Table 4. Two of these articles were reports about one trial [22, 61].
In the 2BFit study there was a significant reduction in resprains in the training group [22, 61]. Two studies found that conventional treatment of ankle sprains combined with supervised exercises does not lead to differences in the occurrence of resprains [6, 60]. However, one of these studies showed that patients, who received a balance board training were more active .
Randomized controlled trials about the effect of training for prevention of ankle sprain
Three prospective randomized studies about the effect of balance board training for the prevention of ankle sprains in athletes could be identified [30, 58, 60]. Two studies report about the same trial (Table 5).
Both trials showed that a balance training program significantly reduces the risk of ankle sprains only in the subgroup of athletes with a previous sprain [30, 58, 60]. A subsequent economic analysis of Verhagens trial showed that balance training could be cost-effective if it is aimed only at players with the previous ankle sprains .
Randomized controlled trials about the preventive effect of braces
We identified four randomized controlled trials about the preventive effect of ankle braces published between 2002 and 2012 (Table 6).
In all of these studies, braces were used to prevent ankle sprains in risk sports (basketball, football, volleyball). Three of these studies found that the use of braces reduces the incidence of ankle sprain in asymptomatic athletes in basketball and football [2, 31–33]. Mickel et al.  compared brace and tape use for the prevention of ankle. In this study, there was no difference in the sprain rate, but the treatment time per athlete was significantly higher in the tape group.
With this systematic review of the literature, we found answers to the research questions stated at the end of the hypothesis. For this purpose, we analyzed 22 articles which met the inclusion criteria.
Surgical versus non-surgical treatment of acute ankle sprains
However, a Cochrane review  has shown that surgical ligament reconstruction is advantageous with regard to the recurrence rate for ankle injuries, the incidence of chronic ankle problems and functional (subjective) and mechanical (objective) instability of the ankle. On the other hand, there was limited evidence for longer recovery times, higher incidences of ankle stiffness, impaired ankle mobility and more complications in the surgical treatment group. Because of the low quality of the analyzed trials, the authors concluded that there is insufficient evidence to determine the relative effectiveness of surgical and conservative treatment for acute ankle sprains.
Two later published prospective randomized trials came to similar findings. In a randomized study with a long-term follow-up, Pihlajamäki et al.  could show that surgery decreased the prevalence of reinjury of the lateral ligaments. A downside for surgical treatment in this study was a higher rate of II degree of osteoarthritis detected by MRI. Takao et al.  have shown in a randomized study with a 2 years follow-up that functional treatment alone had an approximately 10 % failure rate and a slower return to full athletic activity.
Based on these findings, we conclude that the main advantage of surgical ankle ligament repair is that objective instability and recurrence rate was less common when compared with non-operative treatment. Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle sprains can be managed without surgery. However, with regard to its advantages, surgery should not be totally abandoned. The indication for surgical repair should be made on an individual basis. We agree with van den Bekerom et al.  that an acute reconstruction could be indicated in athletes, because increased objective instability is a predictor for future ankle sprains .
Is there evidence for functional treatment or immobilization?
This question can be answered by the meta-analysis published by Kerkhoffs et al. . Based on the analysis of 21 trials involving 2,184 participants these authors concluded that functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with long-term immobilization (4–6 weeks). However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated.
Probably, a short period of rest in a below knee cast helps to reduce swelling and pain during the early inflammatory phase of biological ligament healing. Later during the proliferation phase and remodeling phase, immobilization in a cast could be detrimental for the healing process. According to the principle of causal histiogenesis  functional stress is needed for the remodeling of connective tissue. It is also well known that prolonged immobilization has a detrimental effect on muscles, ligaments and joint surfaces.
Therefore, several authors recommend that initial treatment during the inflammatory phase should be directed towards avoiding or diminishing excess swelling and ongoing injury, thus optimizing the healing process [11, 14, 53]. RICE (Rest, Ice, Compression and Elevation) therapy is considered to be the treatment of choice for the first 4–5 days to reduce pain and swelling  and prefer a short initial period of 5–7 days (max 10 days) of immobilization in a below the knee cast or removable boot.
What is the most effective type of external stabilization for the treatment of acute ankle sprain?
It is generally agreed that the majority of acute grade I–III ankle sprains can be treated by non-operative measures.
During the proliferation phase, the tissue responds with vascular ingrowth, fibroblast proliferation and new collagen formation. Protection of inversion is important during this phase of healing to prevent excess formation of weaker type III collagen formation that can contribute to chronic elongation of the ligament. Controlled stress on the ligament will promote proper collagen fibre orientation. In addition, motion, stretching and strengthening will avoid the harmful effects of immobilization on the muscle, joint cartilage and bone.
We differentiate several options for external ankle protection: bandages, tape, lace up braces and semi rigid ankle orthoses. In a meta-analysis, Kerkhoffs et al.  have shown that the use of an elastic bandage has fewer complications than taping, but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears to be effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape .
Newer randomized trials came to similar results. In all studies patients had better short term results with a semi-rigid ankle brace than with a bandage [5, 7, 9, 27]. Lardenoye et al.  compared a semi rigid brace with tape. In this study, the rate of skin complication in this group was significantly lower as compared to the tape group, but functional outcome of the ankle joint was similar between the two treatment groups, as well as reported pain. Bennyon et al.  showed that even for grades I and II injuries treatment with a semi rigid ankle brace combined with an elastic wrap returned subjects to normal walking and stair climbing in half the time required for those treated with the Air-Stirrup brace alone form those treated with an elastic wrap alone.
From these studies, we conclude that during the proliferation phase the ankle is most effectively protected against inversion by a semi-rigid ankle brace. For grade III injuries, the semi-rigid orthosis is adapted after the initial short immobilization phase.
All studies about non-surgical treatment of ankle sprains have one methodological flaw, because they report only short-term follow-up data and no resprain rates. Malliaropoulos et al.  reported with a cohort study a resprain rate of 17.8 % at 2 years after non-operative ankle sprain treatment. Because of this methodological flaw, we do not know the resprain rates of different types of different types of external support for the treatment of ankle sprains. More prospective randomized studies with a longer follow-up are needed to answer this question.
Is there any evidence for neuromuscular training for treatment of acute ankle sprains?
In 1965, Freeman [15, 16] hypothesized that balance and coordination training could diminish proprioceptive deficits associated with ligamentous injury to the ankle. Contemporary theory suggests that balance and coordination training may have both local and central effects on the sensorimotor system [19, 45, 46]. However, consensus is lacking regarding the clinical evidence of the efficacy and effectiveness of these interventions. In contrast to the hypothesis of Freeman, a previously published systematic review  reported that there was no evidence for effectiveness of physiotherapy as a treatment strategy for acute ankle sprains.
Even the results of the studies analyzed in this systematic review are contradictory. Van Rijn et al.  found that conventional treatment of an ankle sprain combined with supervised exercises as compared to conventional treatment alone after an acute lateral ankle sprain does not lead to differences in the occurrence of resprains or in subjective recovery. Bleakley et al.  could also detect no difference in the resprain rate between the groups with and without exercise after an acute ankle sprain. However, this study showed a positive effect of exercise for improved ankle function and activity. The 2Fit study, however, showed a positive effect of a non-supervised home-based proprioceptive balance board training program in addition to usual care on the resprain rate Hupperets . A process evaluation showed that only 23 % of the intervention group indicated to have fully adhered with the neuromuscular training program. Significantly fewer recurrent ankle sprains were found in the fully adherent group compared with the group that was not adherent . This could be an explanation for the missing effect in the studies conducted by van Rijn  and Bleakery et al. . The power of these studies was with 102 participants each much lower than in the 2 Fit trial with 522 participants.
In conclusion, based on the high level 2 Fit study, we conclude that balance training can be used after an acute ankle sprain in an effort to reduce future ankle sprains.
Is there any evidence for neuromuscular training for prevention of acute ankle sprains?
A meta-analysis about the prevention of ankle sprains published in 2001  found that there was limited evidence for reduction in ankle sprain for those athletes with previous ankle sprains who did ankle disk training exercises.
In this systematic review, we analyzed only studies published between 2002 and 2012. Two of the randomized trials that met the inclusion criteria focused on the primary preventive effect of balance training. In these studies, the ankle sprain rate was significantly lower after balance training only in the group of athletes with a previous sprain [30, 58]. In players without a history of ankle sprains, there was just a tendency towards a lower injury rate in the training group. These studies confirm results of previous studies which were published before 2002 [48, 50]. A sensitivity analysis of Verhagens prevention study  showed that only a balance board training program aimed at players with the previous ankle sprains could be cost-effective over a longer period of time.
Probably, more well-designed prospective studies with larger samples are needed to show a significant effect also for athletes without a previous ankle sprain. However, even if these studies could show an effect, the number to treat is expected to be high.
These findings can be explained since the most important risk factor for an ankle sprain is a previous ankle sprain . This might be due to reduced proprioceptive function [35, 36, 38]. Mitchell et al. [35, 36] have demonstrate a slower reaction time and postural sway deficits in ankles with functional instability. These authors concluded that individuals, who sustain an acute ankle sprain and those with functional instability require rehabilitation that improves proprioception, strengthens the evertors and dorsiflexors, and restores peroneal reaction time.
In conclusion, in accordance with a previous systematic review , the articles published between 2002 and 2012 provide evidence that a balance training can be used in an effort to reduce future ankle sprains in athletes with a previous injury.
Is there any evidence of brace use for the prevention of ankle sprains?
Three of the four identified studies showed that the use of lace up braces reduced the incidence, but not the severity of acute ankle injuries in football and basketball players [2, 30, 31]. One study compared prophylactic bracing or taping in high school football . In this study, there was no difference in the rate of ankle sprains between the two groups. However, the cost analysis showed that tape use was less cost-effective (more time) than brace use.
These results confirm results of a meta-analysis which was published in 2001 . This meta-analysis provided good evidence for the beneficial effect of ankle braces to prevent ankle sprains during high-risk sporting activities (e.g. soccer, basketball).
In conclusion, there is good evidence from high level randomized trials in the literature that the use of a brace is effective for the prevention of ankle sprains.
Limitations of this systematic review
Every effort was made to obtain level one evidence studies to answer our research questions. However, even these high quality studies vary in terms of quality of methodology and reported outcomes.
The problem of the meta-analysis was that many studies that were included had methodological flaws. Therefore, in none of the meta-analysis included in this review, the authors found strong evidence for one of the examined treatment options.
The RCTs about surgical versus non-surgical treatment have an adequate follow-up (2–14 years), but a low number of patients. Therefore, the power of these studies might not be large enough to find out any differences in clinical scores. On the other hand, the RCT about non-surgical treatment of acute ankle sprains have large case numbers, but the follow-up varies between 9 and 12 months. This period is too short to examine resprain rates. Therefore, none of the RCT about non-surgical treatment with external support reports the rate of recurrent sprains. The papers originate from different countries and therefore, may not be applicable in every aspect to all populations. Limiting the review to English language articles only has the risk for high-quality non-English articles to be excluded. We looked only at studies which recruited adults. Therefore, the results are not applicable for the treatment of ankle sprains of children (i.e. 18 years or older).
Owing to the limitation of our search RCTs about pharmacolocgical treatment of ankle sprains were excluded. This was done to limit the scope of this systematic review. Many studies deal with the use of NSAIDs, for example. A new treatment option is the use of hyaluronic acid injections that should be associated with a more rapid return to sport and with only a few associated adverse events, but the relative increased cost of this treatment versus the standard of care has to be considered .
Despite the existing evidence from meta-analysis and RCT, many patients develop chronic problems after injury of the ankle ligaments [17, 29, 55, 57]. Therefore, there is reason to believe that many question for the treatment of ankle injuries are still unsolved. These unresolved issues include time and criteria for return to sports, duration of ankle protection by external support, use of and diagnostics of associated injuries.
Balancing the advantages and disadvantages of surgical and non-surgical treatment we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. The indication for surgical repair should be always made on an individual basis. This systematic review supports a phase adapted non-surgical treatment of acute ankle sprains with a short-term immobilization for grade III injuries followed by a semi-rigid brace. Types I and II injuries might best be treated with a semi-rigid brace. Neuromuscular training should support functional rehabilitation after ankle sprain. Balance training is effective for the prevention of resprains of athletes with previous sprains. Braces are also effective for the prevention of ankle sprains in athletes. More prospective randomized studies with a longer follow-up are needed to find out what type of non-surgical treatment has the lowest resprain rate.
Bahr R, Bahr IA (1997) Incidence of acute volleyball injuries: a prospective cohort study of injury mechanisms and risk factors. Scand J Med Sci Sports 7:166–171
Babins EM (2012) Lace-up ankle braces reduced acute ankle injuries in high school basketball players. Clin J Sport Med 22(4):379–380
Balduini FC, Tetzlaff J (1982) Historical perspectives on injuries of the ligaments of the ankle. Clin Sports Med 1:3–12
Best R, Brüggemann P, Petersen W, Rembitzki I, Ellermann A, Gösele-Koppenburg A, Liebau C (2011) Aktuelle und neue Konzepte in der Behandlung akuter Außenbandverletzungn des Sprunggelenkes, Deutsche Zeitschrift für Sportmedizin Jahrgang 62, Nr. 3:57–62
Beynnon BD, Renström PA, Haugh L, Uh BS, Barker H (2006) A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. Am J Sports Med 34(9):1401–1412
Bleakley CM, O’Connor SR, Tully MA, Rocke LG, Macauley DC, Bradbury I, Keegan S, McDonough SM (2010) Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ 10(340):c1964
Boyce SH, Quigley MA, Campbell S (2005) 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 39(2):91–96
Cass JR, Settles H (1994) Ankle instability: in vitro kinematics in response to axial load. Foot Ankle Int 15:134–140
Cooke MW, Marsh JL, Clark M, Nakash R, Jarvis RM, Hutton JL, Szczepura A, Wilson S, Lamb SE; CAST trial group (2009) Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technol Assess 13(13):iii, ix, x, 1–121
Chan KW, Ding BC, Mroczek KJ (2011) Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Jt Dis 69(1):17–26
Dubin JC, Comeau D, McClelland RI, Dubin RA, Ferrel E (2011) Lateral and syndesmotic ankle sprain injuries: a narrative literature review. J Chiropr Med 10(3):204–219
Ekstrand J, Gillquist J (1983) Soccer injuries and their mechanism: a prospective study. Med Sci Sports Ecerc 15:367–370
Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R (2010) Intrinsic risk factors for acute ankle injuries among male soccer players: a prospective cohort study. Scand J Med Sci Sports 20(3):403–410
Fong DT, Chan YY, Mok KM, Yung PSh, Chan KM (2009) Understanding acute ankle ligamentous sprain injury in sports. Sports Med Arthrosc Rehabil Ther Technol 30(1):14
Freeman MA (1965) Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint Surg Br 47(4):669–677
Freeman MA, Dean MR, Hanham IW (1965) The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br 47(4):678–685
Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC (1998) Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 19(10):653–660
Handoll HH, Rowe BH, Quinn KM, de Bie R (2001) Interventions for preventing ankle ligament injuries. Cochrane Database of Systematic Reviews. Issue 3, Art. No. CD000018
Hertel J (2000) Functional instability following lateral ankle sprain. Sport Med 29(5):361–371
Holme E, Magnusson SP, Becher K (1999) The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports 9(2):104–109
Houglum PA (1992) Soft tissue healing and its impact on rehabilitation. J Sport Rehabil 1:19–23
Hupperets MD, Verhagen EA, van Mechelen W (2009) Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ 9(339):b2684. doi:10.1136/bmj.b2684
Junge A, Engebretsen L, Mountjoy ML, Alonso JM, Renström PA, Aubry MJ, Dvorak J (2009) Sports injuries during the Summer Olympic Games 2008. Am J Sports Med 37(11):2165–2167
Kerkhoffs GMMJ, Rowe BH, Assendelft AJJ, Kelly K, Struis PAA, van Dijk CN (2002) Immobilisation and functional treatment for acute lateral ligament injuries in adults (Review) Cochrane Database Syst Rev Issue 3, Art. No. CD003762. doi:10.1002/14651858.CD003762
Kerkhoffs GM, Struijs PA, Marti RK, Assendelft WJ, Blankevoort L, van Dijk CN (2002) Different functional treatment strategies for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev 3:CD002938
Kerkhoffs GMMJ, Handoll HHG, de Bie R, Rowe BH, Struis PAA (2007) Surgical vs. conservative treatment for acute injuries of the lateral ligament complex in adults (Review). Cochrane Database Syst Rev Issue 2, Art. No. CD000380. doi:10.1002/14651858.CD00038
Lamb SE, Marsh JL, Hutton JL, Nakash R, Cooke MW (2009) Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Collaborative Ankle Support Trial (CAST Group). Lancet 14;373(9663):575–81
Lardenoye S, Theunissen E, Cleffken B, Brink PR, de Bie RA, Poeze M (2012) The effect of taping versus semi-rigid bracing on patient outcome and satisfaction in ankle sprains: a prospective, randomized controlled trial. BMC Musculoskelet Disord 28(13):81. doi:10.1186/1471-2474-13-81
Malliaropoulos N, Ntessalen M, Papacostas E, Longo UG, Maffulli N (2009) Reinjury after acute lateral ankle sprains in elite track and field athletes. Am J Sports Med 37(9):1755–1761
McGuine TA, Keene JS (2006) The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med 34(7):1103–1111
McGuine TA, Hetzel S, Wilson J, Brooks A. The effect of lace-up ankle braces on injury rates in high school football players. Am J Sports Med 40(1):49–57. doi:10.1177/0363546511422332
McGuine TA, Brooks A, Hetzel S (2011) The effect of lace-up ankle braces on injury rates in high school basketball players. Am J Sports Med 39(9):1840–1848
Mickel TJ, Bottoni CR, Tsuji G, Chang K, Baum L, Tokushige KA (2006) Prophylactic bracing versus taping for the prevention of ankle sprains in high school athletes: a prospective, randomized trial. J Foot Ankle Surg 45(6):360–5
Milgrom C, Shlamkovitch N, Finestone A, Eldad A, Laor A, Danon YL et al (1991) Risk factors for lateral ankle sprains: a prospective study among military recruits. Foot Ankle 12:26–30
Mitchell A, Dyson R, Hale T, Abraham C (2008) Biomechanics of ankle instability. Part 1: Reaction time to simulated ankle sprain. Med Sci Sports Exerc 40(8):1515–1521
Mitchell A, Dyson R, Hale T, Abraham C (2008) Biomechanics of ankle instability. Part 2: Postural sway-reaction time relationship. Med Sci Sports Exerc 40(8):1522–1528
Moher D, Liberati A, Tetzlaff J (2009) Altman DG; PRISMA Group (2004) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 21(339):b2535. doi:10.1136/bmj.b2535
Myers JB, Riemann BL, Hwang JH, Fu FH, Lephart SM (2003) Effect of peripheral afferent alteration of the lateral ankle ligaments on dynamic stability. Am J Sports Med 31(4):498–506
McKeon PO, Hertel J (2008) Systematic review of postural control and lateral ankle instability, part II: is balance training clinically effective? J Athl Train 43(3):305–315
Ogilvie-Harris DJ, Gilbart M (1995) Treatment modalities for soft tissue injuries of the ankle: a critical review. Clin J Sport Med 5(3):175–186
Pauwels F (1960) Eine neue Theorie über den Einfluß mechanischer Reize auf die Differenzierung der Stützgewebe. Zehnter Beitrag zur funktionellen Anatomie und kausalen Morphologie des Stützapparates.Z Anat Entwickl Gesch 121:478–515
Petersen W, Liebau C, Brüggemann GP, Ellermann A, Best R, Gösele-Koppenburg A, Rembitzki IV (2010) Phasenadaptierte Therapie akuter Bandverletzungen des Sprunggelenkes beim Sportler Sport-Orthopädie. Sport Traumatologie Sports Orthopaedics Traumatology 26(4):254–260
Petrella RJ, Petrella MJ, Gogliano A (2007) Periarticular hyaluronic acid in acute ankle sprain. Clin J Sports Med 18:474–475
Pihlajamäki H, Hietaniemi K, Paavola M, Visuri T, Mattila VM (2010) Surgical versus functional treatment for acute ruptures of the lateral ligament complex of the ankle in young men: a randomized controlled trial. J Bone Joint Surg Am 92(14):2367–2374
Riemann BL (2002) Is there a link between chronic ankle instability and postural instability? J Athl Train 37(4):386–393
Riemann BL, Myers JB, Stone DA, Lephart SM (2004) Effect of lateral ankle ligament anesthesia on single-leg stance stability. Med Sci Sports Exerc 36(3):388–396
Smith QW, Street RL Jr, Volk RJ, Fordis M (2012) Differing Levels of Clinical Evidence: Exploring Communication Challenges in Shared Decision Making. Med Care Res Rev (epub ahead of print)
Surve I, Schwellnus MP, Noakes T, Lombard C (1994) A fivefold reduction in the incidence of recurrent ankle sprains in soccer players using the Sport-Stirrup orthosis. Am J Sports Med 22(5):601–606
Sultan MJ, McKeown A, McLaughlin I, Kurdy N, McCollum CN (2012) Elastic stockings or Tubigrip for ankle sprain: a randomised clinical trial. Injury 43(7):1079–1083
Sitler M, Ryan J, Wheeler B, McBride J, Arciero R, Anderson J, Horodyski M (1994) The efficacy of a semirigid ankle stabilizer to reduce acute ankle injuries in basketball. A randomized clinical study at West Point. Am J Sports Med 22(4):454–461
Takao M, Miyamoto W, Matsui K, Sasahara J (2012) Matsushita T (2012) Functional treatment after surgical repair for acute lateral ligament disruption of the ankle in athletes. Am J Sports Med 40(2):447–451
van den Bekerom MP, Kerkhoffs GM, McCollum GA, Calder JD, van Dijk CN (2012) Management of acute lateral ankle ligament injury in the athlete. Knee Surg Sports Traumatol Arthrosc (epub ahead of print)
van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM (2012) What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? J Athl Train 47(4):435–443
van Rijn RM, van Os AG, Kleinrensink GJ, Bernsen RM, Verhaar JA, Koes BW, Bierma-Zeinstra SM (2007) Supervised exercises for adults with acute lateral ankle sprain: a randomised controlled trial. Br J Gen Pract 57(543):793–800
van Rijn RM, van Os AG, Bernsen RMD, Luijsterburg PA, Koes BA, Bierma-Zeinstra SMA (2008) What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med 121:324–331
van Rijn RM, van Heest JA, van der Wees P, Koes BW, Bierma-Zeinstra SM (2009) Some benefit from physiotherapy intervention in the subgroup of patients with severe ankle sprain as determined by the ankle function score: a randomised trial. Aust J Physiother 55(2):107–113
Verhagen RA, de Keizer G, van Dijk CN (1995) Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg 114(2):92–96
Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W (2004) The effect of a proprioceptive balance board training program for the prevention of ankle sprains. A prospective clinical trial. Am J Sports Med 32(6):1385–1393
Verhagen E, Van der Beek AJ, Bouter L, Bahr R, Mechelen W (2004) A one season prospective cohort study of volleyball injuries. Br J Sports Med 38(4):477–481
Verhagen EA, van Tulder M, van der Beek AJ, Bouter LM, van Mechelen W (2005) An economic evaluation of a proprioceptive balance board training programme for the prevention of ankle sprains in volleyball. Br J Sports Med 39(2):111–115
Verhagen EA, Hupperets MD, Finch CF, van Mechelen W (2011) The impact of adherence on sports injury prevention effect estimates in randomised controlled trials: looking beyond the CONSORT statement. J Sci Med Sport 14(4):287–292
Wester JU, Jespersen SM, Nielsen KD, Neumann L (1996) Wobble board training after partial sprains of the lateral ligaments of the ankle: a prospective randomized study. J Orthop Sports Phys Ther 23(5):332–336
Conflict of interest
Prof. Dr. Wolf Petersen is consultant for Otto Bock, Duderstadt und Karl Storz, Tuttlingen.
W. Petersen and R. Best contributed equally to the present work
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Petersen, W., Rembitzki, I.V., Koppenburg, A.G. et al. Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg 133, 1129–1141 (2013). https://doi.org/10.1007/s00402-013-1742-5