Evidence for Rehabilitation Interventions After Acute Lateral Ankle Sprains in Athletes: A Scoping Review

in Journal of Sport Rehabilitation

Context: Acute lateral ankle sprain (LAS) is a common injury in athletes and is often associated with decreased athletic performance and, if treated poorly, can result in chronic ankle issues, such as instability. Physical performance demands, such as cutting, hopping, and landing, involved with certain sport participation suggests that the rehabilitation needs of an athlete after LAS may differ from those of the general population. Objective: To review the literature to determine the most effective rehabilitation interventions reported for athletes returning to sport after acute LAS. Evidence Acquisition: Data Sources: Databases PubMed, Embase, CINAHL, SPORTDiscus, and PEDro were searched to July 2020. Study Selection: A scoping review protocol was developed and followed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews guidelines and registered (https://osf.io/bgek3/). Study selection included published articles on rehabilitation for ankle sprain in an athletic population. Data Extraction: Parameters included athlete and sport type, age, sex, intervention investigated, outcome measures, measurement tool, and follow-up period. Data Synthesis: A qualitative synthesis for all articles was undertaken, and a quantitative subanalysis of randomized controlled trials and critical methodological appraisal was also conducted. Evidence Synthesis: A total of 37 articles were included in this review consisting of 5 systematic and 20 narrative reviews, 7 randomized controlled trials, a single-case series, case report, position statement, critically appraised topic, and descriptive study. Randomized controlled trial interventions included early dynamic training, electrotherapy, and hydrotherapy. Conclusions: Early dynamic training after acute LAS in athletes results in a shorter time to return to sport, increased functional performance, and decreased self-reported reinjury. The results of this scoping review support an early functional and dynamic rehabilitation approach when compared to passive interventions for athletes returning to sport after LAS. Despite existing research on rehabilitation of LAS in the general population, a lack of evidence exists related to athletes seeking to return to sport.

Lateral ligament injuries to the ankle are a common musculoskeletal complaint, with an estimated rate of one ankle injury per 10,000 people per day.13 In a sporting population, the incidence is even greater, constituting 15% to 45% of all sport-related injuries.3 When an athlete sustains a lateral ankle sprain (LAS), this can often result in lost playing time, decreased athletic performance and, if treated poorly, chronic ankle issues, such as instability.4 In addition, LAS presents a significant economic burden when medical costs and leave from work are taken into consideration.5 The high frequency of LAS in athletes, alongside the costs of injury management, demonstrate the importance for rehabilitation interventions to be evidence based.

Current research supports nonoperative management for excellent long-term outcomes when compared with surgical intervention in cases not involving a complete ligament rupture.69 The increased costs, intraoperative and postoperative complication risks and prolonged absence that are associated with surgical interventions are also reasons that make conservative management more favorable.911 Clinical practice guidelines have been developed with respect to rehabilitation after LAS; however, these do not appear to inform the efficacy of rehabilitation interventions specific to athletes wishing to return to sport (RTS).10,12

Considering the greater physical requirements, such as cutting, jumping, hopping, and landing, associated with certain sport participation, it would be reasonable to suggest that an athlete’s rehabilitation plan should differ from that of the general population. Therefore, this review aims to scope the literature to determine the most effective rehabilitation interventions reported for athletes returning to sport after sustaining a LAS.

Materials and Methods

Study Design

A scoping review study design was utilized to identify key concepts, knowledge gaps, and types of evidence currently available; the protocol was registered with Open Science Framework (https://osf.io/bgek3/).13

Data Sources and Searches

Two researchers (E.T. and J.M.) conducted the literature search to identify, screen, and select studies to be included in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR).14 The search strategy was developed through the methodological procedure proposed by Arksey and O’Malley13 and Johanna Briggs Institute,15 and followed a 3-step approach:

  1. 1.A pilot search of the database PubMed using the subject headings: ((acute) AND (ankle) AND “sprain OR injury” AND “treat* OR manage* OR rehab* OR therap*” AND “sport* OR athlet* OR “funct* OR exercis*”)
  2. 2.Identification of keywords and terms relating to acute LAS and rehabilitation interventions and RTS.
  3. 3.Execution of the final search strategy and further searching of referenced lists of the selected articles, including systematic and narrative reviews.

A search was formulated and conducted in 5 databases (PubMed, Embase, CINAHL, SPORTDiscus, and PEDro) from inception to 27 July 2020. Articles were downloaded to the EndNote reference management software (http://www.endnote.com/) for selection by E.T. and J.M. according to the PRISMA-ScR statement.14

Study Selection

The eligibility criteria were defined by the population (athletes clinically diagnosed with acute LAS); concept (any study reporting on the effects of rehabilitation interventions for acute LAS); and context (all periods of time, outcomes, comparators, follow-up, RTS setting, and duration and type of intervention). The following types of publications were eligible for inclusion: intervention studies, narrative reviews, scoping reviews, systematic reviews, meta-analysis, case series, and clinical commentaries. Exclusion criteria were (1) non-English language; (2) nonathlete only population; (3) studies involving animals; (4) chronic ankle instability population; (5) fractures and/or dislocations; (6) deltoid ligament, peroneal, syndesmosis injuries; (7) preventative interventions; (8) surgical interventions; and (9) pharmacological interventions. The following were also excluded from our review: conference abstracts/proceedings, magazines and newspaper articles, gray literature, and articles for which the full text was not available.

Data Extraction and Quality Assessment

Data extraction, categorization, and mapping were performed by E.T. and J.M. using methodology adapted from the Joanna Briggs Institute guidelines for scoping reviews.15 The data were extracted into the following categories: (1) author; (2) year; (3) aim/purpose; (4) study population (including demographic details) and size; (5) study design; (6) intervention (type, comparator, duration, and details); (7) outcomes; and (8) key findings.

Data Synthesis and Methodological Quality Appraisal

A qualitative synthesis for all articles was undertaken, and a further quantitative synthesis of randomized controlled trials (RCT) and methodological quality appraisal was included. For critical appraisal, 2 reviewers (E.T. and J.M.) independently scored studies using the PEDro scale. When disagreement existed, a consensus decision was made through discussion. The kappa coefficient statistic was used to measure the interrater reliability and agreement between the 2 reviewers.16 The PEDro scale is a methodological measure of quality used to appraise RCTs; it consists of an 11-item checklist with a maximum possible score of 10.17 Studies of good quality receive a score of greater than 6, fair quality scores are between 4 and 6, and poor studies receive scores of less than 4.18,19

Results

The search strategy yielded 2600 articles, of which 2525 records were removed as duplicates or not meeting the predefined inclusion criteria. Upon completion of the title and abstract screening, 75 articles were retrieved and assessed for eligibility. Subsequently, 38 full-text articles fulfilled the eligibility criteria and were included (Figure 1).

Figure 1
Figure 1

—Flow diagram of included studies.

Citation: Journal of Sport Rehabilitation 31, 4; 10.1123/jsr.2021-0244

The number of published studies relating to rehabilitation interventions following LAS to RTS has been consistent over the last 20 years. Of the 37 articles included in this scoping review, 25 were review articles, comprised of 20 narrative reviews and 5 systematic reviews. Also included were a critically appraised topic, position statement, and a descriptive study (Supplementary Figure S1 [available online]). The 5 systematic reviews investigated a range of interventions including bracing, functional treatment, cryotherapy, manual mobilization, and exercise.20 There were also 7 RCTs included, along with a case series and a case report.

Characteristics of the Included Reviews

There were 5 systematic reviews reported in this review containing 82 original studies (Table 1). The methodological quality of the included articles within the systematic reviews were classified as poor or limited quality. Additionally, methodological quality was not reported in all of the included reviews.7 The 5 systematic reviews contained literature from 1990 to 2012 and there were several outcomes investigated for the rehabilitation of LAS. Two of the reviews investigated early dynamic training.9,21 The remaining 3 articles explored bracing versus functional treatment,7 cryotherapy,22 and exercise and manual therapy.23 A critically appraised topic was included containing 3 studies exploring deep oscillation therapy in athletes with acute LAS.24 A position statement from 2012 proposing an evidence-based clinical guideline to treat LAS was also included in this review.10 This position statement explored the use of early dynamic training, ice and compression, immobilization, electrotherapy, and manual mobilizations. Additionally, a descriptive study relating to the clinical application of cryotherapy was included in this review. The modalities of cryotherapy surveyed included an ice pack, ice pack and cryokinetics, ice immersion, and ice immersion and cryokinetics.25

Table 1

Summary of Included Systematic Reviews

AuthorTitleAimDatesMethodological qualityNumber of studiesKey findings
Kemler et al7A Systematic Review on the Treatment of Acute Ankle Sprain Brace Versus Other Functional Treatment TypesTo evaluate the effectiveness of braces as a treatment compared with functional treatments such as ankle tape and elastic bandages1990–2009Not assessed8A few individual studies reported positive functional outcomes after treatment with an ankle brace compared with other functional methods.
Hubbard et al22Does Cryotherapy Hasten Return to Participation? A Systematic ReviewTo search original research addressing the effect of cryotherapy on return to participation after injury1967–2003Poor quality evidence4Cryotherapy may have a positive effect on return-to-participation measures with the relatively poor quality of the studies reviewed.
Van Der Wees et al23Effectiveness of Exercise Therapy and Manual Mobilisation in Acute Ankle Sprain and Functional Instability: A Systematic ReviewCritically review the effectiveness of exercise therapy and manual mobilization in acute ankle sprains and functional instability by conducting a systematic review of RCTs1966–2005Poor quality evidence17Manual mobilization has an initial positive effect on dorsiflexion ROM.
Petersen et al21Treatment of Acute Ankle Ligament Injuries: A Systematic ReviewTo perform a systematic literature review of the last 10 y regarding evidence for the treatment and prevention of LAS2002–2012Poor quality evidence20Majority of LAS can be managed without surgery. The results support a phase adapted nonsurgical treatment of acute LAS with a short-term immobilization for grade III injuries followed by a semi-rigid brace.
Seah and Mani-Babu9Managing Ankle Sprains in Primary Care: What is Best Practice? A Systematic Review of the Last 10 Years of EvidenceTo summarize the best available evidence in the last decade for managing ankle sprains in the community2000–2009Limited33Management is not readily agreed. In mild-to-moderate sprains, functional treatment was better than immobilization. In severe sprains, short period of immobilization in a cast/brace results in a quicker recovery than compression bandage alone. Supervised rehabilitation with conventional treatment can be beneficial.

Abbreviations: LAS, lateral ankle sprain; RCT, randomized controlled trial; ROM, range of motion. Note: Methodological quality was determined by the individual reviewers, not the authors of this study. The conclusion stated is that of the included review in reference to interventions for rehabilitation following LAS. The number of original studies is only those included in each review.

Characteristics of the Included Intervention Studies

Participants

There was a total of 830 participants across the 7 RCTs and the overall sex ratio was 57% male and 43% female. All RCTs contained both male and female participants apart from one26 which included 22 female participants only; and the average mean age was 27 years. Two studies involved professional athletes (29%), with the remainder of participants in the 5 studies (71%) recreationally or competitively active. The type of sport was unspecified in 5 studies (62.5%). The remainder included the following sports: soccer, football, basketball, mixed martial arts, volleyball, handball, and running. Table 2 provides a summary of participant characteristics across each intervention study including population, type of sport, sample size, age (mean), and gender. The case series contained 3 intercollegiate athletes comprised of 2 males aged 18 and 21, and single female aged 18. The sports of the participants were women’s lacrosse and men’s basketball and soccer.27 The case report examined a 29-year-old male white professional football athlete.28

Table 2

Randomized Controlled Trial Study Characteristics

AuthorTitlePopulationSportNumber of participantsAge (mean)Sex
MaleFemale
Razzano et al.34Noninvasive Interactive Neurostimulation Therapy for the Treatment of Low-Grade Lateral Ankle Sprain in the Professional Contact Sport Athlete Improves the Short-Term Recovery and Return to SportProfessional athletes with a diagnosis of grade I or II LAS that occurred during a contact sport competitionSoccer, football, basketball, and mixed martial arts61232710
Kim et al26Aquatic Versus Land-Based Exercises as Early Functional Rehabilitation for Elite Athletes with Acute Lower Extremity Ligament InjuryProfessional athletes with isolated grade I or II ligament injury in ankleUnspecified2226022
Karlsson et al33Early Functional Treatment for Acute Ligament Injuries of the Ankle JointRecreational or competitive athletes with acute (<24 h) grade I or II lateral ligament rupturesUnspecified86225729
Van Der Linde and Oschman29Comparative Ultrasound Study of Acute Lateral Ankle Ligament Injuries Rehabilitated With Conventional, and Jump Stretch Flex Band ProgramsActive athletes who sustained grade I or grade II ankle ligamentous injuriesUnspecified2521.6196
Holme et al30The Effect of Supervised Rehabilitation on Strength, Postural Sway, Position Sense and Reinjury Risk After Acute Ankle Ligament SprainRecreational athletesUnspecified92264427
Ismail et al31Plyometric Training Versus Resistive Exercises After Acute Lateral Ankle SprainAthletes with grade I or II lateral ankle sprainBasketball, handball, football, and running22271111
Hupperts et al32Effect of Unsupervised Home-Based Proprioceptive Training on Recurrences of Ankle SprainRecreational athletes with a lateral ankle sprain < 2 moUnspecified52248136120

Abbreviation: LAS, lateral ankle sprain.

Intervention Type and Effectiveness

The most investigated intervention in the RCTs was early dynamic training (5 studies),2933 while one study examined the electromodality, noninvasive interactive neurostimulation,34 and one study examined aquatic therapy.26 Early dynamic training included a combination of early weight bearing, range of motion exercises, proprioceptive or balance training, running and plyometrics, resistance strength training, or functional rehabilitation. Hydrotherapy showed more effective improvements in pain than standard land-based therapy.26 Noninvasive interactive neurostimulation was effective in improving short-term outcomes, however showed no significant difference in long-term outcomes to RTS.34

Early dynamic training was effective in increasing functional performance, strength, postural control, decreasing recess fluid, and a shortened time to RTS.2933 All reported key findings and intervention details can be found in Tables 3 and 4, respectively. The case series explored the use of the Mulligan Concept Mobilization with Movement, and all 3 participants from this study showed an increase in pain-free function at the 1-month follow-up.27 The application of acute hydrotherapy with supersaturated hydrogen-rich water for acute LAS was supported in the case report. This study indicated multisession hydrotherapy within the first 24 hours may provide benefits in terms of pain, swelling reduction, and range of motion.28

Table 3

Study Aims and Key Findings

AuthorAimKey findings/conclusionPEDro score /10
Razzano et al.34To compare the results of improvement of a foot functional score, lower level of reported pain, and return to sports in 2 groups of contact sport athletes affected by a grade I or II LASNoninvasive interactive neurostimulation can improve short-term outcomes that can hasten RTS in athletes with acute grade I or II ankle sprain6
Kim et al26To compare outcomes between aquatic and land-based exercises during early-phase recovery from acute lower-extremity ligament injuries in elite athletesAquatic therapy showed more rapid improvement in pain compared with land-based interventions6
Karlsson et al33To compare 2 different nonsurgical treatment modalities in patients with grade I and II LASEarly dynamic training resulted in an earlier RTS4
Van Der Linde and Oschman29To establish the difference in rehabilitation outcomes between the JSFB program and conventional ankle rehabilitation programs of acute LASThe JSFB group showed a decrease in anterior/posterior recess fluid, increase in ligament size, and shortened time to RTS5
Holme et al30The effect of an early rehabilitation program, including postural training, on ankle joint function after LASSupervised early dynamic training showed an increase in isometric ankle strength and postural control3
Ismail et al31To determine the effects of plyometric training vs resistive exercises on muscle strength and function following acute LASPlyometric training improved functional performance after LAS with the combined effect of strength and speed enhancement6
Hupperts et al32To evaluate the effectiveness of an unsupervised proprioceptive training program on recurrences of ankle sprain after usual care in athletes who had sustained an acute sports-related LASProprioceptive training program is effective for the prevention of self-reported recurrences8

Abbreviations: JSFB, Jump Stretch Flex Band; LAB, lateral ankle sprain; RTS, return to sport.

Table 4

Intervention and Outcome Details

AuthorIntervention detailsOutcomeMeasurement tool: unitFollow-up
Razzano et al.34Electro-modalities: noninvasive interactive neurostimulation vs sham device1. Pain

2. Self-Reported Functional Impairment Walking Ability
1. VAS: 0–10

2. IWS: 0–10
2 and 4 mo
Kim et al26Aquatic therapy: aquatic therapy vs land-based exercise1. Pain

2. Static/dynamic stability (Biodex Balance System)

3. Percentage single-limb support time (GAITRite, CIR Systems, Inc., Franklin, NJ)
1. VAS: 100 mm line

2. Biodex Medical System, Electric scale level 1–3

3. Instrumented walkway system, GAITRite: seconds
N/A
Karlsson et al33Early dynamic training: compression pads, early weight bearing, ROM training vs compression wrapping, PWB, and crutches1. Stability

2. Pain

3. Swelling

4. Stiffness

5. Work/sport/activities of daily living

6. Running

7. Stair climbing

8. Support
1–8. Orthopedic surgeon scoring scale: 0–10018 mo
Van Der Linde and Oschman29Early dynamic training: JSFB with ultrasound vs conventional ankle rehabilitation with ultrasound1. Change in ligament size

2. Decrease of fluid in anterior/posterior recess

3. Time until RTS
1–2. Ultrasound machine (7.5–14 MHz linear probe): to the closest 0.01 mm

3. Calendar: days
N/A
Holme et al30Early dynamic training: early ankle mobilization, strength, mobility vs supervised physiotherapy1. Position sense

2. Isometric strength

3. Postural sway
1. Torsiometer: degrees

2. Dynamometer: N·m

3. Force platform: cm
12 mo
Ismail et al31Early dynamic training: plyometric training vs resistive exercises1. Climbing downstairs

2. Raising on heel

3. Raising on toes

4. Single-limb stance

5. Eversion/inversion strength
1. Stopwatch: seconds

2–3. Number repetitions: numerical

4. Stopwatch: seconds

5. Dynamometer: N·m/kg
N/A
Hupperts et al32Early dynamic training: usual care (any form of rehabilitation used by an athlete) vs usual care and proprioceptive training1. Self- reported ankle sprain1. Number of incidences: numerical12 mo

Abbreviations: IWS, Inability Walking Scale; JSFB, Jump Stretch Flex Band program; N/A, not applicable; PWB, partial weight bearing; ROM, range of motion; RTS, return to sport; VAS, visual analog scale.

Outcome Measures

Although a range of outcome measures were utilized across the included RCTs (Table 4), the most common were those related to pain and swelling. The visual analog scale was frequently used to assess pain while the measurement tool to assess swelling was inconsistent across the studies. Only 2 RCTs listed time until RTS as an outcome measure.29,33 The follow-up time for an outcome measure varied between studies with the shortest being 3 days and longest 18 months.33,35 Not all studies included a follow-up assessment.26,29,31 The case series utilized outcome measures examining pain, functional limitations, balance, and self-reported ability to weight bear.27 The case report focused on outcome measures relating to pain, swelling, and weight bearing during lunge.28

Methodological Quality

The methodological quality of the 7 RCTs was assessed using the PEDro scale (Supplementary Table S1 [available online]). The methodological quality in the included articles varied, ranging from 3 to 8 points out of a possible 10 (Table 3). The mean PEDro score was 5.42 out of 10, meaning overall, the studies are classified as fair quality. One study30 demonstrated poor methodological quality, scoring 3/10. Four studies (57%) were classified as fair quality and 2 studies (28%) classified as good quality. None of the studies blinded subjects or therapists. All studies had a between-group comparison.

The interrater agreeability between the 2 reviewers was 81% (6 of 7 items). The kappa score for the measure of agreement between the 2 reviewers on the individual validity was .86 indicating an almost perfect agreement.16 The case series noted a limited number of participants, lack of control group, and randomization of selected interventions as a limitation of the study.27 Similarly, the case report also cited the small number of participants along with a relatively short period of intervention and no medium- or long-term efficacy of topical hydrogen as limitations.28

Discussion

Main Findings

The purpose of this scoping review was to systematically identify the scientific literature reporting on rehabilitation interventions for athletes’ RTS after acute LAS and to (1) provide the type and efficacy of interventions utilized, (2) summarize the studies completed to date, and (3) identify any knowledge gaps to inform future research. This review demonstrated that while there was supporting evidence for the use of early dynamic training to rehabilitate athletes postacute LAS, the evidence was of low to moderate quality.2933 These findings are consistent with existing literature that recommends a combination of early weight-bearing exercises such as proprioception, resistance, plyometric, and functional training.3640

An ankle sprain can result in reduced strength and postural control, which can increase risk of reinjury and delay RTS. Given the high-level maneuvers associated with sport, rehabilitation interventions targeting strength, force production, and functional endurance have been shown to have favorable outcomes.2933 In the early stages of a rehabilitation program following LAS, hydrotherapy was shown to provide advantages over standard land-based therapy for a sooner RTS.26 Following the acute stage, progressive controlled rehabilitation involving jump stretch flex bands and postural sway showed positive outcomes following LAS and should be considered for inclusion in RTS training protocols. Additionally, rehabilitation programs involving plyometric exercises such as cone hops with 180° turn and diagonal cone hops improved functional performance after LAS with the combined effect of strength and speed enhancement.29,30 While passive treatments such as noninvasive interactive neurostimulation may improve short-term outcomes, such as pain, however long-term outcomes show no significant difference on an athlete’s ability to RTS.34

The results of one systematic review favored early mobilization, early exercise, and external ankle support, which may allow a safer and quicker RTS.7 Although this review provided support for functional treatment, the population of interest was not athletes only. Moreover, none of the included systematic reviews had a sole focus on athletes RTS; instead, athletes were combined with the general population in all analyses.7,9,2123 Most sports require movement patterns that involve a combination of forces in multiple directions whilst maintaining the need for optimal technique.41 Given the increased multidirectional forces associated with sports when compared with a typical walking pattern, the increased demands of an athletic population when developing a rehabilitation program should be considered. However, the current body of evidence available is largely focused on nonathletic populations or recreational athletes, which utilize RTS as a secondary outcome.

Limitations

Limitations of this review include the lack of RCTs available on LAS with respect to athletes and RTS and the relatively poor methodological quality of those studies that were available. Although the inclusion criteria for this scoping review was broad, articles not available in English or full text were excluded. Due to the considerable heterogeneity of the interventions and outcomes reported, it remains a challenge for clinicians working with a RTS population to base rehabilitation protocols after LAS on evidence-based practice.

Clinical and Research Implications

Clinicians should utilize the best available evidence within clinical practice to maximize positive outcomes. Through sport-specific rehabilitation, athletes may report less weakness, and achieve greater return to baseline biomechanics and motor patterns of sporting movements. Clinicians should monitor the progression through a multidisciplinary approach involving the medical team, coaches, and athlete using sport-specific outcomes measures, on-field performance, and the athlete’s confidence. Our findings are consistent with other recommendations, which suggest that an active rehabilitation protocol is superior to passive treatment techniques for RTS.12 A combination of short-term immobilization, external ankle support, and early dynamic training such as proprioception, strength, and balance exercises, should be utilized to produce optimal outcomes for athletes wishing to RTS.9,21,38 As previously noted, a limitation of this review was the lack of high-quality RCTs investigating these interventions in an athlete only, RTS population. A consideration for the direction of future research would be for clinical trial design on this topic to be of high quality and consistent use of relevant outcome measures, such as athlete reinjury.

Conclusions

The results of this scoping review provide moderate-quality evidence to support an early weight-bearing and dynamic exercise rehabilitation approach, in contrast to passive or restrictive interventions in rehabilitation protocols for athletes after LAS. Given the higher physical requirements in certain sports like cutting, jumping, and hopping, rehabilitation should be specific to these demands.

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    van der Wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J, de Bie RA. Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: a systematic review. Aust J Physiother. 2006;52(1):2737. PubMed ID: 16515420 doi:10.1016/S0004-9514(06)70059-9

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Hausmann M, Ober J, Lepley AS. The effectiveness of deep oscillation therapy on reducing swelling and pain in athletes with acute lateral ankle sprains. J Sport Rehabil. 2019;28(8):902905. PubMed ID: 30526277 doi:10.1123/jsr.2018-0152

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Hawkins SW, Hawkins JR. Clinical applications of cryotherapy among sports physical therapists. Int J Sports Phys Ther. 2016;11(1):141148. PubMed ID: 26900509

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Kim E, Kim T, Kang H, Lee J, Childers MK. Aquatic versus land-based exercises as early functional rehabilitation for elite athletes with acute lower extremity ligament injury: a pilot study. PM R. 2010;2(8):703712. PubMed ID: 20598958 doi:10.1016/j.pmrj.2010.03.012

    • Crossref
    • PubMed
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    • Export Citation
  • 27.

    May JM, Nasypany A, Paolino J, Baker R, Seegmiller J. Patient outcomes utilizing the mulligan concept of mobilization with movement to treat intercollegiate patients diagnosed with lateral ankle sprain: an a priori case series. J Sport Rehabil. 2017;26(6):486496. PubMed ID: 27834613 doi:10.1123/jsr.2015-0204

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    • PubMed
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    • Export Citation
  • 28.

    Javorac D, Stajer V, Ostojic S. Case report: acute hydrotherapy with super-saturated hydrogen-rich water for ankle sprain in a professional athlete. F1000Res. 2020;9:245. PubMed ID: 32399209 doi:10.12688/f1000research.22850.1

    • Crossref
    • Search Google Scholar
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  • 29.

    Van Der Linde E, Oschman Z. Comparative ultrasound study of acute lateral ankle ligament injuries rehabilitated with conventional and jump stretch flex band programmes. Afr J Phys Health Educ Recreat Dance. 2011;17(4):591602.

    • Search Google Scholar
    • Export Citation
  • 30.

    Holme E, Magnusson SP, Becher K, Bieler T, Aagaard P, Kjaer M. 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. 1999;9(2):104109. PubMed ID: 10220845 doi:10.1111/j.1600-0838.1999.tb00217.x

    • Crossref
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  • 31.

    Ismail MM, Ibrahim MM, Youssef EF, El Shorbagy KM. Plyometric training versus resistive exercises after acute lateral ankle sprain. Foot Ankle Int. 2010;31(6):523530. PubMed ID: 20557819 doi:10.3113/FAI.2010.0523

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Hupperets MD, Verhagen EA, van Mechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ. 2009;339:b2684. PubMed ID: 19589822 doi:10.1136/bmj.b2684

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Karlsson J, Eriksson BI, Swärd L. Early functional treatment for acute ligament injuries of the ankle joint. Scand J Med Sci Sports. 1996;6(6):341345. PubMed ID: 9046544 doi:10.1111/j.1600-0838.1996.tb00104.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Razzano C, Izzo R, Savastano R, Colantuoni C, Carbone S. Noninvasive interactive neurostimulation therapy for the treatment of low-grade lateral ankle sprain in the professional contact sport athlete improves the short-term recovery and return to sport: a randomized controlled trial. J Foot Ankle Surg. 2019;58(3):441446. PubMed ID: 30910488 doi:10.1053/j.jfas.2018.09.009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Nunes GS, Vargas VZ, Wageck B, Hauphental DP, da Luz CM, de Noronha M. Kinesio Taping does not decrease swelling in acute, lateral ankle sprain of athletes: a randomised trial. J Physiother. 2015;61(1):2833. PubMed ID: 25499648 doi:10.1016/j.jphys.2014.11.002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36.

    Anderson SJ. Acute ankle sprains: keys to diagnosis and return to play. Phys Sportsmed. 2002;30(12):2935. PubMed ID: 20086506 doi:10.3810/psm.2002.12.579

  • 37.

    Kennedy JG, Hodgkins CW, Sculco P, Carter T, Robinson SP. Sports injuries of the foot and ankle in the adolescent athlete. Int Sport Med J. 2006;7(2):8597.

    • Search Google Scholar
    • Export Citation
  • 38.

    McKeon PO, Donovan L. A perceptual framework for conservative treatment and rehabilitation of ankle sprains: an evidence-based paradigm shift. J Athl Train. 2019;54(6):628638. PubMed ID: 31135210 doi:10.4085/1062-6050-474-17

    • Crossref
    • PubMed
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  • 39.

    Hudson Z. Rehabilitation and return to play after foot and ankle injuries in athletes. Sports Med Arthrosc Rev. 2009;17(3):203207. PubMed ID: 19680118 doi:10.1097/JSA.0b013e3181a5ce96

    • Crossref
    • PubMed
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  • 40.

    van den Bekerom MP, Kerkhoffs GM, McCollum GA, Calder JD, van Dijk CN. Management of acute lateral ankle ligament injury in the athlete. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):13901395. PubMed ID: 23108678 doi:10.1007/s00167-012-2252-7

    • Crossref
    • PubMed
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    • Export Citation
  • 41.

    Kolt GS. Research on the ankle in sport. J Sci Med Sport. 2013;16(5):387. PubMed ID: 23891051 doi:10.1016/j.jsams.2013.07.001

The authors are with the Bond Institute of Health and Sport, Bond University, Robina, QLD, Australia.

Tee (eugenetee93@gmail.com) is corresponding author.
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    van der Wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J, de Bie RA. Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: a systematic review. Aust J Physiother. 2006;52(1):2737. PubMed ID: 16515420 doi:10.1016/S0004-9514(06)70059-9

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    • PubMed
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    Hausmann M, Ober J, Lepley AS. The effectiveness of deep oscillation therapy on reducing swelling and pain in athletes with acute lateral ankle sprains. J Sport Rehabil. 2019;28(8):902905. PubMed ID: 30526277 doi:10.1123/jsr.2018-0152

    • Crossref
    • PubMed
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    • Export Citation
  • 25.

    Hawkins SW, Hawkins JR. Clinical applications of cryotherapy among sports physical therapists. Int J Sports Phys Ther. 2016;11(1):141148. PubMed ID: 26900509

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Kim E, Kim T, Kang H, Lee J, Childers MK. Aquatic versus land-based exercises as early functional rehabilitation for elite athletes with acute lower extremity ligament injury: a pilot study. PM R. 2010;2(8):703712. PubMed ID: 20598958 doi:10.1016/j.pmrj.2010.03.012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    May JM, Nasypany A, Paolino J, Baker R, Seegmiller J. Patient outcomes utilizing the mulligan concept of mobilization with movement to treat intercollegiate patients diagnosed with lateral ankle sprain: an a priori case series. J Sport Rehabil. 2017;26(6):486496. PubMed ID: 27834613 doi:10.1123/jsr.2015-0204

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Javorac D, Stajer V, Ostojic S. Case report: acute hydrotherapy with super-saturated hydrogen-rich water for ankle sprain in a professional athlete. F1000Res. 2020;9:245. PubMed ID: 32399209 doi:10.12688/f1000research.22850.1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29.

    Van Der Linde E, Oschman Z. Comparative ultrasound study of acute lateral ankle ligament injuries rehabilitated with conventional and jump stretch flex band programmes. Afr J Phys Health Educ Recreat Dance. 2011;17(4):591602.

    • Search Google Scholar
    • Export Citation
  • 30.

    Holme E, Magnusson SP, Becher K, Bieler T, Aagaard P, Kjaer M. 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. 1999;9(2):104109. PubMed ID: 10220845 doi:10.1111/j.1600-0838.1999.tb00217.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Ismail MM, Ibrahim MM, Youssef EF, El Shorbagy KM. Plyometric training versus resistive exercises after acute lateral ankle sprain. Foot Ankle Int. 2010;31(6):523530. PubMed ID: 20557819 doi:10.3113/FAI.2010.0523

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Hupperets MD, Verhagen EA, van Mechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ. 2009;339:b2684. PubMed ID: 19589822 doi:10.1136/bmj.b2684

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Karlsson J, Eriksson BI, Swärd L. Early functional treatment for acute ligament injuries of the ankle joint. Scand J Med Sci Sports. 1996;6(6):341345. PubMed ID: 9046544 doi:10.1111/j.1600-0838.1996.tb00104.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Razzano C, Izzo R, Savastano R, Colantuoni C, Carbone S. Noninvasive interactive neurostimulation therapy for the treatment of low-grade lateral ankle sprain in the professional contact sport athlete improves the short-term recovery and return to sport: a randomized controlled trial. J Foot Ankle Surg. 2019;58(3):441446. PubMed ID: 30910488 doi:10.1053/j.jfas.2018.09.009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Nunes GS, Vargas VZ, Wageck B, Hauphental DP, da Luz CM, de Noronha M. Kinesio Taping does not decrease swelling in acute, lateral ankle sprain of athletes: a randomised trial. J Physiother. 2015;61(1):2833. PubMed ID: 25499648 doi:10.1016/j.jphys.2014.11.002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36.

    Anderson SJ. Acute ankle sprains: keys to diagnosis and return to play. Phys Sportsmed. 2002;30(12):2935. PubMed ID: 20086506 doi:10.3810/psm.2002.12.579

  • 37.

    Kennedy JG, Hodgkins CW, Sculco P, Carter T, Robinson SP. Sports injuries of the foot and ankle in the adolescent athlete. Int Sport Med J. 2006;7(2):8597.

    • Search Google Scholar
    • Export Citation
  • 38.

    McKeon PO, Donovan L. A perceptual framework for conservative treatment and rehabilitation of ankle sprains: an evidence-based paradigm shift. J Athl Train. 2019;54(6):628638. PubMed ID: 31135210 doi:10.4085/1062-6050-474-17

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Hudson Z. Rehabilitation and return to play after foot and ankle injuries in athletes. Sports Med Arthrosc Rev. 2009;17(3):203207. PubMed ID: 19680118 doi:10.1097/JSA.0b013e3181a5ce96

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    van den Bekerom MP, Kerkhoffs GM, McCollum GA, Calder JD, van Dijk CN. Management of acute lateral ankle ligament injury in the athlete. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):13901395. PubMed ID: 23108678 doi:10.1007/s00167-012-2252-7

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41.

    Kolt GS. Research on the ankle in sport. J Sci Med Sport. 2013;16(5):387. PubMed ID: 23891051 doi:10.1016/j.jsams.2013.07.001

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