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Background: Despite being the most commonly incurred sports injury with a high recurrence rate, there are no guidelines to inform return to sport (RTS) decisions following acute lateral ankle sprain injuries. We aimed to develop a list of assessment items to address this gap., Methods: We used a three-round Delphi survey approach to develop consensus of opinion among 155 globally diverse health professionals working in elite field or court sports. This involved surveys that were structured in question format with both closed-response and open-response options. We asked panellists to indicate their agreement about whether or not assessment items should support the RTS decision after an acute lateral ankle sprain injury. The second and third round surveys included quantitative and qualitative feedback from the previous round. We defined a priori consensus being reached at >70% agree or disagree responses., Results: Sixteen assessment items reached consensus to be included in the RTS decision after an acute lateral ankle sprain injury. They were mapped to five domains with 98% panellist agreement-PAASS: P ain (during sport participation and over the last 24 hours), A nkle impairments (range of motion; muscle strength, endurance and power), A thlete perception (perceived ankle confidence/reassurance and stability; psychological readiness), S ensorimotor control (proprioception; dynamic postural control/balance), S port/functional performance (hopping, jumping and agility; sport-specific drills; ability to complete a full training session)., Conclusion: Expert opinion indicated that pain severity, ankle impairments, sensorimotor control, athlete perception/readiness and sport/functional performance should be assessed to inform the RTS decision following an acute lateral ankle sprain injury., Trial Registration Number: ACTRN12619000522112., Competing Interests: Competing interests: KT, TB, OBAO, ED and EV are on the BJSM Editorial Board., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

This guideline aimed to advance current understandings regarding the diagnosis, prevention and therapeutic interventions for ankle sprains by updating the existing guideline and incorporate new research. A secondary objective was to provide an update related to the cost-effectiveness of diagnostic procedures, therapeutic interventions and prevention strategies. It was posited that subsequent interaction of clinicians with this guideline could help reduce health impairments and patient burden associated with this prevalent musculoskeletal injury. The previous guideline provided evidence that the severity of ligament damage can be assessed most reliably by delayed physical examination (4-5 days post trauma). After correct diagnosis, it can be stated that even though a short time of immobilisation may be helpful in relieving pain and swelling, the patient with an acute lateral ankle ligament rupture benefits most from use of tape or a brace in combination with an exercise programme. New in this update: Participation in certain sports is associated with a heightened risk of sustaining a lateral ankle sprain. Care should be taken with non-steroidal anti-inflammatory drugs (NSAIDs) usage after an ankle sprain. They may be used to reduce pain and swelling, but usage is not without complications and NSAIDs may suppress the natural healing process. Concerning treatment, supervised exercise-based programmes preferred over passive modalities as it stimulates the recovery of functional joint stability. Surgery should be reserved for cases that do not respond to thorough and comprehensive exercise-based treatment. For the prevention of recurrent lateral ankle sprains, ankle braces should be considered as an efficacious option., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Ankle sprains are highly prevalent with high risk of recurrence. Consequently, there are a significant number of research reports examining strategies for treating and preventing acute and recurrent sprains (otherwise known as chronic ankle instability (CAI)), with a coinciding proliferation of review articles summarising these reports., Objective: To provide a systematic overview of the systematic reviews evaluating treatment strategies for acute ankle sprain and CAI., Design: Overview of intervention systematic reviews., Participants: Individuals with acute ankle sprain/CAI., Main Outcome Measurements: The primary outcomes were injury/reinjury incidence and function., Results: 46 papers were included in this systematic review. The reviews had a mean score of 6.5/11 on the AMSTAR quality assessment tool. There was strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence of an ankle sprain. For the combined outcomes of pain, swelling and function after an acute sprain, there was strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques. There was conflicting evidence regarding the efficacy of surgery and acupuncture for the treatment of acute ankle sprains. There was insufficient evidence to support the use of ultrasound in the treatment of acute ankle sprains., Conclusions: For the treatment of acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function. Exercise therapy and bracing are supported in the prevention of CAI., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Unlabelled: Ice hockey is a high contact sport where players are inherently at an increased risk for traumatic and time-loss injury. With its increasing popularity and high incidence of injury, further research is necessary to understand the risks and injuries associated with the sport and to develop performance-based outcome measures to guide return to play. This review, tailored to the practicing sports medicine team physician, focuses on the stepwise identification, treatment, time loss, return to play and subsequent risk of injury for the most common areas of injury: the head, shoulder, hip and knee. Injuries were categorised into upper and lower extremity with an emphasis on glenohumeral and acromioclavicular joint injuries, femoroacetabular impingement, medial collateral ligament tears, and high ankle sprains. With return to play a primary goal for these high-level athletes, recovery in ice hockey becomes a complex issue with efficient protocols tailored to the requirements of the sport vital to the athlete and clinician alike. By reviewing the treatments and sport-specific care, athletes can be better managed with the ultimate goal of returning to their preinjury level of play., Level of Evidence: Level IV.

Ankle injuries are a huge medical and socioeconomic problem. Many people have a traumatic injury of the ankle, most of which are a result of sports. Total costs of treatment and work absenteeism due to ankle injuries are high. The prevention of recurrences can result in large savings on medical costs. A multidisciplinary clinical practice guideline was developed with the aim to prevent further health impairment of patients with acute lateral ankle ligament injuries by giving recommendations with respect to improved diagnostic and therapeutic opportunities. The recommendations are based on evidence from published scientific research, which was extensively discussed by the guideline committee. This clinical guideline is helpful for healthcare providers who are involved in the management of patients with ankle injuries.

Background: Acute ankle sprains are usually managed functionally, with advice to undertake progressive weight-bearing and walking. Mechanical loading is an important modular of tissue repair; therefore, the clinical effectiveness of walking after ankle sprain may be dose dependent. The intensity, magnitude and duration of load associated with current functional treatments for ankle sprain are unclear., Aim: To describe physical activity (PA) in the first week after ankle sprain and to compare results with a healthy control group., Methods: Participants (16-65 years) with an acute ankle sprain were randomised into two groups (standard or exercise). Both groups were advised to apply ice and compression, and walk within the limits of pain. The exercise group undertook additional therapeutic exercises. PA was measured using an activPAL accelerometer, worn for 7 days after injury. Comparisons were made with a non-injured control group., Results: The standard group were significantly less active (1.2 ± 0.4 h activity/day; 5621 ± 2294 steps/day) than the exercise (1.7 ± 0 .7 h/day, p=0.04; 7886 ± 3075 steps/day, p=0.03) and non-injured control groups (1.7 ± 0.4 h/day, p=0.02; 8844 ± 2185 steps/day, p=0.002). Also, compared with the non-injured control group, the standard and exercise groups spent less time in moderate (38.3 ± 12.7 min/day vs 14.5 ± 11.4 min/day, p=0.001 and 22.5 ± 15.9 min/day, p=0.003) and high-intensity activity (4.1 ± 6.9 min/day vs 0.1 ± 0.1 min/day, p=0.001 and 0.62 ± 1.0 min/day p=0.005)., Conclusion: PA patterns are reduced in the first week after ankle sprain, which is partly ameliorated with addition of therapeutic exercises. This study represents the first step towards developing evidence-based walking prescription after acute ankle sprain.

Ice is commonly used after acute muscle strains but there are no clinical studies of its effectiveness. By comparison, there are a number of basic scientific studies on animals which show that applying ice after muscle injury has a consistent effect on a number of important cellular and physiological events relating to recovery. Some of these effects may be temperature dependant; most animal studies induce significant reductions in muscle temperature at the injury site. The aim of this short report was to consider the cooling magnitudes likely in human models of muscle injury and to discuss its relevance to the clinical setting. Current best evidence shows that muscle temperature reductions in humans are moderate in comparison to most animal models, limiting direct translation to the clinical setting. Further important clinical questions arise when we consider the heterogenous nature of muscle injury in terms of injury type, depth and insulating adipose thickness. Contrary to current practice, it is unlikely that a 'panacea' cooling dose or duration exists in the clinical setting. Clinicians should consider that in extreme circumstances of muscle strain (eg, deep injury with high levels of adipose thickness around the injury site), the clinical effectiveness of cooling may be significantly reduced.

Objective: Ankle sprain is the most frequently occurring acute injury in tennis, accounting for 20-25% of all injuries. In the current paper, we assess the cause of ankle sprain and suggest possibilities to be considered during diagnosis., Methods: We assessed a professional tennis player with a partial tear of the long peroneal tendon after an ankle sprain by physical exam, X-ray and MRI., Results: Conservative treatment by means of soft cast and propriocepsis training led to full recovery., Conclusion: Peroneal tendon disorders must be part of the differential diagnosis after ankle sprain in the professional athlete.

Background: The use of cryotherapy in the management of acute soft tissue injury is largely based on anecdotal evidence. Preliminary evidence suggests that intermittent cryotherapy applications are most effective at reducing tissue temperature to optimal therapeutic levels. However, its efficacy in treating injured human subjects is not yet known., Objective: To compare the efficacy of an intermittent cryotherapy treatment protocol with a standard cryotherapy treatment protocol in the management of acute ankle sprains., Subjects: Sportsmen (n = 44) and members of the general public (n = 45) with mild/moderate acute ankle sprains., Methods: Subjects were randomly allocated, under strictly controlled double blind conditions, to one of two treatment groups: standard ice application (n = 46) or intermittent ice application (n = 43). The mode of cryotherapy was standardised across groups and consisted of melting iced water (0 degrees C) in a standardised pack. Function, pain, and swelling were recorded at baseline and one, two, three, four, and six weeks after injury., Results: Subjects treated with the intermittent protocol had significantly (p<0.05) less ankle pain on activity than those using a standard 20 minute protocol; however, one week after ankle injury, there were no significant differences between groups in terms of function, swelling, or pain at rest., Conclusion: Intermittent applications may enhance the therapeutic effect of ice in pain relief after acute soft tissue injury.

A common soft tissue injury in sports involving sprinting and jumping is the hamstring strain. A major problem with hamstring strains is the high incidence of reinjury. Muscle injuries can be classified as direct or indirect and are typically grouped into three categories according to severity. A number of potential risk factors have been proposed for hamstring strains. Only a few are evidence based and some are mainly based on theoretical assumptions. There is a lack of clinical research on the effectiveness of rehabilitation programmes for hamstring strains. Although the initial treatment of rest, ice, compression, and elevation is accepted for muscle strains, no consensus exists for their rehabilitation. Not much evidence based research has been carried out on prevention of hamstring strain. To our knowledge only two prospective studies have so far been published. As the injuries are common in football and other sports involving sprinting and jumping, there is a need for further research preferably in the form of randomised controlled trials.

Background: Ankle sprains are common sporting injuries generally believed to be benign and self limiting. However, some studies report a significant proportion of patients with ankle sprains having persistent symptoms for months or even years., Aims: To determine the proportion of patients presenting to an Australian sports medicine clinic who had long term symptoms after a sports related inversion ankle sprain., Methods: Consecutive patients referred to the NSW Institute of Sports Medicine from August 1999 to August 2002 with inversion ankle sprain were included. Exclusion criteria were fracture, ankle surgery, or concurrent lower limb problems. A control group, matched for age and sex, was recruited from patients attending the clinic for upper limb injuries in the same time period. Current ankle symptoms, ankle related disability, and current health status were ascertained through a structured telephone interview., Results: Nineteen patients and matched controls were recruited and interviewed. The mean age in the ankle group was 20 (range 13-28). Twelve patients (63%) were male. Average follow up was 29 months. Only five (26%) ankle injured patients had recovered fully, with no pain, swelling, giving way, or weakness at follow up. None of the control group reported these symptoms (p<0.0001). Assessments of quality of life using short form-36 questionnaires (SF36) revealed a difference in the general health subscale between the two groups, favouring the control arm (p<0.05). There were no significant differences in the other SF36 subscales between the two groups., Conclusion: Most patients who sustained an inversion ankle injury at sport and who were subsequently referred to a sports medicine clinic had persistent symptoms for at least two years after their injury. This reinforces the importance of prevention and early effective treatment.

Background: Lateral ligament ankle sprains are the single most common sports injury., Objective: To determine the functional outcome of the ankle joint after a moderate or severe inversion injury, comparing standard treatment with an elastic support bandage against an Aircast ankle brace., Design: Prospective, randomised controlled trial., Setting: Two accident and emergency departments., Method: Fifty patients presenting consecutively were randomised into two equal groups: one group was treated with an elastic support bandage and the other with an Aircast ankle brace. All patients were given a standardised advice sheet referring to rest, ice, compression, and elevation. Patients were reviewed after 48-72 hours, 10 days, and one month., Primary Outcome Measure: Ankle joint function assessed at 10 days and one month using the modified Karlsson scoring method (maximum score 90)., Secondary Outcome Measure: The difference in ankle girth (swelling) and pain score at 10 days., Results: Seventeen patients in the elastic support bandage group (six defaulted, two excluded) and 18 patients in the Aircast ankle brace group (six defaulted, one excluded) completed the study. There were no significant differences between the two groups at presentation in terms of age (mean 35.3 and 32.6 years respectively), sex, dominant leg, left or right ankle injured, previous injury, time to presentation (median three and four hours respectively), difference in ankle girth (mean 14.5 and 14.3 mm respectively), and pain scores (mean 6.2 and 5.8 respectively). The Karlsson score was significantly higher in the Aircast ankle cast group than in the elastic bandage group at 10 days (mean 50 v 35, p = 0.028, 95% confidence interval (CI) 1.7 to 27.7) and one month (mean 68 v 55, p = 0.029, 95% CI 1.4 to 24.8) (Student's t test). There was no difference between the groups in the secondary outcome measures (swelling, p = 0.09; pain, p = 0.07). When hierarchical multiple regression analysis was used to correct for possible baseline confounding factors, the Aircast ankle brace group was significantly associated with higher Karlsson scores at 10 days (p = 0.009) and one month (p = 0.024)., Conclusion: The use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function at both 10 days and one month compared with standard management with an elastic support bandage.

The clinical features of 10 cases of lateral trunk muscle injury in first class cricket pace bowlers are described. Typically the injury occurs during a single delivery, is associated with considerable pain, and prevents the bowler from continuing. The clinical picture is typical of a muscular or musculotendinous injury. The most consistent clinical tests were focal tenderness on palpation and pain with resisted side flexion towards the painful side. The magnetic resonance image in 70% of cases was consistent with an injury to the internal oblique, the external oblique, or the transversalis muscles at or near their attachments to one or more of the lowest four ribs. The injury occurs on the non-bowling arm side. Recovery can be prolonged. The injury was a recurrence in six of the 10 cases. The biomechanics of the injury are not yet understood.

The case is reported of a 59 year old woman who suffered a 1% total body surface area superficial partial thickness burn to her calf following the application of an ice pack. The cause, resulting injury, and subsequent management are discussed. It is possible that such injuries are common, but no similar reports were found in a literature search. Awareness of the risk of this type of injury is important for all those entrusted with advising patients on the treatment of minor soft tissue injuries.

Adhesive tape is often used to help athletes recover from ligament sprains of the ankle or to prevent further injury. The choice of taping technique or material is often decided by personal preference, superstition, or anecdote. More recently, the use of ankle braces has become more prevalent, but reasons for their use are similarly variable. As ankle sprains are a major cause of an athlete's disability and time off sport, the choice of the method of support should be more scientifically reasoned. This paper attempts to review the literature concerning the effects of various methods of ankle support on swelling, stability, range of movement, proprioception, muscle function, gait, and performance tests. There is still some contradiction in the literature about the effects of taping and braces in both the acute and chronic phases of ligament sprains of the ankle.

Medial knee pain is an increasingly common presentation in sports medicine practice. A prospective review was undertaken of 72 patients, mean age 48 years, seen in 1986-1987. The physical findings which were most diagnostic were a loss of some degrees of flexion which was painful medially when forced, and tenderness over the posteromedial joint line. Treatment was either injection of local steroid, or physiotherapy, together with emphasis on quadriceps exercise. Five patients failed to respond and were referred for arthroscopy. Nine patients relapsed once but no subsequent episode has occurred. Meniscotibial ligament strain is a common cause of knee pain in middle-aged sports people.

Fifty-one patients with fibular ligamentous injury of the ankle are presented. The treatment consisted of complete non-weight-bearing of the affected foot by use of elbow crutches for three weeks. All patients were seen at follow-up eighteen months after the accident. The results are discussed in the light of previous literature on conservative and operative treatment of lateral ligament injuries.

Three different adhesive and two non-adhesive tapes were used by three operators to assess the compressive action exerted on the ankle at the moment of strapping, during different phases of gait, and after some days of treatment in ten volunteers. Only the adhesive tapes were still able to prevent swelling after five days. They should be used if a prolonged compressive action is required.

The following case is presented as one of unusual foot and leg lesions encountered in an adolescent long-distance runner. The associated problems of a first metatarsal Salter Harris type II epiphyseal stress fracture, and an accessory calf muscle with "shin splints" in the contralateral leg are discussed. Treatment of these conditions is outlined with eventual return to full function by the athlete.