Diagnosis and management options of ankle sprain injury

Ankle sprain is a common injury that accounts for a significant proportion of attendances at A&E. This article describes the anatomy and physiology of the ankle and discusses options for the diagnosis and management of ankle sprain injuries using a case study approach.

Long term outcomes of inversion ankle injuries

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.

A Theoretical Model for Treatment of Soft Tissue Injuries: Treatment of an Ankle Sprain in a College Tennis Player

OBJECTIVE

To present theories of manual treatment approaches to soft tissue injuries using an example case report.

CLINICAL FEATURES

A college tennis player with an ankle sprain for 6 weeks, not responding to standard treatment, was unable to play tennis or compete in tournaments.

INTERVENTION AND OUTCOME

Soft tissue treatment was applied to the ankle for 2 visits. The patient experienced complete resolution of the problem and returned to play without relapse during a 9-month follow-up period. Theories of myofascial distortion treatment are discussed.

CONCLUSION

This treatment approach may have potential for soft tissue problems that are not amenable to current therapy approaches.

Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace

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.

Waterproof casts for immobilization of children's fractures and sprains

This study was designed to determine the efficacy of waterproof cast-lining materials in children with short-arm, long-arm, and short-leg casts. Eligible patients had healing fractures 2 weeks after reduction, stable fractures requiring no reduction, or sprains. A total of 165 waterproof-lined casts were applied and 124 children and parents completed a survey (76.9%) upon cast removal. Results revealed 79% very satisfied, 21% satisfied, and 0% dissatisfied. There were 16 (12.9%) minor skin integrity issues. Waterproof casts in stable fractures and sprains allow acceptable immobilization with no significant associated unusual risk and allow children to resume their usual recreational water activities and hygiene regimen without risk of adverse results.

Radiologic case study. First metarsophalangeal plantar plate injury (turf toe)

Turf toe and related injuries to the first metatarsophalangeal joint are common injuries that occur in several sports. Although often a clinical diagnosis, advanced imaging can help grade severity of sprain and evaluate for associated or unsuspected injuries. Without proper rest and conservative management, a treatable injury can have chronic sequelae and morbidity. Operative management is uncommon, but successful in returning high-level competitive athletes to their sport.

Clinical and magnetic resonance imaging features of cricket bowler's side strain

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.

Acute Disposition of Neck Injuries

Neck injuries can be some of the most serious and anxiety-producing injuries that occur during sporting events. It is important for the team physician to be prepared for the care of these injuries and be able to identify some of the more serious injuries. Proper care of these injuries can be life saving and prevent further injury and permanent disability. This article reviews the principles of management and latest evidence for acute neck injuries.

Clinical and cost effectiveness of mechanical support for severe ankle sprains: design of a randomised controlled trial in the emergency department [ISRCTN 37807450]

Background

The optimal management for severe sprains (Grades II and III) of the lateral ligament complex of the ankle is unclear. The aims of this randomised controlled trial are to estimate (1) the clinical effectiveness of three methods of providing mechanical support to the ankle (below knee cast, Aircast^® brace and Bledsoe^® boot) in comparison to Tubigrip^®, and (2) to compare the cost of each strategy, including subsequent health care costs.

Methods/design

Six hundred and fifty people with a diagnosis of severe sprain are being identified through emergency departments. The study has been designed to complement routine practice in the emergency setting. Outcomes are recovery of mobility (primary outcome) and usual activity, residual symptoms and need for further medical, rehabilitation or surgical treatment. Parallel economic and qualitative studies are being conducted to aid interpretation of the results and to evaluate the cost-effectiveness of the interventions.

Discussion

This paper highlights the design, methods and operational aspects of a clinical trial of acute injury management in the emergency department.

Population based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains

OBJECTIVES

To estimate the incidence of ankle sprains and severe ankle sprains attending accident and emergency (A&E) units; to describe current practice for severe ankle sprains in A&E units in the United Kingdom.

METHODS

Crude age and sex specific incidence rates were calculated for four health districts from cases ascertained from data on seven A&E clinical information systems. Case records of patients with ankle sprains at an A&E unit in another health district were audited and the proportion of severe ankle sprains calculated. UK A&E units were surveyed about their usual treatment of patients with severe ankle sprains.

RESULTS

The estimate of the crude incidence rate of ankle sprains was a minimum of 52.7 per 10 000, rising to 60.9 (95% CI 59.4 to 62.4) when figures were adjusted for the proportion of patients without a diagnostic code (13.7%). There were important age-sex differences with unadjusted rates observed from 127.8 per 10 000 (CI 115.5 to 140.0) in girls aged 10-14 years to 8.2 (CI 4.2 to 12.3) in men aged 70-74 years. As 14% of ankle sprains attending A&E were classed as severe, this would equate to 42 000 severe ankle sprains per year in the UK. In the UK wide survey, there was a response rate of 79% (211 of 266). Among the responders, Tubigrip was used routinely in 55%, below knee casts in 3%, and braces in 2%. Boots were not used routinely in any unit.

CONCLUSION

While there is considerable variation in severe ankle sprain management in UK A&E units, most are treated with the minimal mechanical support of Tubigrip.

A survey of current consultant practice of treatment of severe ankle sprains in emergency departments in the United Kingdom

OBJECTIVE

To determine current consultant practice in larger UK emergency departments in the management of severe ankle sprains.

DESIGN

Questionnaire study to all UK emergency departments seeing more than 50 000 new patients per year.

RESULTS

70% response rate. Most popular treatment was ice, elevation, Tubigrip, and exercise, each of which was reported as used in most cases by over 70% of respondents. Crutches, early weight bearing, and non-steroidal anti-inflammatory drugs were each reported as used in most cases at over half of responding departments. Physiotherapy was usually only used in selected cases. Rest was usually advised for one to three days (35%). Follow up was only recommended for selected patients.

CONCLUSIONS

The results of this survey suggest that there is considerable variation in some aspects of the clinical approach (including drug treatment, walking aids, periods of rest) taken to the management of severe ankle sprains in the UK, although in some areas (for example, not routinely immobilising, early weight bearing as pain permits, use of physiotherapy, use of rest, ice, and elevation) there was concordance.

Acute shoulder injuries

The shoulder is the most mobile joint in the human body. The cost of such versatility is an increased risk of injury. It is important that family physicians understand the anatomy of the shoulder, mechanisms of injury, typical physical and radiologic findings, approach to management of injuries, and indications for referral. Clavicle fractures are among the most common acute shoulder injuries, and more than 80 percent of them can be managed conservatively. Humeral head fractures are less common and usually occur in elderly persons; 85 percent of them can be managed nonoperatively. Common acute soft tissue injuries include shoulder dislocations, rotator cuff tears, and acromioclavicular sprains. Acromioclavicular injuries are graded from types I to VI. Types I and II are treated conservatively, types IV to VI are treated surgically, and there is debate about the best approach for type III. Eighty percent of shoulder dislocations are anterior. Diagnosis of this injury is straightforward. The injury usually can be reduced by employing a number of nonsurgical techniques. Traumatic or acute rotator cuff tears can be managed conservatively or surgically, depending on the patient and the degree of injury.

The effect of an ankle brace on the 3-dimensional kinematics and tibio-talar contact condition for lateral ankle sprains

Ten fresh-frozen cadaveric ankles were studied to investigate the effect of an ankle brace (Air-Stirrup) on the three-dimensional (3-D) motion and contact-pressure distribution of the talo-tibial joint with lateral ligamentous injury. Three-dimensional motion and contact-pressure distribution were simultaneously measured under dynamic conditions employing a direct linear-transformation technique and a dynamic-pressure sensor, respectively. Inversion increased significantly upon severing of the anterior talo-fibular (ATF) ligament and calcaneo-fibular (CF) ligaments; however, restoration to the intact level was observed following application of the ankle brace. Internal rotation also increased upon severing of the lateral ligaments in the plantar flexion; however, this difference was not altered by using the ankle brace. The contact area on the articular surface of the talus shifted from posterior to anterior between plantar flexion and dorsal flexion; additionally, a high pressure area was evident in the medial aspect of the talus following severing of the lateral ligaments. Upon application of the ankle brace, however, no significant changes were apparent in the contact condition. The results of this study suggest that stabilization against inversion is the major function of braces in terms of protection of ankle sprains. Ankle sprains, however, often occur in combinations of inversion, plantar flexion and internal rotation; therefore, restriction of plantar flexion and internal rotation may also be an important function of the ankle brace.

[Sprained ankle in children]

OBJECTIVE

To review the literature on sprained ankle in children. We can describe our clinical experience but not statistical analysis because of the few cases.

MATERIALS AND METHODS

We searched MedLine with sprain, ankle, children, talo-fibular ligament, ligament injury as key words.

RESULTS

We found few and no results from a prospective or randomized trial. We analyzed three surgical publications: Vahvanen (1983, 1984), and Chaumien (1986). Vahvanen's studies concerned 50 ankles treated nonoperatively and 40 treated operatively, and Chaumien described 19 patients. Vahvanen's results suggest that sprained ankle is surprisingly common in children and that primary repair of the ligament will resolve symptoms and lead to a stable ankle joint. Chaumien's description revealed severe lesions defined by radiographic criteria. Sixteen of the 18 patients who underwent surgery healed without any complications. The surgical repair of acute ankle sprain in children has generated much controversy.

CONCLUSION

Ankle sprain is a common injury in children and probably underestimated. Clinical evaluation and pain on pressure at the anterior talo-fibular ligament are used in diagnosis. Radiographic studies are necessary to eliminate fractures or an avulsion fragment. Ultrasound can be helpful. Most practitioners and orthopedic surgeons prefer to treat ankle sprains in children nonoperatively.

Chiropractic care of a patient with low back pain associated with subluxations and a Malgaigne-type pelvic fracture

OBJECTIVE

To describe the chiropractic care of a patient with a pelvic ring fracture and concomitant subluxations of multiple segments of the spinal column.

CLINICAL FEATURES

A 23-year-old male, after falling down a flight of stairs, was initially hospitalized for fractures of the pelvis. Five weeks posthospitalization, the patient initiated chiropractic care with complaints of severe low back pain with lower extremity involvement. He also complained of neck pain and occipital headache. The patient had several positive low back orthopedic tests with bilaterally absent Achilles deep tendon reflexes. The anteroposterior radiographic view revealed ununited fractures at the left superior and inferior pubic ramus, noted as a type I Malgaigne fracture. Subluxations were detected at the left innominate (ie, fracture-subluxation) and at the patient's lumbar, thoracic, and cervical spine.

INTERVENTION AND OUTCOME

The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral and sacroiliac subluxations. The patient's response to care was positive, receiving great pain relief. Less than 3 months after initiating care, the patient returned to work on regular duty.

CONCLUSION

There are indications that patients suffering from the injuries described above may derive benefits from chiropractic care. The practitioner must pay careful attention to issues of biomechanical and vascular stability and adjustment modifications in these types of patients.

Prevention and treatment of ankle sprain in athletes

The frequent nature of ankle sprains and persistent disability that often ensues has lead to considerable medical costs. As prevention of disease and injury becomes an increasingly important part of the practice of medicine today, we strive to understand and identify interventions that optimally reduce the frequency of ankle sprain and re-injury. In doing so, considerable morbidity and unnecessary medical expenditures may potentially be averted. The prophylactic use of ankle braces is fairly common. Recent critical evaluation of their effectiveness supports their use for at least 6 months following injury in athletes who have sustained a moderate or severe sprain; however, their role in primary prevention of ankle sprain is less evident. Functional ankle rehabilitation is the mainstay of acute ankle sprain treatment and in recent reviews has been deemed preferable to immobilisation or early surgery for initial treatment of acutely injured ankles. Furthermore, certain components of ankle rehabilitation, such as proprioceptive exercises, have been found to protect the joint from re-injury. Multifaceted ankle sprain prevention programmes that incorporate a variety of strategies for injury reduction are also effective in sprain prevention, although the relative importance of each component of such programmes warrants further investigation. Surgery for ankle sprain is principally reserved for patients who fail a comprehensive non-operative treatment programme and can be highly successful in treating chronic functional instability. This paper examines the current literature regarding common ankle sprain prevention strategies and provides a review of appropriate treatment schemes.

Low-Level Laser Treatment Can Reduce Edema in Second Degree Ankle Sprains

OBJECTIVE

Low-level laser therapy (LLLT) has been used for the last few years to treat sports injuries. The purpose of this study was to compare three therapeutic protocols in treating edema in second degree ankle sprains that did not require immobilization with a splint, under placebo-controlled conditions.

MATERIALS AND METHODS

Forty-seven soccer players with second degree ankle sprains, selected at random, were divided into the following groups: The first group (n = 16) was treated with the conventional initial treatment (RICE, rest, ice, compression, elevation), the second group (n = 16) was treated with the RICE method plus placebo laser, and the third group (n = 15) was treated with the RICE method plus an 820-nm GaA1As diode laser with a radiant power output of 40 mW at 16 Hz. Before the treatment, and 24, 48, and 72 h later, the volume of the edema was measured.

RESULTS

A three by three repeated measures ANOVA with a follow up post hoc test revealed that the group treated with the RICE and an 820-nm GaA1As diode laser presented a statistically significant reduction in the volume of the edema after 24 h (40.3 +/- 2.4 mL, p < 0.01), 48 h (56.4 +/- 3.1 mL, p < 0.002), and 72 h (65.1 +/- 4.4 mL, p < 0.001).

CONCLUSIONS

LLLT combined with RICE can reduce edema in second-degree ankle sprains.

Treatment of Bipolar, Seizure, and Sleep Disorders and Migraine Headaches Utilizing a Chiropractic Technique

OBJECTIVE

To discuss the use of an upper cervical technique in the case of a 23-year-old male patient with rapid-cycling bipolar disorder, sleep disorder, seizure disorder, neck and back pain, and migraine headaches.

CLINICAL FEATURES

The patient participated in a high school track meet at age 17, landing on his head from a height of 10 ft while attempting a pole vault. Prior to the accident, no health problems were reported. Following the accident, the patient developed numerous neurological disorders. Symptoms persisted over the next 6 years, during which time the patient sought treatment from many physicians and other health care practitioners.

INTERVENTION AND OUTCOME

At initial examination, evidence of a subluxation stemming from the upper cervical spine was found through thermography and radiography. Chiropractic care using an upper cervical technique was administered to correct and stabilize the patient's upper neck injury. Assessments at baseline, 2 months, and 4 months were conducted by the patient's neurologist. After 1 month of care, the patient reported an absence of seizures and manic episodes and improved sleep patterns. After 4 months of care, seizures and manic episodes remained absent and migraine headaches were reduced from 3 per week to 2 per month. After 7 months of care, the patient reported the complete absence of symptoms. Eighteen months later, the patient remains asymptomatic.

CONCLUSION

The onset of the symptoms following the patient's accident, the immediate reduction in symptoms correlating with the initiation of care, and the complete absence of all symptoms within 7 months of care suggest a link between the patient's headfirst fall, the upper cervical subluxation, and his neurological conditions. Further investigation into upper cervical trauma as a contributing factor to bipolar disorder, sleep disorder, seizure disorder, and migraine headaches should be pursued.

[Diagnostic image (172). A man with blisters after the use of a cold pack. Cryotrauma caused by frozen cold pack]

A 19-year-old soccer player developed cryotrauma after the prolonged application of a cold pack to a sprained ankle.

Evaluation and treatment of chronic ankle pain

The evaluation and treatment of chronic ankle pain presents a challenge to the orthopaedic surgeon. A detailed history helps to determine causative factors resulting from earlier trauma or surgery. A careful physical examination and radiographic studies also are helpful in making an accurate diagnosis, which is the basis for choosing a specific and effective treatment regimen.

[Effectiveness of manual therapy combined with physiotherapy in musicians' occupational overloads]

BACKGROUND

Manual therapy, kinesitherapy and physiotherapy are very helpful in the treatment of musicians' occupational overloads. The aim of this work is the estimation of the effectiveness of these three methods in the therapy of instrumentalists' occupational overloads.

MATERIALS AND METHODS

Examinations were made among 689 professional musicians. They were divided into three groups: functional disorders, primary organic disorders, and secondary organic disorders. Before and after the treatment some parameters of the movement organs were estimated.

RESULTS

Among patients with functional disorders, after manual therapy all estimated movement organs' parameters improved, however among patients with organic disorders, bigger improvement of some parameters were noticed after kinesitherapy and physiotherapy.

CONCLUSIONS

Manual therapy is effective method of treatment of movement functions disorders caused by occupational overloads.

Factors Associated with Recurrent Hamstring Injuries

A history of muscle injury represents a predominant risk factor for future insult in that muscle group. The high frequency of re-injury and persistent complaints after a hamstring strain comprise major difficulties for the athlete on return to athletic activities. Some of the risk factors associated with the possible recurrence of the injury are, in all probability, already implicated in the initial injury. One can distinguish between those events peculiar to the sport activity modalities (extrinsic factors) and other contributing factors based on the athletes individual features (intrinsic factors). For both categories, the persistence of mistakes or abnormalities in action represent an irrefutable component contributing to the re-injury cycle. Additional factors leading to chronicity can come from the first injury per se through modifications in the muscle tissue and possible adaptive changes in biomechanics and motor patterns of sporting movements. We emphasise the role of questionable approaches to the diagnosis process, drug treatment or rehabilitation design. To date, the risk factors examined in the literature have either been scientifically associated with injury and/or speculated to be associated with injury. In this context, quantifying the real role of each factor remains hypothetical, the most likely ones corresponding to inadequate warm-up, invalid structure and the content of training, muscle tightness and/or weakness, agonist/antagonist imbalances, underestimation of an extensive injury, use of inappropriate drugs, presence of an extensive scar tissue and, above all, incomplete or aggressive rehabilitation. Such a list highlights the unavoidable necessity of developing valid assessment methods, the use of specific measurement tools and more rigorous guidelines in the treatment and rehabilitation. This also implies a scientific understanding as well as specifically qualified medical doctors, physiotherapists and trainers acting in partnership.

Sprains—residual instability of subtalar, Lisfranc joints, and turf toe

Sprains of the hindfoot, midfoot and forefoot are being diagnosed with more regularity in athletes. Each of these injuries can go on to develop chronic instability with associated disability. With early diagnosis and appropriate treatment significant morbidity and loss of playing time can be avoided. Knowledge of the relevant anatomy, mechanism of injury, and available diagnostic tools is essential for making the proper diagnosis. Once the correct diagnosis is made, proper treatment can be implemented to avoid long term complications of instability.

The major traumas in youth football

For 4 years we followed a group of football players in the youth division of a professional club, ranging in age from 9 to 19 years, and analyzed the major injuries, i.e., those which required them to be sidelined for at least 4 weeks. We observed 23 sprains, 16 fractures, 16 cases of osteochondrosis, 7 muscle lesions, 6 cases of groin pain (athletic pubalgia), and 4 tendonopathies. The most frequent sites were the knee (n=30) and the ankle (n=11); the trauma factor was predominant (65.2%) with respect to overuse; noncontact traumas were more numerous (63.8%) than those resulting from contrast. Of a total 72 cases 8 regarded goalkeepers, and the remaining 64 cases were distributed among the other positions. As regards the age categories we detected a prevalence of osteochondrosis, traumatic detachments, and some fractures in the younger players, while in the older athletes we observed more sprains, muscle lesions, and tendonopathies.

Current treatment options for ankle injuries: lateral ankle sprain, Achilles tendonitis, and Achilles rupture

The ankle is the site of many sports-related injuries. There is, however, continued debate over which treatment strategies are most effective for various conditions. This article reviews the relevant literature from the past year to shed some light on the ongoing controversy regarding the best treatment options along the treatment continuum, from conservative to operative management, for three common ankle conditions: lateral ankle sprains, Achilles tendonitis, and Achilles tendon rupture.

Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries

STUDY OBJECTIVE

The purpose of this study was to evaluate the efficacy of osteopathic manipulative treatment (OMT) as administered in the emergency department (ED) for the treatment of patients with acute ankle injuries.

METHODS

Patients aged 18 years and older with unilateral ankle sprains were randomly assigned either to an OMT study group or a control group. Independent outcome variables included edema, range of motion (ROM), and pain. Both groups received the current standard of care for ankle sprains and were instructed to return for a follow-up examination. Patients in the OMT study group also received one session of OMT from an osteopathic physician.

RESULTS

Patients in the OMT study group had a statistically significant (F = 5.92, P = .02) improvement in edema and pain and a trend toward increased ROM immediately following intervention with OMT. Although at follow-up both study groups demonstrated significant improvement, patients in the OMT study group had a statistically significant improvement in ROM when compared with patients in the control group.

CONCLUSIONS

Data clearly demonstrate that a single session of OMT in the ED can have a significant effect in the management of acute ankle injuries.

High-intensity training with a bi-directional bicycle pedal improves performance in mechanically unstable ankles--a prospective randomized study of 19 subjects

A bi-directional bicycle pedal that combines proprioceptive training and evertor strengthening has been developed for the treatment of residual instability after ankle sprains. A prospective randomized study was carried out on 19 subjects with recurrent ankle sprains and positive stress X-ray films. The subjects were randomized to use either a bi-directional test pedal or a traditional uni-directional bicycle pedal and then completed a 6-week high-intensity training program on a cycle ergometer. Assessment of training intensity level was based on maximum oxygen uptake values, heart rate and lactate concentration in blood at various submaximal workloads. After completion of the training program, the subjects who had used the test pedal increased peak eversion torque at 180 degrees degrees s-1 by 14.2% (P = 0.020), reduced figure-of-eight running time by 0.24 s (P = 0.003), improved single leg stance speed from 72.5% to the maximum speed of 80% (P = 0.005), and improved Karlsson functional score by 5.1 points (P = 0.005). In the control group, single leg stance improved from 56.1 to 67.8% (P = 0.018), but otherwise no significant effects were found. This study indicates that short-term high-intensity training with a bi-directional pedal improves ankle performance and may be an option in the treatment of recurrent ankle sprains.

Ankle and foot disorders in skeletally immature athletes

As one of the most commonly injured areas in the immature athlete, the foot and ankle has many disorders. Knowledge of congenital and developmental abnormalities and possible injury patterns enables the clinician to correctly diagnose these disorders. Physical examination and appropriate use of imaging technology provide confirmation of the initial impression. As children and adolescents participate in sports with greater intensity, there is a higher incidence of overuse injuries that may have long-term implications.

Hyperbaric oxygen therapy for lower-extremity soft-tissue sports injuries

Lower-extremity injuries have become increasingly common as sports performance demands have risen. Hyperbaric oxygen therapy is one method used to return athletes to competition as quickly as possible, but it has received criticism and lacks support. This review examines the literature on hyperbaric oxygen therapy and soft-tissue sports injuries. In the various studies, the location of the injury seemed to influence the effectiveness of treatment. Injuries at areas of reduced perfusion such as muscle-tendon junctions and ligaments seemed to benefit more from hyperbaric oxygen treatment than injuries at the muscle belly. Differences in the magnitude of the injury and in the time between injury and treatment may also affect outcomes. The authors sought to explore these variables as they relate to soft-tissue sports injuries and to weigh the benefits of hyperbaric oxygen therapy against its potential risks and high cost. More randomized controlled clinical trials with larger sample sizes must be conducted before hyperbaric oxygen can be established as a safe adjunctive therapy for soft-tissue sports injuries.

Cervical sprains, disc herniations, minor fractures, and other cervical injuries in the athlete

In today's health-conscious society, more people are participating in athletic endeavors. As participation increases, so does the incidence of cervical injuries. Fortunately, most of the cervical injuries seen in sports are minor and can be treated successfully with minimal morbidity. It is important, however, to accurately assess the patient sustaining a cervical injury to rule out the presence of a more severe cervical injury. When practitioners understand the pathophysiology and treatment of common injuries, including sprains, strains, contusions, disc herniations, and simple fractures, most athletes can be returned to full function.

Arthroscopic drilling for chondral, subchondral, and combined chondral-subchondral lesions of the talar dome

PURPOSE

We investigated the efficacy of drilling as a treatment for chondral (C), subchondral (S), and combined chondral-subchondral (CS) lesions of the talar dome associated with trauma, using magnetic resonance imaging (MRI), ankle arthroscopy, and the ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society (AOFAS score).

TYPE OF STUDY

Case series study.

METHODS

Arthroscopic drilling was performed on 72 patients whose lesions were less than 7 mm in diameter. The patients included 45 men and boys and 27 women and girls whose age at the time of surgery was between 14 and 57 years (mean age, 30.7 +/- 9.5 years). They were followed up for 24 to 71 months (mean follow-up, 39 +/- 6.4 months).

RESULTS

There were 13 cases of chondral lesions, 10 cases of S lesions, and 49 cases of CS lesions. The MRI findings revealed that in the chondral lesion group, 13 cases were unchanged and 0 deteriorated; in the S lesion group, 2 improved, 8 were unchanged, and 0 deteriorated; and in the CS lesion group, 13 improved, 36 were unchanged, and 0 deteriorated. The arthroscopic findings showed that in the chondral lesion group, 2 improved, 9 were unchanged, and 1 deteriorated; in the S lesion group, all 8 cases deteriorated; and in the CS lesion group, 28 improved, 22 were unchanged, and 0 deteriorated. Drilling did not always improve the MRI and arthroscopic findings of the 3 respective types of lesions. However, the mean AOFAS score at the most recent follow-up was excellent; 91.7 +/- 2.4 points in the chondral lesion group, 93.1 +/- 2.1 points in the S lesion group, and 98.8 +/- 1.2 points in the CS lesion group.

CONCLUSIONS

Our study shows that drilling did not always improve the MRI and arthroscopic findings. However, the clinical results obtained as measured by the AOFAS score were excellent.

Sacroiliac joint dysfunction in athletes

The sacroiliac (SI) joint is a common source of low back pain in the general population. Because it is the link between the lower extremities and the spine, it sustains even higher loads during athletic activity, predisposing athletes to a greater probability of joint dysfunction and pain. The diagnosis and treatment of SI joint dysfunction remains controversial, due to complex anatomy and biomechanics, and a lack of universally accepted nomenclature and terminology, consistently reliable clinical tests and imaging studies, and consistently effective treatments. This article clarifies these issues by presenting a model of SI joint anatomy and function, a systematic approach to the diagnosis of dysfunction, and a comprehensive treatment plan.

Alternative treatments for neck sprain

A short cut review was carried out to establish whether osteopathy or chiropractic treatments improve outcome in patients with neck sprain. Altogether 206 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated

Treatment of complete rupture of the lateral ligaments of the ankle: a randomized clinical trial comparing cast immobilization with functional treatment

This study compared the therapeutic efficacy between cast immobilization and functional treatment of grade III ruptures of the lateral ankle ligaments. Subjects ( n=121) had closed physeal cartilage, age under 35 years, grade III rupture without previous or associated injuries, and practiced regular sports. Patients were randomized into an immobilization group (21 days plaster cast) or a functional one (15 days strapping plus early controlled mobilization). Symptoms (pain, swelling, stiffness, subjective instability), joint laxity, return to preinjury activity (time and level) and rate of reinjury were assessed 3, 6, and 12 months after sprain. Objective joint laxity was related to constitutional laxity, creating a new variable [talar tilt at injury - talar tilt at control]/contralateral talar tilt. The functional group showed significantly earlier and better return to physical activity, fewer symptoms at 3 and 6 months but no intergroup difference at 12 months. Functional treatment also showed better decrease in joint laxity. No intergroup differences were found in the reinjury rate. We conclude that functional treatment is safe, associated with a more rapid recovery, and particularly suitable in athletic populations.