What are the clinical recommendations for the use of ankle braces? A scoping review

Abstract

Background

Ankle braces can be used in the treatment and prevention of lateral ankle sprains. However, there is a limited understanding and consensus about which type of brace should be used, for how long, and when to stop using ankle braces.

Objective

To review the clinical recommendations made in guidelines or position statements for the use of ankle braces.

Design

Scoping review.

Methods

Ten electronic databases and Google were searched. Guidelines and/or position statements about treatment and/or prevention of lateral ankle sprains or chronic ankle instability were included if derived from a peer-reviewed source or from an official national or international professional group, society or association, and made recommendations on the use ankle braces. Recommendations for brace use and cessation were extracted, collated, reviewed, and presented in tabular format.

Results

Eleven guidelines and two position statements were included. All recommended ankle braces for the treatment of grade I and II ankle sprains and prevention of recurring sprains. Inconsistencies were present for; grade III sprains, the classification and definitions for brace types, the level of restriction ankle braces provide, how long ankle braces should be worn, and indicators for cessation of use.

Conclusion

Ankle braces are recommended for prevention of recurring sprains and the treatment of grade I and II sprains. Further information is needed on the duration or indicators for cessation of ankle brace use. A standardised classification and definitions used for the type of brace, and the level of restriction ankle braces provide is also warranted.

1. Introduction

Lateral ankle sprains are the most common injury to the ankle joint complex reported in the general population and during sports activities [1,2]. Lateral ankle sprains are characterised by stretching or tearing of ankle ligaments that support the lateral ankle column [2]. The prevalence of lateral ankle sprains may lead to chronic ankle instability (CAI), which is a condition that is characterised by recurring sprains, perception of the ankle ‘giving way’, pain, weakness, reduced self-reported function, and reduced range of motion (ROM) [1]. CAI is an umbrella term that also includes persistent impairments such as, reduced inversion strength, greater sway when standing on stable surfaces with eyes closed, longer time to stabilise after a jump as well as gait alterations [3].

Ankle braces are external supports for the ankle joint complex, that claim to limit excessive motion associated with the mechanism of lateral ankle sprains, which often includes excessive inversion with plantarflexion [3]. It is widely known and accepted that there are a variety of different ankle braces available, including; lace-up style, semi-rigid, rigid ankle braces, or elastic ankle protectors [4,5]. Elis et al. [5] have offered three subcategories for ankle braces which are; rigid, semi-rigid and soft, although no clear definition to distinguish between the three categories was offered it was mentioned that the manufacturers recommended the intended purpose for the use of all semi-rigid and soft braces was for prophylactic prevention of recurrent sprains. Ankle braces have been known to have different applications, functions, or intended purpose, most ankle braces have the same advantages of being adjustable and reusable [4].

Ankle braces can be used in the treatment of lateral ankle sprains [6] and prevention of recurring ankle sprains [7]. Ankle braces have been recommended for the treatment of lateral ankle sprains by supporting the ankle, allowing for progressive weight bearing and early functional rehabilitation [8]. Ankle bracing has been accepted as part of secondary prevention for recurrent sprains among clinicians, coaches and sports personnel [9]. Some sporting and athletic trainers have adopted a ‘bracing policy’ that requires athletes to wear ankle braces during practice and/or games to prevent ankle injuries, whether or not they have had a previous injury [7,10] however, controversy remains about the best treatment for acute lateral ankle sprains, in particular grade III sprains [11]. One recommendation made is that ankle braces should only be used in conjunction with other therapies, such as exercise [12].

Although ankle braces have been indicated for the treatment and prevention of lateral ankle sprains, it has been estimated that between 10 and 30% of people developed chronic ankle instability (CAI) after an initial lateral ankle sprain [13]. A possible reason may be that ankle braces have not been universally accepted or adopted into clinical and/or sporting practices to treat or prevent lateral ankle sprains. A recent scoping review [14] investigating current injury prevention programs for netball athletes found that netball injury prevention programs did not endorse the prophylactic use of ankle braces for netballers. The review [14] suggested that such prevention programs should revise their recommendations as there is a body of evidence demonstrating the effectiveness of ankle braces in preventing recurring ankle sprains. This review, however, only considered the recommendations provided to netball athletes, and recommendations for the general population and other athletes has yet to be summarised. It is also important to identify recommendations on how long a person with an acute lateral ankle sprain or CAI should wear an ankle brace or when they should stop wearing one.

Our scoping review, therefore, aimed to summarise the recommendations and indications for (1) the use of ankle braces in the treatment of people after an acute lateral ankle sprain or CAI, (2) the use of ankle brace in preventing first-time lateral ankle sprains or recurring ankle sprains, (3) when to stop wearing ankle braces, and (4) compare guidelines and/or position statements for prevention and/or treatment of acute lateral ankle sprains or CAI.

2. Methods

2.1. Protocol and registration

A scoping review was chosen as the best approach [15] to systematically and thoroughly gather and summarise existing knowledge from guidelines and position statements. As the topic regarding the use of ankle braces for treating and preventing lateral ankle sprains was broad, a scoping review was used to synthesise existing information and identify gaps. This scoping review was conducted in accordance with the PRISMA-ScR reporting standards [16]. The protocol for this scoping review was registered and can be found on Open Science Framework (https://osf.io/3fhvx/?view_only=8c65225195a34464ad9dfe4721e65684).

2.2. Eligibility criteria

Guidelines or position statements were included if: a) they derived from a peer-reviewed source or from an official nationally or internationally recognised professional group, society or association, and b) recommendations and/or indications on the use ankle braces (such as lace-up style, semi-rigid, rigid ankle braces or elastic ankle protectors) in the management and prevention of acute lateral ankle sprains or CAI were included.

We aimed to examine recommendations by guidelines and position statements concerning the use of ankle braces for treating and preventing lateral ankle sprains. The present study was interested in understanding the direct application of recommendations made by guidelines and position statements on clinical practice as well as identifying consensus and differences between recommendations, with the aim to focus the breadth of recommendations made across varying guidelines and position statements. Therefore, we excluded guidelines or position statements if they: a) were clinical trials, systematic reviews, or other primary and secondary sources that were not guidelines or position statements, b) reported on recommendations for the use of exoskeletons, wedges, ankle-foot-orthosis or similar orthotic devices as interventions, and c) were not peer-reviewed or not official guidelines or statements from national or international professional groups, societies, or associations.

2.3. Setting

Guidelines or position statements for any form of healthcare practice setting were included. Settings outlined in the guidelines were categorised in this review as being either primary or secondary healthcare, tertiary healthcare, sports/athletic, or emergency settings.

2.4. Search strategy

Relevant keywords and Medical Subject Headings (MeSH) related to ankle sprain and chronic ankle instability were searched to obtain the literature pertaining to clinical practice guidelines and/or position statements on treatment and/or prevention of acute lateral ankle sprains or CAI that included indications and/or recommendations for the use of ankle braces.

2.5. Sources of evidence

Ten electronic databases were searched from inception to 28th February 2023: CINAHL via EBSCOhost, SportsDiscus via EBSCOhost, Medline via Ovid, Trip database, JBI EBP database via Ovid, AMED via Ovid, Embase via OvidSP, Scopus via Elsevier, BMC Medicine via Springer and Google Scholar. No restrictions (including publication year and language, gender or age) were applied. A sample of the search strategy used can be seen in Appendix (Table 1). A manual search of the Google search engine was performed to extract results from official national and international professional bodies that were not found in the database search. This included: institutes, organisations, associations or establishments appointed by governments or regions. Search terms used for the Google search included ‘ankle sprain AND position statement OR guidelines. The first five pages with 10 entries per page of results from the Google search were reviewed for eligibility. References for all included papers were hand searched.

Table 1.

Characteristics of the included guidelines and positions statements.

Author, year	Title of Guideline	Setting	Professional group/body	Country
Van der Wees et al., 2006	aKNGF- Guideline for Physical Therapy in patients with acute ankle sprain: Acute ankle sprain practice guidelines	Primary or secondary	Royal Dutch Society for Physical Therapy	Netherlands
Vuurberg et al., 2018	Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline	Primary or secondary	Unclear	United States
Song et al., 2019	Clinical guidelines for the surgical management of chronic lateral ankle instability: A consensus reached by systematic review of the available data	Sports and athletic	Chinese Society of Sports Medicine	China
Richie & Izadi, 2015	Return to play after an ankle sprain: Guidelines for the Podiatric Physician	Primary or secondary	Podiatric physicians	United States
Martin et al., 2021	Ankle stability and movement coordination impairments: Lateral ankle ligament sprains revision 2021	Primary or secondary	Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association	United States
Kerkhoffs et al., 2012	Diagnosis, treatment and prevention of ankle sprains: An evidence-based clinical guideline	Primary or secondary	Netherlands Organization for Health Research And Development	Netherlands
Kaminski et al., 2013	National Athletic Trainers Association position statement: Conservative management and prevention of ankle sprains in athletes	Sports	National Athletic Trainers Association	United States
Inklaar & van Beek, 2011	Guideline for diagnosis and treatment of acute ankle inversion trauma in sports people	Primary or secondary	The Sports Medicine Association	Netherlands
De Bie et al., 2003	KNGF Guidelines for Physical Therapy in patients with chronic ankle pain: Clinical practice guidelines for physical therapy in patients with chronic ankle sprain	Secondary	Royal Dutch Society for Physical Therapy	Netherlands
Czajka et al., 2014	Ankle Sprains and Instability	Tertiary	Orthopaedic surgery	United States
Sports Medicine Australia, 2022	Ankle sprain	Sports and athletic	Sports Medicine Australia	Australia
First Nations and Inuit Health Branch, 2011	Adult care: Clinical practice guidelines for Nurses in primary care, Chapter 7: Musculoskeletal system	Primary or secondary	Canada Government	Canada
Steffen et al., 2010	bECSS Position Statement 2009: Prevention of acute sports injuries	Sports	European College of Sports Science	Europe

^aKNGF: Royal Dutch Society for Physiotherapy.

^bECSS: European College of Sports Science.

2.6. Source of evidence selection, data extraction and analysis

Articles were imported from the database search to the online platform Covidence [17] for removal of duplicates and the screening process. Two independent reviewers (TM and PB/CH) screened each article by title and abstract. Following this, two independent reviewers (TM and CH/AFY/PB) screened the full-text of the potentially eligible guidelines and position statements. Qualitative data was extracted from the included guidelines and position statements by two independent reviewers (TM and AFY) using a data extraction form. Disagreements were solved by discussion or arbitration by a third reviewer (CH). The data extracted from the full-text articles of the included guidelines or position statements included: a) title, date of publication and author; b) setting; c) professional group/association/society and country; and d) recommendations and indications for brace use and when to stop wearing braces. Qualitative information was extracted, collated by phase of ankle sprain management (acute treatment, chronic treatment, prevention) and presented in tabular format.

3. Results

3.1. Search results

After removing 1148 duplicates, 4905 articles were identified as potentially eligible from the initial screening by title and abstract, and 98 articles were included for the full-text screening. A total of 13 guidelines and position statements met the inclusion criteria and were included in the review. Fig. 1 depicts the PRISMA flow diagram for the scoping review.

Fig. 1.

PRISMA flow diagram.

3.2. Study characteristics

Of the 13 guidelines and position statements included, 11 were identified as guidelines [6,8,10,12,[18], [19], [20], [21], [22], [23], [24]] and two were position statements [25,26]. The characteristics of the included guidelines and position statements are presented in Table 1.

Five were from the Netherlands [8,10,20,24,27], five from the United States [6,[20], [21], [22],25], one from Australia [18], one from Canada [19], and one from China [23].

Of the 13 identified guidelines and position statements, eight were directed to primary and secondary settings [8,10,12,[19], [20], [21], [22],24], four were for sports and athletic settings [18,23,25,26] and one for a tertiary hospital setting [6].

Three guidelines were directed to physiotherapists [10,21,24], one to athletic trainers [25], three to sports medicine clinicians [8,18,23], two to nurses [19,20], one to sports scientists [26], one to podiatric physicians [22], one to orthopaedic surgeons [6], and one guideline [12] was directed to all healthcare professionals.

3.2.1. Treatment

All thirteen included guidelines and position statements recommended the use of ankle braces for the treatment of lateral ankle sprains and CAI. However, there were differences in the recommendations regarding the use of semi-rigid support or immobilisation based on ankle sprain severity, which are presented below. The recommendations of the guidelines and position statements included in this review are presented in Table 2.

Table 2.

Recommendations made by the included guidelines and position statements.

Author, year	Recommendations
Van der Wees et al., 2006	If patients frequently feel the ankle “giving way”, advise them to tape the ankle or use a brace during the period in which the load is being increased. Advise patients to tape the ankle or use a brace when putting extra weight on the ankle, for instance when resuming high-risk work and/or exercising. As soon as good muscular stability has been achieved and the patient can perform the functional exercises satisfactorily, external support should preferably be reduced. Phase 1: Inflammatory (0–3 days): Tape/brace: In this phase, taping is generally not a good idea, because of the swelling. If the patient is in sports-specific rehabilitation, taping may be applied at an earlier stage, provided the tape can be replaced every day. The Guideline Committee recommends the use of an adhesive bandage underneath the tape. Phase 2: Proliferation phase (4–10 days): Tape/brace: Tape the injury as soon as the swelling has sufficiently subsided. The choice between taping and a brace depends on the patient's own preference. The Guideline Committee recommends re-taping once a week. Phase 3: Early remodelling phase (11–21 days): Taping/brace: Advise the patient to use tape or a brace during sports or other strenuous physical exertion. This should be continued until the patient is sufficiently able to do the static and dynamic balance and coordination exercises to promote functional stability. Advise the patient not to use a brace or taping as a standard precaution during training and other sports activities, but to use such devices during competitive games (especially in high-risk sports like indoor and contact sports). This reduces the risk of relapse and the severity of any re-injuries. If preferred, the patient can be advised to use tape, bandage or a brace if they experience complaints or have to engage in activities involving causative movements (for instance when returning to work). It is essential to advise the patient about a balanced use of tape, bandage or brace.
Vuurberg et al., 2018	Use of functional support for 4–6 weeks is preferred over immobilisation. The use of an ankle brace shows the greatest effects compared with other types of functional support (level 2 - randomised double blind comparative clinical research of good quality and sufficient sample size).
Song et al., 2019	For patients who undergo anatomic repair or reconstruction, range of motion (mostly dorsiflexion) and partial weightbearing with a brace are encouraged from the second day after surgery.
Richie & Izadi, 2015	Ankle braces are mandatory in the treatment of the ankle sprain and should be considered mandatory for use after the athlete returns to play. All athletes who have suffered significant ligament injury of the ankle should wear prophylactic ankle braces when returning to sport for a minimum of 6 months. Taping is less effective than bracing in preventing ankle sprains. The researchers concluded that, contrary to popular clinical opinion, a period of immobilization was the most effective strategy for promoting rapid recovery, which was achieved best by the application of a below-knee cast, an intervention that has previously been discouraged in favour of air stirrup braces.
Martin et al., 2021	Clinicians should recommend the use of prophylactic bracing to reduce the risk of a first-time lateral ankle sprain, particularly for those with risk factors for lateral ankle sprain. Clinicians should prescribe prophylactic bracing and use proprioceptive and balance-focused therapeutic exercise training programs to address impairments identified on physical examination to reduce the risk of a subsequent injury in patients with a first-time lateral ankle sprain. Clinicians should advise patients with an acute lateral ankle sprain to use external supports, such as braces or taping, and to progressively bear weight on the affected limb. The type of external support and gait assistive device recommended should be based on the severity of the injury, phase of tissue healing, level of protection indicated, extent of pain, and patient preference. In more severe injuries, immobilization ranging from semi-rigid bracing to below-knee casting may be indicated for up to 10 days post injury. Clinicians should implement a return-to-work schedule and use a brace early in rehabilitation, occupational or sport-related training, and/or a work-hardening program to mitigate activity limitation and participation restriction following a lateral ankle sprain. Clinicians should not use external support, including braces or taping, as a stand-alone intervention to improve balance and postural stability in individuals with CAIa.
Kerkhoffs et al., 2012	A short period of plaster immobilization or similar rigid support facilitating a rapid decrease of pain and swelling can be helpful in the acute phase of the treatment of lateral ankle injury. Functional treatment for 4–6 weeks is preferable to immobilization in a cast. The preference for brace or tape depends on the individual situation. Due to considerations about practical usability and evaluation of costs, a brace is initially preferable to a tape. It is recommended to use a brace or a tape to prevent a relapse. The use of a brace or a tape is a personal choice. On the basis of practical usability and evaluation of costs, a brace is initially the preferable means of support. It is recommended to phase out the use of brace or tape in time. Workers with lateral ankle injury should preferably be treated with a brace to speed up work resumption.
Kaminski et al., 2013	Functional Rehabilitation: The standard of care for grade I and II lateral ankle sprains is functional rehabilitation, which consists of ankle stabilization (via elastic bandage, bracing, taping, or external support or a combination of these) with progressive weight bearing and exercise. The optimal management of grade III ankle sprains is less clear, but the current gold standard is functional rehabilitation. Functional rehabilitation is more effective than immobilization in managing grade I and II ankle sprains. (Evidence Category: A – recommendation based on consistent and good-quality patient-oriented evidence). Grade III sprains should be immobilized for at least 10 days with a rigid stirrup brace or below-knee cast and then controlled therapeutic exercise instituted. (Evidence category: B – recommendation based on inconsistent or limited-quality patient-oriented evidence). Athletes with a history of previous ankle sprains should wear prophylactic ankle supports in the form of ankle taping or bracing for all practices and games. Both lace-up and semirigid ankle braces and traditional ankle taping are effective in reducing the rate of recurrent ankle sprains in athletes. Taping and bracing of the ankle are common practices in the athletic setting. Generally, taping and bracing are used prophylactically in an effort to prevent a first-time ankle sprain or, more often, to prevent recurrent ankle sprains. A significant amount of research on taping and bracing has been conducted, but few authors have investigated if these measures can reduce the incidence of lateral ankle sprains.
Inklaar & van Beek, 2011	It is plausible that functional treatment with a lace brace leads to better results than functional treatment with tape or bandage. It is likely that the use of tape causes rapid loss of mechanical support and is therefore not the first choice of protection. Semi-rigid brace protection should become a standard treatment. After the acute inversion trauma of the ankle, treatment should be carried out with semi-rigid protection, whereby the ankle can be actively moved and loaded in the acute phase in a controlled manner. A distinction must be made between rigid protection, in which immobilization is imposed, and semi-rigid protection, in which especially the inversion movement of the ankle is limited, but other movements remain possible (partial mobilization). Semi-rigid protection has been shown to have advantages over rigid protection in terms of sport and return to work, pain, swelling, subjective and objective instability, passive range of motion and satisfaction.
De Bie et al., 2003	If the patient indicates that the ankle is being, or feels as though it is being, repeatedly sprained, tape, a brace or bandages can be used during therapy. The use of tape, bandages or a brace is advisable if the patient returns to, perhaps heavy, work or to sporting activities. When good muscular stability has been achieved and functional exercises can be performed satisfactorily, it is advisable to reduce the use of tape, bandages and braces. To reduce the chance of a recurrent ankle sprain, or relapse, the following advice should be followed: do not use taping or a brace as a standard precaution during training or regular sporting activities. Reserve the use of these techniques for competition sports and for high-risk sports such as contact or indoor sports. Not only does this reduce the chance of a new injury occurring, but it also reduces the extent of the damage should are lapse occur. A sports brace is preferable to taping.
Czajka et al., 2014	The use of a brace should continue until the athlete is cleared to play without restrictions. Additionally, taping or bracing the affected ankle can provide extra mechanical support and improved proprioception. A brace allows for improved proprioceptive feedback during exercise.
Sports Medicine Australia, 2022	Wearing ankle taping or bracing especially for previously injured ankles: Taping or bracing the ankle may be prescribed to provide support until full function is regained. If, while performing a rehabilitation exercise, ankle joint pain or discomfort is experienced, stop immediately and re-consult a sports medicine professional. Players with significant ligament injuries (Grade II or III) are advised to use bracing or protective taping when playing sport for a minimum of 6–12 months post injury.
First Nations and Inuit Health Branch, 2011	During movement, the ankle should have a lace-up ankle brace applied, if possible, or a tensor bandage to help prevent re-injury. Counsel client about strategies to prevent further injuries to ankle (for example, doing warm-up exercises before physical activities such as sports; wearing high-top, lace-up shoes and/or external ankle supports for walking and running, watching surfaces that one is ambulating on, maintaining strength, balance and flexibility).
Steffen et al., 2010	External support (bracing, taping) has been shown to reduce the risk of re-injury in athletes with a history of ankle sprains, but not in athletes with no previous history. However, as for external ankle support, the effect appears to be limited only to athletes with a history of previous sprains.

^aCAI: Chronic ankle instability.

3.2.2. Acute lateral ankle sprains

Of the nine guidelines and position statements that recommended the use of ankle braces in the treatment of acute lateral ankle sprains, seven guidelines [6,8,12,20,21,24,25] recommended the use of semi-rigid brace protection over immobilisation, with two guidelines [12,20] recommending functional treatment for four to six weeks being preferable over immobilisation (plaster cast or similar rigid support). Four of the guidelines and position statements [[20], [21], [22],25] recommended the use of immobilisation for severe (grade III) injuries, however they also indicated that immobilisation should involve the use of external ankle braces, such as stirrup brace support. One guideline [24] indicated that during the ‘early remodelling phase’, ankle braces should be worn only while participating in sport or other strenuous physical activity until the patient could perform tasks while weight bearing ‘sufficiently’.

3.2.3. Chronic ankle instability

One guideline and a position statement [10,24] recommended that patients with CAI should wear ankle braces initially when weight-bearing on to the ankle, especially for resuming high-risk activities, such as work or sports. Only one guideline [23] indicated the use of ankle braces as a post-surgical intervention for patients with CAI and stated that they should wear a brace from day two post-surgery to help with partial weight bearing activities. One guideline [21] indicated that ankle braces should not be used as a stand-alone treatment, but could be considered by clinicians if they assist with achieving short-term treatment goals and to help with patients’ engagement in rehabilitation.

3.2.4. Prevention

Seven guidelines and two position statements [10,12,[19], [20], [21], [22],24,25,27] recommended the use of brace for prevention of first-time or recurring lateral ankle sprains.

3.2.5. Prevention of first-time lateral ankle sprains

One guideline [21] recommended that clinicians should advise patients to use ankle braces in combination with balance exercises to reduce the risk of first-time lateral ankle sprains, especially in those identified with high risk of having a lateral ankle sprain (intrinsic risk factors or individuals who engage in high risk activities such as court sports [21]). One guideline [25] suggested that ankle braces should be worn in sport settings prophylactically to prevent first-time lateral ankle sprains. One position statement [27] indicated that wearing ankle braces to reduce the risk of a first-time lateral ankle sprain has not been proven effective, but there is evidence that ankle braces are effective in preventing recurring lateral ankle sprains, hence, they are indicated for people after they have the first ankle sprain to prevent recurrent sprains.

3.2.6. Prevention of recurring lateral ankle sprains

Five of the six guidelines [10,12,19,22,24] indicated that therapists should advise patients not to use braces as a standard precaution during training, and that patients should be advised to only wear ankle braces on game day, especially in high-risk sports, to reduce relapse and the severity of a re-injury. One position statement [25] indicated that athletes with a history of ankle sprains should wear prophylactic ankle bracing for all practices and games. The position statement [25] also suggested that both lace-up and semirigid ankle braces were the most effective in reducing the rate of re-injury in athletes. First Nations and Inuit Health Branch [19] recommended that clinicians should advise patients to use a combination of warm-up exercises and wearing an ankle brace to prevent re-injury. Two guidelines [18,22] indicated that patients should wear ankle braces during sports participation for 6–12 months following the initial ankle sprain to prevent further injury.

3.2.7. When to stop wearing ankle braces?

Two guidelines [10,24] indicated that ankle braces should be worn until the patient is ‘sufficiently able to perform functional tasks’, such as static and dynamic balance and coordination exercises. Two guidelines [10,24] also recommended that, as soon as ‘good muscular stability is achieved’ and ‘patients can perform functional tasks satisfactorily’, they should be encouraged to reduce the use of ankle braces. One guideline [6] indicated that ankle braces should be worn until patients are cleared to play in sporting activities without restrictions. Sport Medicine Australia [18] recommended that patients should stop using the brace immediately if they experience pain or discomfort in the affected ankle while wearing the brace. One guideline [24] also indicated that patients can be advised to stop the use of an ankle brace if they experience pain during activities that involve “specific movements”.

3.2.8. Differences in recommendations between guidelines/position statements

Differences among the included guidelines and position statement were noted in the terminology used to define the level of restriction braces provide in the treatment of lateral ankle sprains; when patients should wear ankle braces versus when to immobilise the affected ankle and when to stop wearing ankle braces.

Regarding the definition of different levels of protection and type of ankle braces used, only Inklaar & Van Beek [8] defined “rigid protection/immobilisation” as a movement that is completely restricted, and “semi-rigid protection” as one where inversion movement of the ankle is limited but other movements remain possible during functional treatment. Vuurberg et al. [12] defined “functional support” as ankle bracing or taping used to preserve joint motion but limiting extreme joint position, such as maximum inversion. Czajka et al. [6] defined the different phases of functional treatment as two stages of therapy: “acute treatment” and “early mobilisation with gradual rehabilitation”. In the same guideline, “acute treatment” was defined as the period when the treatment should focus on minimising swelling, controlling pain, protection from further injury, promoting healing and initiating rehabilitation. Czajka et al. [6] defined “early mobilisation with gradual rehabilitation” as restoring range of motion, strength, proprioception and safe return to activity. Czajka et al. [6] indicated that ankle braces, such as the commonly used Aircast ankle brace, can be used during both acute treatment and early mobilisation with gradual rehabilitation. Czajka et al. [6] suggested that an Aircast ankle brace can be used to restrict inversion and eversion stress on an injured ankle while maintaining other movements and can be useful in resolving any issues of swelling, strength and flexibility deficits.

When considering the recommendations made to patients wanting to return to usual sport and work and reducing the use of an ankle braces, two guidelines (De Bie et al. [9] & Van der Wees et al. [22]) lacked clarity about defining what the terms “sufficiently” and “good” meant when referring to muscular stability, in addition to terms such as “specific” when referring to performing work or sports related tasks that induce or cause pain [10,24].

Regarding the use of immobilisation versus functional treatment, three guidelines (Inklaar & Van Beek [8]; Vuurberg et al. [12] & Kerkhoffs et al. [20]) recommended the use of semi-rigid brace protection over immobilisation. Vuurberg et al. [12] indicated that, in order to speed up return to work, patients should be advised to wear a brace in combination with immediate functional treatment in the form of progressive weight-bearing. Inklaar & Van Beek [8] indicated that semi-rigid ankle braces were superior to rigid protection for earlier return to sport/work, reduced pain, swelling, subjective and objective instability, passive range of motion, and overall patient satisfaction. Czajka et al. [6] also recommended that an Aircast brace should be used to restrict the inversion and eversion stress on the injured ankle, while maintaining full dorsiflexion and plantarflexion, and suggested that braces allow for improved proprioceptive feedback during exercise. Czajka et al. [6] recommended that an Aircast ankle brace should be used continuously until swelling, strength deficits, and flexibility deficits resolve, then the use may be limited to during exercise.

Two guidelines and one position statement (Martin et al. [19]; Richie & Izadi [20] & Kaminski et al. [23]) recommended the use of immobilisation for severe (grade III) injuries. However, one guideline (First Nations and Inuit Health Branch (FNIHB) [19]) indicated that, for grades II and III sprains, patients should be advised to remain non-weight bearing with a cast or device, or to partial weight bear with crutches, with limited weight bearing activities, and only patients with a grade I sprain should be advised that weight bearing can occur as tolerated with the use of a lace-up ankle brace. Kaminski et al. [25] recommended functional treatment as being more effective than immobilisation in managing grade I and II ankle sprains, while grade III sprains should be immobilised for at least 10 days with a rigid stirrup brace or a below-knee cast, followed by controlled therapeutic exercises. Kerkhoffs et al. [20] also recommended that a short period (ten days) of plaster immobilisation or similar rigid support can be applied to reduce pain and swelling, but recommended functional treatment for 4–6 weeks over immobilisation in a cast, with a lace-up brace or a semirigid brace being preferable.

4. Discussion

4.1. Overview of main findings

Our review found that ankle braces have been consistently recommended for the treatment of acute lateral ankle sprains. Ankle braces were also recommended by one guideline as a post-surgical intervention for CAI. Some of the key findings of our scoping review include; (a) there were inconsistencies across the different guidelines and position statements on the terminology used to address the different types of ankle braces and the level of protection they provide (as well as their use in functional treatment versus immobilisation), (b) there was limited information, lack of clarity and differences about the duration and cessation of ankle brace use, and (c) ankle braces were recommended to prevent recurring ankle sprains.

Ankle braces should be used during treatment and prevention of ankle sprains. Despite the lack of definition of the level of protection of ankle braces in the guidelines, recent evidence [28] that provided clear definitions between the different brace types, found no difference or superiority in the level of restriction or protection between brace types. An important distinction should be made between using ankle braces for “immobilisation” and other modalities such as a removable boot and below knee-cast, because ankle braces were recommended to immobilise the ankle similar to a below-knee cast or removable boot in preference over semi-rigid protection for severe injuries (grade III) [[20], [21], [22],25]. However, the categorisation of the Aircast brace as a form of immobilisation is in contrast to other individual studies [28,29], where the Aircast brace was referred to as a semi-rigid support, aligning with the definition of semi-rigid protection and “functional support” presented in two guidlines [8,12]. If a clear classification of ankle brace types was provided, that is reflective of current evidence demonstrating the level of protection they provide, this could bring the classification of ankle braces in line with other lower limb braces commonly used, like knee brace classification and their use for managing knee osteoarthritis [30]. The clear classification of braces assists clinicians in standardising clinical practice, to ensure the appropriate selection of braces based on the level of sprain severity as well as the needs of the patient being met in accordance with guidelines. For example, a rigid brace that is characterised by the shell design being rigid at the shank and hindfoot would be more appropriate for immobilisation [31] particularly if there is a suspected underlying fracture. However, a soft brace or semi-rigid brace may be more appropriate for mild or moderate injuries [31]. This will ensure patient compliance and improve education for both the patient and practitioner [32]. Our review has concluded that there needs to be an emphasis on the terminology used to define the different types of ankle braces that are available, provide advice to distinguish between the different braces, and specify which brace/s are referred to in guidelines.

There was a lack of guidance about the appropriate duration and when to stop wearing ankle braces. Two guidelines [18,22] recommended patients wear ankle braces during sports participation for 6–12 months to prevent recurring sprains, while two other guidelines [12,20] recommended four to six weeks during functional treatment to aid in early return-to-sport and four guidelines [[20], [21], [22],25] agreed that rigid protection should be used for a maximum of 10 days following the injury, and long term use should be avoided. Six to twelve months is a lengthy period for a patient to be advised to wear an ankle brace to prevent recurring sprains given the limited evidence that suggests semi-rigid braces provided significant improvements in symptoms and function, after the 10 day and 1 month follow-up [33]. Only two guidelines attempted to provide clinical indicators for cessation of brace use, however they did not define the terms “sufficiently”, “good” or “specific” when they referred to muscular stability, weightbearing during activities [10] or when they referred to performing tasks that could lead to recurring sprains [24] respectively. Research should be conducted to identify the appropriate duration for wearing an ankle brace and clinical indicators for cessation of brace application. This evidence will optimise ankle brace use and avoid the use of vague terms, assisting clinicians to apply precise and efficient treatment that cannot be misinterpreted, potentially leading to a negative impact on the management of ankle sprains.

Our review showed that the majority of the guidelines and position statements recommended the use of ankle braces to prevent recurring ankle sprains. The understanding of the recommendations made is, while it is beneficial to wear ankle braces to prevent recurring sprains, patients would also benefit and should be advised to perform balance and proprioceptive exercises [10,12,19,21,22,24,25,27] which aligns with current evidence [9]. However, there is an inconsistency in the recommendations made between the different guidelines and position statements. Four guidelines recommended ankle braces should only be used during heavy work or competition but not during regular training [10,12,22,24], while one position statement and two guidelines have recommended ankle brace to be used during all activities to prevent recurring sprains [19,21,25]. Recent literature [13] has shown that a combination of training and brace use is much more effective than ankle brace use alone or neuromuscular training alone. It was also noted in one guideline [10] that, if required, ankle braces should be used during physical therapy treatment as well in patients with CAI, while loading the ankle or undertaking heavy work, to improve the feeling of being repetitively sprained or to reduce symptoms such as pain. Only two guidelines [10,24] provided clear clinical indications for when to commence the use of ankle braces use during treatment for recurring sprains and stated that if patients feel their ankle being repeatedly sprained or ‘giving way’ to commence use. While there are some recommendations made, further research and clarity is required to provide the appropriate advice that clinicians should give to patients regarding the use ankle braces in combination with exercises.

4.2. Strengths and limitations

This scoping review has several strengths, including a well-planned and robust methodology that was rigorous in design, with two independent reviewers completing the full-text screening and data extraction.

A limitation for this scoping review was that there was a limited number of guidelines and position statements that met the inclusion criteria for this scoping review. Eight guidelines for ankle sprain and/or CAI management were excluded because they did not mention the use of ankle braces, which is surprising given that there is high quality evidence that demonstrates the effectiveness of ankle braces in the prevention of recurring sprains [12,20,21,25]. There were also guidelines that were excluded because they were not derived from national or international groups, associations or societies or mention the use of braces in their management of lateral ankle sprains, given the scope of this review and what we were interested in understanding about the recommendations and indication for use of ankle braces.

4.3. Implications

Further information is needed to classify the type of brace, level of restriction needed and when to stop wearing ankle braces. The use of ankle braces should be recommended, in addition to exercises, during high-risk activities to prevent recurring sprains. Although there is still debate about how ankle braces work, ankle braces should be recommended for use in first line treatment of acute (grade I and II) lateral ankle sprains. However, clinicians should evaluate and consider the advice they give about the type of ankle brace they would recommend. Clinicians should consider the grade of the injury and outcomes from assessments undertaken in clinical decision making before using an ankle brace over immobilisation in each individual case. How long clinicians should recommend an ankle brace to be worn is uncertain and further research should be undertaken. Clinicians are encouraged to reassess patients and make the appropriate clinical judgement based on their clinical findings, and the needs and preferences of the individual patient. Patients should be advised to stop wearing an ankle brace if pain is present when wearing the brace and should pursue a different brace option or form of treatment. By understanding the recommended duration of use for ankle braces this will ensure that the injured ankle receives adequate support during the important phases of healing, and promoting fast and effective recovery without risk of reinjury.

5. Conclusion

Ankle braces are recommended for the prevention of recurring sprains and treatment of grade I and II sprains. Guidelines and position statements need to be updated to include clear description about the type of ankle brace being recommended. There is a need for a standardized classification system for the distinct types of ankle braces, the level of restriction ankle braces provide, the duration and/or clinical indicator for cessation of their use. A standardised classification system will ensure that the injured ankle receives adequate support during the important phases of healing and promote fast and effective recovery without risk of reinjury.

Funding information

No financial support for the conduct of the research and/or preparation of the article.

Declaration of competing interest

None.

Appendix 1.

Table 1.

Example of search strategy used in Medline.

Database: MEDLINE via Ovid
exp guideline/
(Guideline∗ or practice guideline∗ or clinical guideline∗).mp.
Ankle Injuries/
Ankleinjur∗.mp.
Ankle sprain∗.mp.
Ankle strain∗.mp.
Chronic ankle instabilit∗.mp.
Recurrent sprain∗.mp.
“Sprains and Strains”/
Ankle instabilit∗.mp.