1 – Prevent or Eliminate Soft Tissue Swelling
Focal and generalized compression. To appreciate why focal compression around both malleoli in the early stages plays such an important role in the management of uncomplicated lateral ankle sprains, one must recognize that the anatomy of the ankle consists of peaks and valleys—with the lateral and medial malleoli being the peaks and the areas anteroinferior and posterior to the malleoli being the valleys. As a result of soft tissue trauma, swelling accumulates in the “areas of least resistance”—the lateral and medial valleys. Emphasis must be placed on filling these valleys as soon as possible with focal compression to prevent swelling or eliminate swelling that has already occurred (Figure 1).
Compression devices. For years, felt horseshoe pads, secured in position with an elastic wrap, have been the gold standard for focal and generalized compression in the athletic trainer community (Figure 2). However, horseshoe pads can be fabricated from other materials that are typically found in the office, such as 4 × 4 gauze pads (1 packet for each side of the ankle) and ABD (abdominal) pads, or anything that can fill in the valleys and be secured in position with an elastic wrap or bandage (eg, Tubigrip).
Self-adhesive donut pads, which are sold as part of "ankle sprain kits" can also be used to either retain or re-create the valleys. Proper placement is easily achieved by ensuring that the lateral and medial malleoli are in the hole of the donut pad (see Figure 2, C).
Importance of early compression. Too frequently, the importance of focal compression is overlooked as an integral part of the initial management at the time of the injury, and only elastic wrap is applied for compression. However, the use of an elastic wrap alone cannot accommodate the anatomy of the ankle, with its peaks and valleys, and instead forces the ankle into the shape of a cylinder, which allows soft tissue swelling to develop or persist in the lateral and medial valleys. Even if a patient has significant soft tissue swelling, the application of fabricated pads to re-create the lateral and medial valleys, coupled with elevation and motion exercises, can rapidly reduce the swelling.
Duration of compression. With continuous focal and generalized compression (ie, when the compression device is not taken off to shower), soft tissue swelling typically resolves within 24 to 72 hours. This time frame primarily depends on how often and how well the patient elevates the leg and performs motion exercises. The patient can discontinue the use of the focal and generalized compression once the injured ankle shows no evidence of swelling, compared with the noninjured ankle.
Crutches. Patients who have pain with normal (heel-to-toe) gait require crutches. These patients are instructed to walk with a heel-to-toe gait (ie, place weight on their injured ankle rather than carry it in the air) and use pain as the indicator of how much weight they place on the ankle. The crutches can be discontinued once the patient is able to walk normally without pain.
2 – Support and Protect the Ankle
A myriad of braces can support and protect the ankle during the treatment phase. The selection of a brace is based on what the clinician wants the brace to provide. Some clinicians prefer to provide support and protection with a brace as part of the initial treatment. This typically requires a brace that laces up in the front and can accommodate not only the increased girth of the ankle from the soft tissue swelling but also the focal compression pads and elastic wrap. Other clinicians prefer to wait until the swelling resolves before adding a brace to the treatment program; for initial support and protection, they rely on the compression pads, elastic wrap, the patient's shoe, and sprain-induced limited activity.
Regardless of the method of management, the brace used should:
•Be easy to put on.
•Fit comfortably into a shoe.
•Provide the necessary support and protection with ambulation and yet allow the patient to perform motion exercises.
•Continue to support and protect the ankle after the soft tissue swelling resolves.