Evidence Based Physiotherapy Guideline for Conservative Management of Ankle Sprain

Ankle sprain is considered to be a commonest sports injury
globally [1]. Sprain to the lateral ligaments of ankle in inversion
mechanism consists more than 85% of ankle sprains...

and tracking are the premier sports to incident ankle sprain. Ankle sprain is also evident to be one of the commonest injuries around ankle in non-sports persons [5]. A study estimated 18% of the female athletes trained at BKSP has ankle sprain in Bangladesh [6].
Physiotherapy is one of the primer contributors to conservative management approach for ankle sprain [7] hence there are recommendations to establish a comprehensive physical therapy guideline for ankle sprain in customized to region and cultural context.

Methodology
Authors searched BHPI library database which omit links with publications were Scopus indexed journals. The interventions of the guideline was formulated by synopsis of systematic reviews following PRISMA and RCT's having PEDro score equal or more than 5 out of 10. After the preparation of guideline, authors discussed with senior clinicians having more than 10 years' experience in practicing physiotherapy in Bangladesh to re-check the applicability of the guideline.

Diagnosis of Ankle Sprain
Diagnosis is considered to be the first attempt in managing ankle sprain. Polzer and colleagues reviewed the diagnosis of lateral ankle sprain that is comprehensive to Magnetic resonance imaging findings that nested as sign of inflammation, soft tissue tension test, activity limitations and radiographic findings [8].

Physiotherapy Management Protocol
Brison and colleagues [9] explored a structured scheme for managing ankle sprain cases based on duration and impairments.
The protocol designed to be implemented from 72 hours to 6 weeks after injury. The principle of the protocol advances with the remission of inflammatory sign; improve joint play, promotion of strength and regaining proprioception.

Acute Stage (0-7 days)
Ice application is a gold standard management protocol in all grades of acute ankle sprain [10], recent studies suggests the procedure where ankle is submerged in a cold immersion cylinder in 50-60 degree Fahrenheit for 20 minutes is the superior approach to relieve pain and swelling 3-5 days prior to injury. Some studies suggest ice compression by crushed ice over anterolateral aspect in elevated limb above heart level for 20 minutes twice a day for 7 days has significant effect on pain and swelling in lateral ankle sprain cases. Also, elevation of limbs was noted to put on 25% of total day time for 7 days. Moreover, Protection can be performed by using bandage and tapes [11].

Chronic Stage (21 Days Onwards)
In chronic stage, Neuromuscular training alone or with proprioceptive training found to be effective to improve stability and functional outcome in ankle sprain in a meta-analysis [13]. The customized neuromuscular exercise (Table 1) is recommended to apply for the rehabilitation stage of managing Ankle sprain for one to three sessions a week, with a maximum duration of 30 min per session for 8 weeks. Also, proprioceptive exercises alone (Table 2) found effective measure to regain ankle stability and improving functions in addition to conventional measures in ankle sprain cases [14]. Vasconcelos and colleagues [15]

Exercise mats or floor
Maintain single leg standing on floor and of several thick mattress from 1 to 10 cm. progress from 1 cm to 10 cm in three phases

Tilting table
Maintain standing position in a double and single limb combined with ball throwing and catching.
First 2 weeks perform only double limb stance. Then perform Single limb stance up to 4 weeks and progress to throwing and catching in double and single limb stance.

Oval board
In first 2 weeks, Maintain proper balance in a double and single leg stance. Progress to same work with convex surface on the floor. And in weeks 4/6: Standing position in a double and single limb stance with convex surface on the floor combined with throwing and catching.
Trampoline Start withstanding in a single limb stance in 2 weeks, progress to jumping with affected leg in 4 weeks and ball throwing and catching in 6 weeks.

Foam roller
Start in first 2 weeks by maintaining proper balance on a double limb stance with semicircular foam. Progress to single limb stance in 4 weeks and double and single limb stance on cylindrical foam in 6 weeks.
Studies suggest 6 weeks individualized concentric strength training with balance training improves stability and prevent recurrences in ankle sprain [15]. Home exercises play a vital role in ankle sprain cases. The home exercise designed as per capability and generalized skills of patients or caregiver is an integral approach to conservative management of ankle sprain [16]. Other interventions have been mentioned as Laser therapy, ultrasound, hyperbaric oxygen therapy, platelet rich plasma, hyaluronic acid [17] and these treatments should not be considered as part of the standard regime in treating acute ankle injuries. Return to work or sports are premier concern in rehabilitation. Evidence [18] suggests, in case of distortion injury it takes 2 weeks to return to light work and 3-4 weeks for full restoration to work. And in case of partial or total rupture of ligaments, it takes 3-6 weeks to introduce light work and 6-8 weeks for full restoration of work. The full workload considered as full sitting activities lifting less than10 kg weight. Although, this can vary according to extend and management of injury.

Conclusion
Ankle sprain is one of the prime causes of instability of the ankle leading to functional impairments and decreased participation to sports and work. Conservative management found to be a gold standard treatment option that depends upon the diagnosis and assessing extends of injury. Physiotherapy plays an important role in relieving inflammatory sign, improving function, stability, proprioception and prevention of recurrences.