Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete

BACKGROUND

Midfoot sprains in athletes represent a spectrum of injuries to the Lisfranc ligament complex, from partial sprains with no displacement to complete tears with frank diastasis. Treatment of these injuries varies from the treatment of high-velocity injuries seen in nonathletes.

PURPOSE

We wanted to report the outcome of treatment in athletes with Lisfranc injuries classified according to our system.

STUDY DESIGN

Retrospective cohort study.

METHODS

Weightbearing radiographs and bone scintigrams were used to diagnose midfoot sprains in 15 athletes who were treated surgically or nonoperatively according to the following classification: nonoperative management for stage I injuries (undisplaced) and anatomic reduction with fixation for stage II (diastasis with no arch height loss) and stage III (diastasis with arch height loss) injuries.

RESULTS

We achieved an excellent outcome in 93% of 15 athletes with midfoot sprains at an average follow-up of 27 months (range, 9 to 72).

CONCLUSIONS

Weightbearing radiographs and bone scintigrams are sensitive, reproducible, and relatively inexpensive methods of investigation of these injuries. Restoration and maintenance of the anatomic alignment of the Lisfranc joint is the key to appropriate treatment of injury to the midfoot.

Common injuries of the foot and ankle

This article is aimed at accident and emergency and orthopaedic senior house officers. It emphasizes key points of the safe initial management of common foot and ankle injuries.

Clinical perspectives regarding eccentric muscle injury

Muscle strain injuries occur to predictable muscles at consistent locations during expected sporting maneuvers when a muscle is stretched and then activated, particularly during high intensity bursts of activity. More than 30% of the injuries seen in the clinician's office are injuries to skeletal muscle. The typical location of the injury is just proximal to the distal muscle tendon junction regardless of strain rate or architecture of the muscle. After the injury, the muscle is weaker, continues to weaken, then recovers during the next week. An inflammatory response is seen in the following 1 to 2 days. By the seventh day, fibrous tissue replaces the inflammatory reaction and a scar forms. When a muscle is stretched, its tension still is reduced making the healing muscle more susceptible to a repeat injury. Viscoelastic properties of muscle also can help explain how muscle can be protected against strain injury. A 1 degree C increase in muscle temperature (warm-up) increases the muscle length to failure and a fatigued muscle is more susceptible to strain injury. It probably is impossible to prevent muscle strain injury; however, preventive measures can make muscle more resistant to these stretch-induced injuries.

Acupuncture analgesia in a new rat model of ankle sprain pain

The lack of suitable experimental animal models for persistent pain showing clear acupuncture analgesia, has been the major stumbling block in the investigation of the physiological mechanisms of acupuncture analgesia. The present study developed a new rat model of ankle sprain pain and the effect of electroacupuncture (EA) on this model was examined. A common source of persistent pain in humans is the lateral ankle sprain. To model this condition, the rat's right ankle was bent repeatedly, overextending lateral ligaments, for 4 min under halothane anesthesia. The rat subsequently showed swelling of the ankle and a reduced stepping force of the affected limb for the next several days. The reduced stepping force of the limb was presumably due to a painful ankle since systemic injection of morphine produced temporary improvement of weight bearing. EA was applied to the SI-6 acupuncture point on the contralateral forelimb for 30 min under halothane anesthesia. After the termination of EA, behavioral tests measuring stepping force were periodically conducted during the next 4h. EA produced a 40% recovery in the stepping force of the sprained foot lasting for at least 2h. The magnitude of this improvement was equivalent to that obtained after a systemic injection of 2mg/kg of morphine and this improvement of stepping pressure was interpreted as an analgesic effect. The analgesic effect was specific to the acupuncture point since (1). the analgesic effect on the ankle sprain pain model could not be mimicked by EA applied to a nearby point, LI-4 and (2). EA applied to the SI-6 point was not effective in the knee arthritis pain model. The analgesic effect could not be blocked by systemic injection of opioid antagonists naloxone or naltrexone. These data suggest that EA produces a potent analgesic effect on the ankle sprain pain model in the rat. This analgesic effect is produced by applying EA to a site remote from the painful area in a stimulus point-specific way. The present study provides a powerful experimental animal model that can be used for investigating the unique physiological mechanisms involved in acupuncture analgesia.

Syndesmosis injuries in athletes

The key to syndesmosis injuries is early recognition of the injury pattern and appropriate treatment. The clinician must be wary of the ankle sprain that is slow to heal. Radiographic criteria should be examined closely when considering the diagnosis; if surgery is warranted, attention to the health of the soft tissue envelope is key. Late repairs or reconstructions never have as favorable an outcome as the properly repaired acute injury. Postoperative rehabilitation should be monitored closely and care should be taken to avoid early return to activity that could result in reinjury or damage to the surgical repair or reconstruction.

Bloodletting acupuncture of the engorged vein around Bl-40 (Wei-Chung) for acute lumbar sprain

Bloodletting acupuncture is one of the most classic methods of acupuncture therapy, and is still popularly used to treat acute lumbar sprain in the oriental world. However, most physicians in the western world are not familiar with bloodletting acupuncture, though they may know ordinary acupuncture well. Furthermore based on the literature reviewed, there have been few studies which have investigated the effect of bloodletting acupuncture upon acute lumbar sprain. In this study, we tried to determine if bloodletting acupuncture is effective for acute lumbar sprain. In total, twelve patients were enrolled for analysis. Five patients were treated with ordinary acupuncture upon the contralateral SI-3 (Hou-Hsi) point alone. Seven patients were first treated with bloodletting acupuncture to the engorged vein around the ipisilateral Bl-40 (Wei-Chung), and then followed by ordinary acupuncture upon the contralateral SI-3. It was demonstrated that bloodletting acupuncture to the engorged vein around the ipisilateral Bl-40 followed by ordinary acupuncture upon the contralateral SI-3 had more pain relief than ordinary acupuncture upon the contralateral SI-3 alone (83 +/- 23% vs. 44 +/- 28%) (P < 0.01). And bloodletting acupuncture to the engorged vein around the ipisilateral Bl-40 decreased pain by 56 +/- 23%, similar to that of ordinary acupuncture upon the contralateral SI-3 alone (44 +/- 28%). These findings suggest that bloodletting acupuncture to the engorged vein around the ipisilateral Bl-40 (Wei-Chung) has a substantial contribution for treatment of acute lumbar sprain.

Prediction of outcome in whiplash-associated disorders using West Haven-Yale Multidimensional Pain Inventory

OBJECTIVE

To investigate the predictive capacity of the West Haven-Yale Multidimensional Pain Inventory (MPI) with regard to prolonged pain, using car occupants who had sustained a neck sprain in a traffic accident.

DESIGN

A prospective cohort study including a one-year follow-up.

PATIENTS

One hundred thirty adults were examined by a specialized neck-injury team after a first visit to an accident and emergency department. The subjects answered the MPI questionnaire within one month of the accident.

OUTCOME MEASURES

One year later, the patients answered a questionnaire about residual neck pain. The main outcome was determined by the question, "Do you have residual pain which you relate to the accident?"

RESULTS

One hundred twenty-three (95%) of the subjects completed the study. Ninety-seven reported pain of some degree that they related to the accident. All but one of the MPI variables differed significantly between the group with residual pain and the group without pain. The variable interference had the strongest correlation with the outcome. Its discriminative capacity was 81% for those with pain and 94% for those without pain one year later.

CONCLUSIONS

The MPI may be used at an early stage to identify patients who may develop chronic neck-pain after a traffic accident, at least in those who want a follow-up session after an initial visit to an accident and emergency department.

Adductor muscle strains in sport

An in-season adductor muscle strain may be debilitating for the athlete. Furthermore, an adductor strain that is treated improperly could become chronic and career threatening. Any one of the six muscles of the adductor group could be involved. The degree of injury can range from a minor strain (Grade I), where minimal playing time is lost, to a severe strain (Grade III) in which there is complete loss of muscle function. Ice hockey and soccer players seem particularly susceptible to adductor muscle strains. In professional ice hockey players throughout the world, approximately 10% of all injuries are groin strains. These injuries, which have been linked to hip muscle weakness, previous injuries to that area, preseason practice sessions and level of experience, may be preventable if such risk factors can be addressed before each season. Hip-strengthening exercises were shown to be an effective method of reducing the incidence of adductor strains in one closely followed National Hockey League ice hockey team. Despite the identification of risk factors and strengthening intervention for ice hockey players, adductor strains continue to occur throughout sport. Clinicians feel an active training programme, along with completely restoring the strength of the adductor muscle group, is the key to successful rehabilitation. Surgical intervention is available if nonoperative treatment fails for 6 months or longer. Adductor release and tenotomy was reported to have limited success in athletes.

Lower extremity injuries in youth sports

The lower extremity is the most commonly injured anatomic area in sports. An appropriate history and physical examination is sufficient to diagnose most injuries. By knowing the position where a joint has the greatest and least bony stability, one can predict the likelihood of bony and ligament injury. Such information is helpful in determining which structures are most susceptible to injury as well as identifying when radiographs or other diagnostic studies are indicated. An accurate diagnosis is crucial for planning effective therapy and in determining the need for surgical referral. An understanding of common injury patterns is also helpful in differentiating sources of musculoskeletal pain that are not injury related.

Sprains about the foot and ankle encountered in the workmans' compensation patient

Soft tissue injury in the workmans' compensation patient population has been previously poorly understood. Injuries that do not show up easily on radiographs are often undertriaged and undertreated. With the advent of improved imaging techniques, an enhanced understanding of soft tissue injuries has evolved over the past few years. Coupled with improved surgical and rehabilitation techniques, severely injured patients are able to experience remarkable recoveries. Many cannot return to previous function. These patients pose challenges to the astute clinician with regards to psychosocial issues relative to secondary gain. In addition, State-to-State variations in the workmans' compensation laws can confuse clinicians. Because of the protections and laws set in place in the United States, these patients can frequently be returned to the workforce as grateful and productive members of society.

Upper extremity injuries in youth sports

This article provides an overview of common upper extremity injuries in youth sports, including injuries to the shoulder, elbow, and wrist. Pain in the shoulder and elbow is common among youngsters who participate in throwing sports, raquet sports, and swimming, while wrist pain is common among young gymnasts. Acute trauma to the shoulder and elbow can occur in almost any sporting activity. This article provides descriptions of common injuries and guidelines for treatment.

Seven years follow-up after ankle inversion trauma

During one year all ankle inversion injuries seen at the acute ward of our institution were divided into grades of severity and classified according to the maximal area of tenderness at the time of clinical examination. Seven years later 648 of the subjects (91%) evaluated their ankle with the help of a questionnaire. Location of maximal tenderness at the time of injury was: lateral fibular ligaments 61%, lateral midfoot ligaments 24%, base of the fifth metatarsal/peroneal tendons 5% and combined lesions 8%. 39% were considered minor, 46% were moderate, and 15% severe. All cases followed a functional treatment protocol. Seven years post- injury 32% reported chronic complaints of pain, swelling or recurrent sprains. 72% of the subjects with residual disability reported that they were functionally impaired by their ankle - in most cases a question of not performing sports at a desired level. 4% experienced pain at rest and were severely disabled. 19% were bothered by repeated inversion injuries - 43% of these subjects felt that they could compensate by using an external ankle support. There was no correlation between the severity of the sprain as judged at the time of injury and the frequency of residual disability or between the area of maximal tenderness at the time of injury and the area of maximal pain at the time of follow-up.

Anterior cruciate ligament injuries in the National Football League: epidemiology and current treatment trends among team physicians

PURPOSE

To review the epidemiology of anterior cruciate ligament (ACL) injuries in the National Football League (NFL) and current treatment trends within this population.

TYPE OF STUDY

Descriptive.

METHODS

Part 1 of this study reviews the data collected in the NFL Injury Surveillance System from 1986 to 1995 with respect to these injuries. Included in this review are the specifics surrounding these injuries such as exposure type (game versus practice), position, mechanism, and playing surface on which the injury occurred. Part 2 of this analysis focuses on present treatment performed on these high-level athletes through a survey that was sent to and completed by all 31 NFL team orthopaedic surgeons.

RESULTS

The total number of ACL injuries in this select population has remained constant over the period analyzed.

CONCLUSIONS

Current preferred treatment technique favors endoscopic patellar tendon autograft reconstruction.

Conservative treatment of acute lateral ankle sprains

Lateral ankle sprains are among the most common sports injuries. Although ankle sprains are treated conservatively at the present time, for years the treatment was based on acute repair of the ruptured ligaments. Several differing opinions currently exist as to the treatment of lateral ankle sprains. A review of the literature and explanation of the benefits and risks of each treatment protocol is undertaken.

The effect of standard care, ibuprofen, and distraction on pain relief and patient satisfaction in children with musculoskeletal trauma

INTRODUCTION

The purpose of this study was to determine the effectiveness of nursing interventions in decreasing pain for children with minor musculoskeletal trauma and moderate pain and to examine patient satisfaction.

METHODS

Children were assigned to 1 of 3 intervention groups: (1) standard care (ice, elevation, and immobilization) only; (2) standard care and ibuprofen; or (3) standard care and distraction. Children were monitored for pain ratings for 60 minutes. Children who sustained minor musculoskeletal trauma within the past 24 hours and presented with pain ratings of 2 or greater using the 0-5 Wong/Baker faces scale were included. Two patient satisfaction questions were asked of parents upon their child's discharge from the emergency department.

RESULTS

A statistically significant decrease in pain for all patients (76) occurred at 30 minutes (F = 4.39, P <.05) and was maintained at 60 minutes. The distraction group demonstrated a statistically significant reduction in pain compared with the other groups at 30 minutes; this reduction was maintained at 60 minutes (F = 47.07, P <.05). Parents of only 6 children expressed dissatisfaction with overall pain management. Twelve percent of children who were not in the group receiving medication received analgesics while in the emergency department. At discharge, only 37% of children with fractures and/or sprains had received medications for pain.

DISCUSSION

Children with musculoskeletal trauma may be under-medicated. Distraction techniques can be an effective adjunct to analgesia for children with musculoskeletal pain in the emergency department and should be made available. Ibuprofen may not be an effective analgesic for children with these injuries; stronger analgesics may be required.

Ligamentous injuries about the ankle and subtalar joints

Ligamentous injuries at the ankle and subtalar joint range from simple sprains to severe talar dislocations. While lateral ankle sprains are among the most frequently encountered injuries and do not pose a greater diagnostic problem, the surgeon must be suspicious not to overlook associated ligamentous injuries at the subtalar and midtarsal level that may result in chronic painful conditions. Syndesmotic instabilities with or without ankle fractures must be assessed carefully and treated properly, since these are prearthrotic conditions. In the treatment of chronic ankle or subtalar instability tenodeses provide mechanical stability while reducing subtalar mobility. Anatomic reconstruction methods therefore should be considered for both conditions.

The sprained ankle

The sprained ankle is the most common musculoskeletal injury seen by physicians caring for active youngsters and adults. It accounts for approximately one fourth of all sports-related injuries and is commonly seen in athletes participating in basketball, soccer, or football. It has been shown that one third of West Point cadets suffer an ankle sprain during their 4 years at the military academy. While diagnosis and management of the sprained ankle is usually straightforward, several serious injuries can masquerade as an ankle sprain, and it is important for the clinician to recognize these to prevent long-term morbidity. In this article the basic anatomy of the ankle, mechanisms by which the ankle is injured, and the differential diagnosis of the acutely injured ankle are reviewed. Appropriate evaluation of the injured ankle and the criteria that should be utilized for determining the necessity of radiographs are discussed as well as management of the acutely sprained ankle and the role of prevention in reducing the risk of ankle injury.

Ultrasound therapy for acute ankle sprains

BACKGROUND

Ultrasound is used in the treatment of a wide variety of musculoskeletal disorders.

OBJECTIVES

To evaluate the effects of ultrasound therapy in the treatment of acute ankle sprains.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (November 15th 2001), the Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2001), MEDLINE (1966 to October 2001), EMBASE (1983 to 2001 week 45), CINAHL (1982 to October week 4 2001), and PEDro - The Physiotherapy Evidence Database (http://ptwww.cchs.usyd.edu.au/pedro/ accessed 15.11.01). We also searched the Cochrane Rehabilitation and Related Therapies Field database, reference lists of articles, and contacted colleagues.

SELECTION CRITERIA

Randomised or pseudo-randomised trials were included in the review if the following conditions were met: at least one study group was treated with active ultrasound; the study included patients with acute lateral ankle sprains; and outcome measures included general improvement, pain, swelling, functional disability, or range of motion. Final selection of papers was conducted by two independent reviewers.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality using a standardised checklist, and extracted data. Whenever possible, the results were analysed on an intention-to-treat basis. Relative risks together with 95 per cent confidence intervals were calculated for dichotomous outcomes, and weighted or, where different scales were used, standardised mean differences together with 95 per cent confidence intervals for continuous outcome measures. Pooling of data was undertaken where there was clinical homogeneity in terms of subjects, treatments, outcomes, and follow-up time points.

MAIN RESULTS

Five trials were included, involving 572 patients. Four of these trials were only of modest methodological quality and one placebo-controlled trial was considered to be of good quality. None of the four placebo-controlled trials (sham ultrasound) could demonstrate statistically significant differences between true and sham ultrasound therapy for any outcome measure at seven to 14 days of follow-up. The pooled relative risk for general improvement was 1.04 (random effects model, 95% confidence interval 0.92 to 1.17) for the comparison between ultrasound and sham ultrasound. The differences between intervention groups were generally small, between zero and six per cent for most dichotomous outcomes. However, one trial reported relatively large differences for pain free status (20%) and swelling (25%) in favour of ultrasound treatment.

REVIEWER'S CONCLUSIONS

The extent and quality of the available evidence for the effects of ultrasound therapy for acute ankle sprains is limited. The results of four placebo-controlled trials do not support the use of ultrasound in the treatment of ankle sprains. The magnitude of most reported treatment effects appeared to be small, and may be of limited clinical importance. As yet, only few trials are available and no conclusions can be made regarding an optimal and adequate dosage schedule for ultrasound therapy, and whether such a schedule would improve on the reported effectiveness of ultrasound for ankle sprains.

Different functional treatment strategies for acute lateral ankle ligament injuries in adults

BACKGROUND

Acute lateral ankle ligament ruptures are common problems in present health care. Early mobilisation and functional treatment are advocated as a preferable treatment strategy. However, functional treatment comprises a broad spectrum of treatment strategies and as of yet no optimal strategy has been identified.

OBJECTIVES

The objective of this review is to assess different functional treatment strategies for acute lateral ankle ligament ruptures in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field.

SELECTION CRITERIA

Randomised clinical trials describing skeletally mature individuals with an acute lateral ankle ligament rupture and comparing different functional treatment strategies were evaluated for inclusion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of included trials and extracted relevant data on treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcome and (weighted) mean differences (WMD) for continuous outcome measures with 95 per cent confidence intervals (95%CI). Heterogeneity between trials was tested using a standard chi-squared test.

MAIN RESULTS

Nine trials involving 892 participants were included. Lace-up ankle support had significantly better results for persistent swelling at short-term follow up when compared with semi-rigid ankle support (RR 4.19, 95% CI 1.26 to 13.98); elastic bandage (RR 5.48; 95% CI 1.69 to 17.76); and to tape (RR 4.07, 95% CI 1.21 to 13.68). Use of a semi-rigid ankle support resulted in a significantly shorter time to return to work when compared with an elastic bandage (WMD (days) 4.24; 95% CI 2.42 to 6.06); one trial found the use of a semi-rigid ankle support saw a significantly quicker return to sport compared with elastic bandage (RR 9.60; 95% CI 6.34 to 12.86) and another trial found fewer patients reported instability at short-term follow-up when treated with a semi-rigid support than with an elastic bandage (RR 8.00; 95% CI 1.03 to 62.07). Tape treatment resulted in significantly more complications, the majority being skin irritations, when compared with treatment with an elastic bandage (RR 0.11; 95% CI 0.01 to 0.86). No other results showed statistically significant differences.

REVIEWER'S CONCLUSIONS

The use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears to be effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. However, definitive conclusions are hampered by the variety of treatments used, and the inconsistency of reported follow-up times. The most effective treatment, both clinically and in costs, is unclear from currently available randomised trials.

Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults

BACKGROUND

Inversion injuries, primarily sprains, of the ankle are one of the most commonly treated injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilisation with plaster cast or splint, 'functional treatment' comprising early mobilisation and the use of an external support (e.g. ankle brace or taping), and surgical repair or reconstruction.

OBJECTIVES

We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating acute injuries to the lateral ligament complex of the ankle in adults.

DATA COLLECTION AND ANALYSIS

At least two, usually three, reviewers independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled using fixed and random effects models and relative risks with 95% confidence intervals for dichotomous outcomes calculated. Heterogeneity between trials was tested using a standard chi-squared test. We undertook sensitivity analyses to explore the effects of inclusion of quasi-randomised trials and subgroup analyses by the two main methods of conservative treatment.

MAIN RESULTS

Seventeen studies, involving a total of 1950 mostly young active adult males, were included. All trials had methodological flaws. In particular, allocation was rated as effectively concealed in only one trial and there was no report of masking outcome assessors to the interventions in any trial. Outcome measures were variously defined and data for pooling for individual outcomes were only available for a maximum of 11 studies. While there were statistically significant differences for three primary outcomes (non-return to pre-injury level of sports; undefined pain or pain on activity; and subjective or functional instability) in favour of the surgical treatment group using the fixed effects model, these findings failed to demonstrate robustness in sensitivity analyses. Exclusion of the data from explicitly quasi-randomised trials or, given the highly statistically significant heterogeneity, analyses using the random effects model modified these findings to non-statistically significant differences. There was no statistically significant difference in ankle sprain recurrence, the other primary outcome measure. Though there was a statistically significantly higher incidence of objective instability in conservatively treated patients, the functional implications of this are uncertain. There was some evidence for a lower incidence of long-term ankle swelling in surgically treated patients. However, as well as tending to take longer to resume normal activities, including work, there was some limited evidence from a few trials for a higher incidence of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group. Subgroup analyses by type of conservative treatment (plaster cast or functional treatment) revealed no statistically significant differences in effect for any of the six outcomes examined.

REVIEWER'S CONCLUSIONS

There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. Sufficiently powered, good quality and adequately reported randomised trials of primary surgical repair versus the best available conservative treatment for well-defined injuries are required.

Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults

BACKGROUND

Acute lateral ankle ligament injuries (ankle sprains) are common problems in acute medical care. The treatment variation observed for the acutely injured lateral ankle ligament complex suggests a lack of evidence-based management strategies for this problem.

OBJECTIVES

The objective of this review was to assess the effectiveness of methods of immobilisation for acute lateral ankle ligament injuries and to compare immobilisation with functional treatment methods.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001); the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966-May 2000), EMBASE (1988-May 2000), reference lists of articles, and contacted organisations and researchers in the field.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing either different types of immobilisation or immobilisation versus functional treatments for injuries to the lateral ligament complex of the ankle in adults were included. Trials which investigated the treatment of chronic instability or post-surgical treatment were excluded.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two authors. Where appropriate, results of comparable studies were pooled using fixed effects models. Individual and pooled statistics were reported as relative risks with 95% confidence intervals for dichotomous outcomes and weighted (WMD) or standardised (SMD) mean differences and 95% confidence intervals for continuous outcome measures. Heterogeneity between trials was tested using a standard chi-squared test.

MAIN RESULTS

Twenty-one trials involving 2184 participants were included. The mean validity score of the included trials increased from 9.1 (SD 3.0) to 10 (SD 2.9) after retrieving further information (maximum 18 points). Statistically significant differences in favour of functional treatment when compared with immobilisation were found for seven outcome measures: more patients returned to sport in the long term (relative risk (RR) 1.86, 95% confidence interval (CI) 1.22 to 2.86); the time taken to return to sport was shorter (WMD 4.88 (days), 95% CI 1.50 to 8.25); more patients had returned to work at short term follow-up (RR 5.75, 95% CI 1.01 to 32.71); the time taken to return to work was shorter (WMD 8.23 days, 95% CI 6.31 to 10.16); fewer patients suffered from persistent swelling at short term follow-up (RR 1.74, 95% CI 1.17 to 2.59); fewer patients suffered from objective instability as tested by stress X-ray (WMD 2.60, 95% CI 1.24 to 3.96); and patients treated functionally were more satisfied with their treatment (RR 1.83, 95% CI 1.09 to 3.07). A separate analysis of trials that scored 50 per cent or more in quality assessment found a similar result for time to return to work only (WMD (days) 12.89, 95% CI 7.10 to 18.67). No significant differences between varying types of immobilisation, immobilisation and physiotherapy or no treatment were found, apart from one trial where patients returned to work sooner after treatment with a soft cast. In all analyses performed, no results were significantly in favour of immobilisation.

REVIEWER'S CONCLUSIONS

Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated.

Acupuncture granulomas

Silicone compounds have recently been a source of controversy with regard to their potential role in the genesis of collagen vascular diseases. Foreign body reactions to injectable silicone were noted early in its cosmetic use and led to subsequent abandonment of this procedure. Here we report the first documented case of silicone granulomas to occur after acupuncture.

Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine

OBJECTIVE

The chiropractic care of a patient with vertebral subluxations, neck pain, and cervical radiculopathy after a cervical diskectomy is described.

CLINICAL FEATURES

A 55-year-old man had neck pain and left upper extremity radiculopathy after unsuccessful cervical spine surgery.

INTERVENTION AND OUTCOME

Contact-specific, high-velocity, low-amplitude adjustments (i.e., Gonstead technique) were applied to sites of vertebral subluxations. Rehabilitation exercises were also used as adjunct to care. The patient reported a decrease in neck pain and left arm pain after chiropractic intervention. The patient also demonstrated a marked increase in range of motion (ROM) of the left glenohumeral articulation.

CONCLUSION

The chiropractic care of a patient with neck pain and left upper extremity radiculopathy after cervical diskectomy is presented. Marked resolution of the patient's symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of an unsuccessful cervical spine surgery. This is the first report in the indexed literature of chiropractic care after an unsuccessful cervical spine surgery.

Immobilisation for acute ankle sprain. A systematic review

The variation of practice with respect to the treatment of the acutely sprained ankle suggests a lack of evidence-based management strategies for this problem. The objective of this review was to assess the effectiveness of the various methods of immobilisation for acute ankle sprain. An electronic database search was conducted using MEDLINE, EMBASE, BIOSIS, CINAHL, Cochrane Controlled Trial Register and Current Contents. Randomised and quasi-randomised clinical trials describing skeletally mature individuals with an acute ankle sprain and comparing immobilisation for the treatment of injuries to the lateral ligament complex of the ankle were evaluated for inclusion. Two reviewers independently assessed the validity of included trials and extracted relevant data on the treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcomes and weighted mean differences (WMD) for continuous outcome measures with 95% confidence intervals (95% CI). Heterogeneity between trials was tested using a standard chi-square test. A total of 22 studies met the inclusion criteria. Statistically significant differences were found for six outcome measures, all in favour of functional treatment compared with immobilisation: return to sports (RR: 1.85; 95% CI: 1.2 to 2.8), (WMD: 4.57 days; 95% CI: 1.5 to 7.6), return to work (WMD: 7.12 days; 95% CI: 5.6 to 8.7), persistent swelling (RR: 1.44; 95% CI: 1.1 to 2.0), objective instability by stress X-ray (WMD: 2.48; 95% CI: 1.3 to 3.6), range of motion (RR: 1.64; 95% CI: 1.1 to 2.6) and patient satisfaction (RR: 6.50; 95% CI: 1.8 to 24) . None of the other results were significantly in favour of immobilisation. Sensitivity analysis showed that a non-concealed treatment allocation did not influence the statistical significance of the overall results. Based on our results, functional treatment currently seems a more appropriate treatment and should be encouraged. Concerning effectiveness, immobilisation, if necessary, should be restricted to certain patients and for short time periods.

Hip and groin injuries in athletes

Although athletic injuries about the hip and groin occur less commonly than injuries in the extremities, they can result in extensive rehabilitation time. Thus, an accurate diagnosis and well-organized treatment plan are critical. Because loads of up to eight times body weight have been demonstrated in the hip joint during jogging, presumably even greater loads can occur during vigorous athletic competition. The available imaging modalities are effective diagnostic tools when selected on the basis of a thorough history and physical examination. Considerable controversy exists as to the cause and optimal treatment of groin pain in athletes, or the so-called "sports hernia." There has also been significant recent attention focused on intraarticular lesions that may be amenable to hip arthroscopy. This article briefly reviews several common hip and groin conditions affecting athletic patients and highlights some newer topics.

Comparison of search strategies and quality of medical information of the Internet: a study relating to ankle sprain

OBJECTIVES

to evaluate the quality of web sites on ankle sprain diagnosis and treatment and to assess the impact of Internet search expertise on quality of retrieved information.

METHOD

two internet search strategies were conducted - one developed by an experienced information officer (expert's search) and the other based on the search terms used by orthopaedic medical staff (doctors' search).

RESULTS

the expert's search revealed 32 web sites, of which nine were relevant, whereas the doctors' search revealed 61 web sites of which 27 were relevant. Of the relevant web sites in the expert's search, one complied with all quality criteria, whereas none of the web sites in the doctors' search complied with all criteria (11 vs. 0%, P=0.25). The web sites identified by expert's search had higher credibility (median scores 70 vs. 44, P=0.01) and accuracy of content (median scores 50 vs. 35, P=0.24).

CONCLUSION

the quality of medical information on the internet is generally poor and information experts can capture higher quality web sites compared with doctors.

Sprain of the neck in clinically treated patients in The Netherlands: an inventory of different categories of car accidents

Different categories of car accidents of victims with sprain of the neck were investigated for both drivers and passengers. The predominant category of the car crash was a collision with another car for drivers as well as for passengers. The second cause was unknown. The distribution of the accidents was statistically significantly different for drivers and passengers.

[Os subfibulare in children secondary to an osteochondral fracture]

PURPOSE

The understanding of the os subfibulare in childhood.

MATERIAL AND METHODS

A retrospective study of radiographs following for indirect ankle injury in childhood over a period of two years.

RESULTS

The daily use of an oblique view during the exploration of ankle sprains in emergency has allowed us to image 12 small and linear chiplike fractures of the fibula by avulsion of the antero-medial part of the malleolar's tip where the talo-fibular collateral ligament is attached. Two children were reviewed one year after for a recurrent sprain: a larger and rounder fragment of bone has taken the place of the first piece of bone.

CONCLUSION

Symptomatic ossicles of the lateral malleolus in children is frequently if not always the consequence of an avulsion of the tip of the fibula. The outcome of these children may be a localised tenderness and recurrent episodes of sprains for minimal injury due to the weakness of the lateral ligament.

Impact of quality items on study outcome. Treatments in acute lateral ankle sprains

OBJECTIVE

This study investigates the influence of different aspects of methodologic quality on the conclusions of a systematic review concerning treatments of acute lateral ankle sprain.

METHOD

A data set of a systematic review of 44 trials was used, of which 22 trials could be included in this study. Quality assessment of the individual studies was performed using the Delphi list. We calculated effect sizes of the main outcome measure in each study in order to evaluate the relationship between overall quality scores and outcome. Next, we investigated the impact of design attributes on pooled effect sizes by subgroup analysis.

RESULTS

The quality of most studies (82%) was low; only 4 of 22 trials were of high quality. Studies with proper randomization and blinding procedure produce a slightly higher (not statistically significant) effect estimate compared to the other studies.

CONCLUSION

Previous research has suggested that methodologically poorly designed studies tend to over-estimate the effect estimate. Our study does not confirm these conclusions.

A randomised controlled trial to determine the effectiveness of double Tubigrip in grade 1 and 2 (mild to moderate) ankle sprains

OBJECTIVE

To compare functional outcome in patients with acute grade 1 or 2 (mild to moderate) lateral ankle sprains randomised to treatment with or without a double tubigrip bandage (DTG).

METHODS

400 patients presenting to the accident and emergency (A&E) departments of a teaching hospital and a district general hospital and diagnosed with grade 1 or 2 lateral ankle sprains were randomised to treatment with or without a DTG bandage. A standardised telephone questionnaire was performed one week after presentation. The main outcome measures were: number of days until walking unaided, number of days off work, whether the injury kept the patient awake at night, whether analgesia was taken.

RESULTS

197 of 400 patients completed follow up. There were no significant differences in terms of age, sex and occupation between the treatment groups. There were no significant differences between those who did and those who did not complete follow up. There was no significant difference between the treatment groups for number of days until walking unaided (95% CI -0.21 to 0.88 days), number of days off work (95% CI -0.70 to 1.02 days) or whether the injury kept the patient awake at night (95% CI -10 to 17%). There was a significant difference between the groups in the use of analgesia (95% CI 10 to 36%); the difference seemed to be that patients treated with DTG required significantly more analgesia.

CONCLUSIONS

Treatment of grade 1 and 2 ankle sprins with DTG does not seem to lead to a shorter time to functional recovery and may increase the requirement for analgesia.

The efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains

OBJECTIVE

The purpose of this study was to determine the efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains.

DESIGN

A single-blind, comparative, controlled pilot study.

SETTING

Technikon Natal Chiropractic Day Clinic.

PARTICIPANTS

Thirty patients with subacute and chronic grade I and grade II ankle inversion sprains. Patients were recruited from the public; they responded to advertisements placed in newspapers and on notice boards around the campus and local sports clubs.

INTERVENTION

Each of the 15 patients in the treatment group received the ankle mortise separation adjustment. Each of the 15 patients in the placebo group received 5 minutes of detuned ultrasound treatment. Each participant received a maximum of 8 treatment sessions spread over a period of 4 weeks.

MAIN OUTCOME MEASURE

Patients were evaluated at the first treatment, at the final treatment, and at a 1-month follow-up consultation. Subjective scores were obtained by means of the short-form McGill Pain Questionnaire and the Numerical Pain Rating Scale 101. Objective measurements were obtained from goniometer readings measuring ankle dorsiflexion range of motion and algometer readings measuring pain threshold over the ankle lateral ligaments. A functional evaluation of ankle function was also used.

RESULTS

Although both groups showed improvement, statistically significant differences in favor of the adjustment group were noted with respect to reduction in pain, increased ankle range of motion, and ankle function.

CONCLUSIONS

This study appears to indicate that the mortise separation adjustment may be superior to detuned ultrasound therapy in the management of subacute and chronic grade I and grade II inversion ankle sprains.

Management of ankle sprains

Without adequate care, acute ankle trauma can result in chronic joint instability. Use of a standardized protocol enhances the management of ankle sprains. In patients with grades I or II sprains, emphasis should be placed on accurate diagnosis, early use of RICE (rest, ice, compression and elevation), maintenance of range of motion and use of an ankle support. Sprains with complete ligament [corrected] tears (grade III) may require surgical intervention. Although early motion and mobility are recommended, ligamentous strength does not return until months after an ankle sprain.

Rotator cuff injuries

Different types of rotator cuff injuries frequently present to Accident and Emergency departments and minor injury units but can be difficult to differentiate clinically. This brief case study describes the examination and diagnosis of related shoulder injuries, specifically rotator cuff tears/disruption and calcifying supraspinatus tendinitis. The relevant anatomy and current therapies for these injuries is also discussed to enable the emergency nurse practitioner to have a greater understanding of the theory surrounding their diagnosis and treatments.

[The syndrome of external ligament sprain in the horse]

The treatment of acute complete (grade III) tears of the lateral ligaments of the ankle has generated much controversy in the medical literature. Functional treatment has become the standard treatment as it has been shown that there is no significant difference in long term results whatever the treatment (operative repair and cast, cast alone, or early controlled mobilization). Functional treatment includes only a short period of protection by tape bandage or brace and allows early weight-bearing. Major trauma with avulsion of bone and severe ligamentous damage on both medial and lateral sides of the ankle is however an indication for surgical treatment in the acute phase. Secondary operative reconstruction can be performed in case of persistent instability and laxity of the ankle. Secondary anatomic repair as proposed by Brodström, Duquennoy et al. and Karlsson et al. has a high rate of success and avoids the potential morbidity of harvesting partially or totally the peroneus brevis or other tendon grafts. Evaluation of the injured ankle has improved and in selected patients ultrasonography, arthrography, magnetic resonance imaging or bone scintigraphy may be useful for further evaluation of the injury. The frequency of associated injuries has probably been underestimated. Although ankle sprain is often thought of as an injury involving only the lateral ankle ligaments, there are varied and multiple components to the common sprained ankle. This condition would perhaps more appropriately be designated as the sprained ankle syndrome.