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Three Part Question

In [adults with lateral ligament ankle sprains] is [immediate mobilisation better than immobilisation in a cast] at [decreasing pain and reducing time to full recovery].

Clinical Scenario

A 28 year old man presents to the emergency department with a swollen, bruised and painful ankle following an inversion injury. After examination and appropriate investigations a grade 2 inversion ankle sprain is diagnosed. You wonder whether early mobilisation or immobilisation in a short leg cast is more suitable for this patient.

Search Strategy

Medline 1966-12/98 using the OVID interface.
[{exp ankle OR ankle$.mp OR exp ankle injuries OR exp ankle joint OR exp lateral ligament, ankle} AND {exp sprains and strains OR sprain$.mp} AND {mobilis$.mp OR mobilisation$.mp OR mobilization$.mp}] LIMIT to human and english language.

Search Outcome

20 papers found of which 15 were irrelevant to the study question or of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hedges JR and Anwar RA 1980 UK	93 patients aged 15-65 with ankle sprains Elastic bandage and early weight bearing vs non-weight bearing plaster splint Followed at 1 week and 8 months	PRCT	Functional disability	No significant difference	Many patients had previous injuries. 8 month follow-up in only 33%.
			Pain	No significant difference
			Swelling	No significant difference
			Recurrent injury	No significant difference
Dettori JR et al 1994 USA	64 military personnel with ankle sprains Plaster cast vs air-stirrup vs elastic wrap for 2 weeks Followed during early course2 and at 1 year3	PRCT	Return to work and running	Quicker with early mobilisation (P=0.029)	Moderate and severe sprains only. Long term follow-up by postal questionnaire
			Range of motion	Significantly more with early mobilisation
			Swelling and pain	Significantly less with early mobilisation
			Difficulty running at 1 year	No significant difference
Eiff MP et al 1994 USA	82 military personnel with ankle sprains Elastic wrap for 2 days followed by air stirrup for 8 days vs non weight-bearing splint for 10 days Followed up at 3 and 6 weeks and 6 and 12 months	PRCT	Return to work	Significantly more likely in elastic wrap group
			Pain	Less pain (P=0.02) at 3 weeks in elastic wrap group
			Residual symptoms	No significant difference
Ogilvie-Harris DJ and Gilbart M 1995 Canada	84 articles on soft tissue ankle injuries	Critical review	Functional outcome	Early mobilisation appears to be better	No formal meta-analysis. Not all studies directly relevant to the study question.
Shrier I 1995 Canada	13 RCTs on ankle sprains	Critical appraisal	Pain	Less with early mobilisation	No formal meta-analysis. Not all studies directly relevant to the study question.
			Swelling	Less with early mobilisation
			Instability	Less with early mobilisation

Comment(s)

While many papers have addressed the question there are few relevant RCTs. The two relevant reviews do not address the question directly and do not attempt formal meta-analysis.

Clinical Bottom Line

Early mobilisation of ankle sprains leads to quicker short term recovery without affecting long term outcome. It is the treatment of choice.

References

1. Hedges JR, Anwar RA. Management of ankle sprains. Ann Emerg Med 1980;9:298-302.
2. Dettori JR, Basmania CJ, Pearson BD et al. Early ankle mobilisation, Pt 1: The immediate effect on acute, lateral ankle sprains. Military Med 1994;159:15-20.
3. Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med 1994;22:83-8.
4. Ogilvie-Harris DJ, Gilbart M. Treatment modalities for soft tissue injuries of the ankle: a critical review. Clin J Sport Med 1995;5:175-86.
5. Shrier I. Treatment of lateral collateral ligament sprains of the ankle: a critical appraisal of the literature. Clin J Sport Med 1995;5:187-95.