Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial

The influence of dosing on effect size of exercise therapy for musculoskeletal foot and ankle disorders: a systematic review

OBJECTIVE

The purpose of this review was to identify doses of exercise therapy associated with greater treatment effect sizes in individuals with common musculoskeletal disorders of the foot and ankle, namely, achilles tendinopathy, ankle sprains and plantar heel pain.

METHODS

AMED, EMBASE and MEDLINE were searched from 2005 to August 2017 for randomized controlled trials related to exercise for these three diagnoses. The Physiotherapy Evidence Database scale was used for methodological quality assessment. Exercise dosing variables and outcome measures related to pain and function were extracted from the studies, and standardized mean differences were calculated for the exercise groups.

RESULTS

Fourteen studies met the final inclusion. A majority of the studies showed large effects and two small trends were identified. Patients with plantar heel pain may benefit more from a daily home exercise program than two supervised visits per week (SMD=3.82), but this recommendation is based on weak evidence. In achilles tendinopathy, a relationship was also seen when sets and repetitions of eccentric exercise were performed as tolerated (SMD=1.08 for function, -1.29 for pain).

CONCLUSIONS

Session duration, frequency, total number of visits, and overall length of care may all be dosing variables with limited value for determining effective exercise prescription. However, the limited number of studies prevents any definitive conclusions. Further investigation is warranted to improve our understanding of the influence exercise dosing has on treatment effect sizes. Future randomized controlled trials comparing specific exercise dose variables should be conducted to clarify the impact of these variables.

Prognostic factors for recovery following acute lateral ankle ligament sprain: a systematic review

Background

One-third of individuals who sustain an acute lateral ankle ligament sprain suffer significant disability due to pain, functional instability, mechanical instability or recurrent sprain after recovery plateaus at 1 to 5 years post injury. The identification of early prognostic factors associated with poor recovery may provide an opportunity for early-targeted intervention and improve outcome.

Methods

We performed a comprehensive search of AMED, EMBASE, Psych Info, CINAHL, SportDiscus, PubMed, CENTRAL, PEDro, OpenGrey, abstracts and conference proceedings from inception to September 2016. Prospective studies investigating the association between baseline prognostic factors and recovery over time were included. Two independent assessors performed the study selection, data extraction and quality assessment of the studies. A narrative synthesis is presented due to inability to meta-analyse results due to clinical and statistical heterogeneity.

Results

The search strategy yielded 3396 titles/abstracts after duplicates were removed. Thirty-six full text articles were then assessed, nine of which met the study inclusion criteria. Six were prospective cohorts, and three were secondary analyses of randomised controlled trials. Results are presented for nine studies that presented baseline prognostic factors for recovery after an acute ankle sprain. Age, female gender, swelling, restricted range of motion, limited weight bearing ability, pain (at the medial joint line and on weight-bearing dorsi-flexion at 4 weeks, and pain at rest at 3 months), higher injury severity rating, palpation/stress score, non-inversion mechanism injury, lower self-reported recovery, re-sprain within 3 months, MRI determined number of sprained ligaments, severity and bone bruise were found to be independent predictors of poor recovery. Age was one prognostic factor that demonstrated a consistent association with outcome in three studies, however cautious interpretation is advised.

Conclusions

The associations between prognostic factors and poor recovery after an acute lateral ankle sprain are largely inconclusive. At present, there is insufficient evidence to recommend any factor as an independent predictor of outcome. There is a need for well-conducted prospective cohort studies with adequate sample size and long-term follow-up to provide robust evidence on prognostic factors of recovery following an acute lateral ankle sprain.

Trial registration

Prospero registration: CRD42014014471

Electronic supplementary material

The online version of this article (10.1186/s12891-017-1777-9) contains supplementary material, which is available to authorized users.

Management of Chronic Lateral Epicondylitis With Manual Therapy and Local Cryostimulation: A Pilot Study

Objective

The purpose of this pilot study was to evaluate the feasibility and efficacy of adding cryostimulation to manual therapy in patients with chronic lateral epicondylitis.

Methods

The control group (n = 19) was treated with manual therapy consisting of soft-tissue therapy and radial head mobilizations. The experimental group (n = 18) received cryostimulation in addition to manual therapy care similar to that for the control group. Both protocols consisted of 8 treatments over a 4-week period. Outcome measures included pain intensity (visual analog scale), pain-free grip strength (handheld dynamometer), and functional index (Patient-Rated Tennis Elbow Evaluation questionnaire). Assessments were performed at baseline, postintervention, and 3-month follow-up. Adherence and dropout rates were also considered.

Results

Both groups exhibited significant improvements in pain intensity and functional index at postintervention assessments, which were maintained at follow-up. All participants attended the prescribed number of treatments, but 27% were lost at follow-up. Minor adverse events were reported after cryostimulation in 4 cases.

Conclusions

This study indicated that it is feasible to complete a clinical trial evaluating the efficacy of adding cryostimulation to manual therapy in patients with chronic lateral epicondylitis. On the basis of these preliminary data, the combination of cryostimulation and manual therapy care did not provide any additional benefits in both the short term and the long term. Manual myofascial point treatment and mobilization techniques yielded positive outcomes in chronic lateral epicondylitis. Further studies should focus on the sole therapeutic effect of cryostimulation in both patients with acute and those with chronic conditions.

Current Trends in the Management of Lateral Ankle Sprain in the United States

OBJECTIVE

To characterize trends in the acute management (within 30 days) after lateral ankle sprain (LAS) in the United States.

DESIGN

Descriptive epidemiology study.

PATIENTS

Of note, 825 718 ankle sprain patients were identified; 96.2% were patients with LAS. Seven percent had an associated fracture and were excluded from the remaining analysis.

SETTING

Primary and tertiary care settings.

INTERVENTIONS

We queried a database of national health insurance records for 2007 to 2011 by ICD-9 codes for patients with LAS while excluding medial and syndesmotic sprains and any LAS with an associated foot or ankle fracture.

MAIN OUTCOME MEASURES

The percentage of patients to receive specific diagnostic imaging, orthopedic devices, or physical therapy treatments within 30 days of the LAS diagnosis and the associated costs.

RESULTS

Over two-thirds of patients with LAS without an associated fracture received radiographs, 9% received an ankle brace, 8.1% received a walking boot, 6.5% were splinted, and 4.8% were prescribed crutches. Only 6.8% received physical therapy within 30 days of their LAS diagnosis, 94.1% of which performed therapeutic exercise, 52.3% received manual therapy, and 50.2% received modalities. The annual cost associated with physician visits, diagnostic imaging, orthopedic devices, and physical therapy was 152 million USD, 81.5% was from physician evaluations, 7.9% from physical therapy, 7.2% from diagnostic imaging, and 3.4% from orthopedic devices.

CONCLUSIONS

Most patients with LAS do not receive supervised rehabilitation. The small proportion of patients with LAS to receive physical therapy get rehabilitation prescribed in accordance with clinical practice guidelines. The majority (>80%) of the LAS financial burden is associated with physician evaluations.

Does the use of a brief cryotherapy intervention with analgesic administration improve pain management after total knee arthroplasty?

BACKGROUND

Prior studies have evaluated only the prolonged use of cryotherapy as a nonpharmacologic pain intervention.

PURPOSE OF THE STUDY

The purpose of this study was to determine whether a 30-minute application of cryotherapy at the time pain medication was given after a total knee arthroplasty (TKA) provided better pain relief than analgesic drugs alone.

METHODS

A pretest, posttest, randomized controlled trial study design with crossover was used to evaluate the effects of cryotherapy on postoperative pain and satisfaction with pain management. A convenience sample of postoperative knee replacement patients constituted participants in the study. Two sequential episodes of pain requiring analgesic administration were studied in each patient, one with a 30-minute cryotherapy application and the other without cryotherapy. Dependent variables were changes in pain (posttest minus pretest) and level of satisfaction with pain management. Data were analyzed with repeated-measures analysis of variance, with p < .05 considered significant.

RESULTS

During two sequential treatments for postoperative pain, a total of 29 TKA patients received analgesic medication administration alone for one pain episode and analgesic medication administration with a brief cryotherapy administration for the other pain episode. No significant difference between the two treatments was found for changes in pain scores after the treatments or patient satisfaction with pain management (p > .05). The order in which the treatments were provided was found to be significant (p = .02) for scores on patient satisfaction with pain management, with cryotherapy as the treatment for the second pain episode having higher scores than when delivered for the first pain episode. Sixty minutes after analgesic administration with or without cryotherapy, average pain scores remained greater than 7.

CONCLUSION

In TKA patients, the short-term application of cryotherapy with analgesic medication administration did not significantly decrease pain or improve patient satisfaction with pain management compared with analgesic medication administration only. Further study is necessary to determine whether short-term cryotherapy shortly after TKA is of benefit to pain relief and patient satisfaction.

Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial

OBJECTIVE

 To assess the efficacy of a programme of supervised physiotherapy on the recovery of simple grade 1 and 2 ankle sprains.

DESIGN

 A randomised controlled trial of 503 participants followed for six months.

SETTING

 Participants were recruited from two tertiary acute care settings in Kingston, ON, Canada.

PARTICIPANTS

 The broad inclusion criteria were patients aged ≥16 presenting for acute medical assessment and treatment of a simple grade 1 or 2 ankle sprain. Exclusions were patients with multiple injuries, other conditions limiting mobility, and ankle injuries that required immobilisation and those unable to accommodate the time intensive study protocol.

INTERVENTION

 Participants received either usual care, consisting of written instructions regarding protection, rest, cryotherapy, compression, elevation, and graduated weight bearing activities, or usual care enhanced with a supervised programme of physiotherapy.

MAIN OUTCOME MEASURES

 The primary outcome of efficacy was the proportion of participants reporting excellent recovery assessed with the foot and ankle outcome score (FAOS). Excellent recovery was defined as a score ≥450/500 at three months. A difference of at least 15% increase in the absolute proportion of participants with excellent recovery was deemed clinically important. Secondary analyses included the assessment of excellent recovery at one and six months; change from baseline using continuous scores at one, three, and six months; and clinical and biomechanical measures of ankle function, assessed at one, three, and six months.

RESULTS

 The absolute proportion of patients achieving excellent recovery at three months was not significantly different between the physiotherapy (98/229, 43%) and usual care (79/214, 37%) arms (absolute difference 6%, 95% confidence interval -3% to 15%). The observed trend towards benefit with physiotherapy did not increase in the per protocol analysis and was in the opposite direction by six months. These trends remained similar and were never statistically or clinically important when the FAOS was analysed as a continuous change score.

CONCLUSIONS

 In a general population of patients seeking hospital based acute care for simple ankle sprains, there is no evidence to support a clinically important improvement in outcome with the addition of supervised physiotherapy to usual care, as provided in this protocol.Trial registration ISRCTN 74033088 (www.isrctn.com/ISRCTN74033088).

Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis

BACKGROUND

Ankle sprains are highly prevalent with high risk of recurrence. Consequently, there are a significant number of research reports examining strategies for treating and preventing acute and recurrent sprains (otherwise known as chronic ankle instability (CAI)), with a coinciding proliferation of review articles summarising these reports.

OBJECTIVE

To provide a systematic overview of the systematic reviews evaluating treatment strategies for acute ankle sprain and CAI.

DESIGN

Overview of intervention systematic reviews.

PARTICIPANTS

Individuals with acute ankle sprain/CAI.

MAIN OUTCOME MEASUREMENTS

The primary outcomes were injury/reinjury incidence and function.

RESULTS

46 papers were included in this systematic review. The reviews had a mean score of 6.5/11 on the AMSTAR quality assessment tool. There was strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence of an ankle sprain. For the combined outcomes of pain, swelling and function after an acute sprain, there was strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques. There was conflicting evidence regarding the efficacy of surgery and acupuncture for the treatment of acute ankle sprains. There was insufficient evidence to support the use of ultrasound in the treatment of acute ankle sprains.

CONCLUSIONS

For the treatment of acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function. Exercise therapy and bracing are supported in the prevention of CAI.

Managing ankle ligament sprains and tears: current opinion

The purpose of this paper is to present a current review of pathoanatomical features, differential diagnosis, objective assessment, intervention, and clinical course associated with managing lateral ankle ligament sprains. Proper diagnosis and identification of affected structures should be obtained through history and objective assessment. From this information, an individualized evidence-based intervention plan can be developed to enable recovery while decreasing the risk of reinjury. An appropriate evaluation is needed not only to determine the correct diagnosis but also to allow for grading and determining the prognosis of the injury in those with an acute lateral ankle sprain. Examination should include an assessment of impairments as well as a measure of activity and participation. Evidence-based interventions for those with an acute lateral ankle sprain should include weight bearing with bracing, manual therapy, progressive therapeutic exercises, and cryotherapy. For those with chronic ankle instability (CAI), interventions should include manual therapy and a comprehensive rehabilitation program. It is essential to understand the normal clinical course for athletes who sustain a lateral ankle sprain as well as risk factors for an acute injury and CAI. Risk factors for both an acute lateral ankle sprain and CAI include not using an external support and not participating in an appropriate exercise program. Incorporating the latest evidence-based rehabilitation techniques provides the best course of treatment for athletes with an acute ankle sprain or CAI.

Football injuries of the ankle: A review of injury mechanisms, diagnosis and management

Football is the most popular sport worldwide and is associated with a high injury rate, most of which are the result of trauma from player contact. Ankle injuries are among the most commonly diagnosed injuries in the game. The result is reduced physical activity and endurance levels, lost game time, and considerable medical cost. Sports medicine professionals must employ the correct diagnostic tools and effective treatments and rehabilitation protocols to minimize the impact of these injuries on the player. This review examines the diagnosis, treatment, and postoperative rehabilitation for common football injuries of the ankle based on the clinical evidence provided in the current literature.

Evaluation of Safety and Cost-Effectiveness of the Low Risk Ankle Rule in One of Europe's Busiest Pediatric Emergency Departments

OBJECTIVES

Low Risk Ankle Rule (LRAR) has 100% sensitivity for identifying clinically important pediatric ankle fractures (high-risk injuries) and has the potential to safely reduce imaging by approximately 60%. This study investigates the safety and cost-effectiveness of this rule in our institution.

METHODS

All patients triaged during July and August 2013 with an "ankle injury" had a retrospective clinical notes and radiology report review. Data were recorded using Excel and tests of significance, χ test.

RESULTS

One hundred twenty-one patients were included. Of these, 65 were female and 56 were male (no significant difference in sex, P = 0.41). Mean age was 9.95 years. Seventy-eight (64%) had LRAR positive examinations. Of these, 77 (98.7%) had an x-ray and 12 (15%) had fractures. Of those with fractures, none had high-risk injuries.Eighteen (100%) of the doctors in our ED felt that a clinical decision rule would be of use within the department. Only 8 (44%) had heard of the LRAR, and of these, only 4 (50%) would be confident to implement the LRAR. Forty-four (88%) of parents felt that an x-ray is required in the diagnosis of ankle injuries in children, and 41 (82%) would want to know whether their child had an ankle sprain or a low-risk fracture even if the management was not different.

CONCLUSIONS

By implementing the LRAR in our institution, we could reduce ankle x-rays by 64%. This would offer a significant reduction in radiation exposure to a radiosensitive population. Estimated costs of an ankle x-ray and interpretation are Euro 47 ($65), thus with more than 800 carried out per year in The Children's University Hospital, a potential annual saving is Euro 25,000 ($34,500).

Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments: 2014 update

The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded on the basis of the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments published in Wilderness & Environmental Medicine 2014;25(1):41-49.

Supervised rehabilitation versus home exercise in the treatment of acute ankle sprains: a systematic review

In competitive sports medicine, supervised rehabilitation is the standard of care; in the general population, unsupervised home exercise is more common. We systematically reviewed randomized, controlled trials comparing outcomes for supervised rehabilitation versus home exercise programs. Supervised rehabilitation programs resulted in (1) less pain and subjective instability, (2) greater gains in ankle strength and joint position sense, and (3) inconclusive results regarding prevention of recurrent ankle sprains. We recommend supervised rehabilitation over home exercise programs owing to the improved short-term patient-recorded evidence with a strength-of-recommendation taxonomy level of evidence of 2B.

Kinesio Taping does not decrease swelling in acute, lateral ankle sprain of athletes: a randomised trial

QUESTION

Does Kinesio Taping reduce swelling in athletes who have suffered an acute, lateral ankle sprain?

DESIGN

Randomised controlled trial with concealed allocation, intention-to-treat analysis and blinded assessment.

PARTICIPANTS

Thirty-six athletes who participated regularly in one of seven different sports modalities and suffered an acute ankle sprain.

INTERVENTION

The experimental group received Kinesio Taping application for 3 days, which was designed to treat swelling. The control group received an inert Kinesio Taping application.

OUTCOME MEASURES

For the comparison between groups, the swelling was measured via volumetry, perimetry, relative volumetry and two analyses of the difference in volume and perimetry between ankles of each participant. Data were collected immediately after the 3 days of intervention and at follow-up, which was 15 days post intervention.

RESULTS

At 3 days after intervention, there were no differences between groups for swelling in volumetry (MD -2 ml, 95% CI -28 to 32); perimetry (MD 0.2 cm, 95% CI -0.6 to 1.0); relative volumetry (MD 0.0 cm, 95% CI -0.1 to 0.1); and the other analyses. At day 15 follow-up, there were no significant between-group differences in outcomes.

CONCLUSION

The application of Kinesio Taping, with the aim of stimulating the lymphatic system, is ineffective in decreasing acute swelling after an ankle sprain in athletes.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials, RBR-32sctf.

Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury

Nonpharmacological treatment strategies for acute musculoskeletal injury revolve around pain reduction and promotion of healing in order to facilitate a return to normal function and activity. Heat and cold therapy modalities are often used to facilitate this outcome despite prevalent confusion about which modality (heat vs cold) to use and when to use it. Most recommendations for the use of heat and cold therapy are based on empirical experience, with limited evidence to support the efficacy of specific modalities. This literature review provides information for practitioners on the use of heat and cold therapies based on the mechanisms of action, physiological effects, and the medical evidence to support their clinical use. The physiological effects of cold therapy include reductions in pain, blood flow, edema, inflammation, muscle spasm, and metabolic demand. There is limited evidence from randomized clinical trials (RCTs) supporting the use of cold therapy following acute musculoskeletal injury and delayed-onset muscle soreness (DOMS). The physiological effects of heat therapy include pain relief and increases in blood flow, metabolism, and elasticity of connective tissues. There is limited overall evidence to support the use of topical heat in general; however, RCTs have shown that heat-wrap therapy provides short-term reductions in pain and disability in patients with acute low back pain and provides significantly greater pain relief of DOMS than does cold therapy. There remains an ongoing need for more sufficiently powered high-quality RCTs on the effects of cold and heat therapy on recovery from acute musculoskeletal injury and DOMS.

Responsiveness of SF-36 and Lower Extremity Functional Scale for assessing outcomes in traumatic injuries of lower extremities

OBJECTIVE

To assess the responsiveness of one generic questionnaire, Medical Outcomes Study Short Form-36 (SF-36), and one region-specific outcome measure, Lower Extremity Functional Scale (LEFS), in patients with traumatic injuries of lower extremities.

DESIGN

A prospective and observational study of patients after traumatic injuries of lower extremities. Assessments were performed at baseline and 3 months later.

SETTING

In-patients and out-patients in two university hospitals in Taiwan.

PARTICIPANTS

A convenience sample of 109 subjects were evaluated and 94 (86%) were followed.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Assessments of responsiveness with distribution-based approach (effect size, standardized response mean [SRM], minimal detectable change) and anchor-based approach (receiver's operating curve analysis, ROC analysis).

RESULTS

LEFS and physical component score (PCS) of SF-36 were all responsive to global improvement, with fair-to-good accuracy in discriminating between participants with and without improvement. The area under curve gained by ROC analysis for LEFS and SF-36 PCS was similar (0.65 vs. 0.70, p=0.26).

CONCLUSIONS

Our findings revealed comparable responsiveness of LEFS and PCS of SF-36 in a sample of subjects with traumatic injuries of lower limbs. Either type of functional measure would be suitable for use in clinical trials where improvement in function was an endpoint of interest.

The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies

BACKGROUND

Ankle sprain is one of the most common musculoskeletal injuries, yet a contemporary review and meta-analysis of prospective epidemiological studies investigating ankle sprain does not exist.

OBJECTIVE

Our aim is to provide an up-to-date account of the incidence rate and prevalence period of ankle sprain injury unlimited by timeframe or context activity.

METHODS

We conducted a systematic review and meta-analyses of English articles using relevant computerised databases. Search terms included Medical Search Headings for the ankle joint, injury and epidemiology. The following inclusion criteria were used: the study must report epidemiology findings of injuries sustained in an observed sample; the study must report ankle sprain injury with either incidence rate or prevalence period among the surveyed sample, or provide sufficient data from which these figures could be calculated; the study design must be prospective. Independent extraction of articles was performed by two authors using pre-determined data fields.

RESULTS

One-hundred and eighty-one prospective epidemiology studies from 144 separate papers were included. The average rating of all the included studies was 6.67/11, based on an adapted version of the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) guidelines for rating observational studies. 116 studies were considered high quality and 65 were considered low quality. The main findings of the meta-analysis demonstrated a higher incidence of ankle sprain in females compared with males (13.6 vs 6.94 per 1,000 exposures), in children compared with adolescents (2.85 vs 1.94 per 1,000 exposures) and adolescents compared with adults (1.94 vs 0.72 per 1,000 exposures). The sport category with the highest incidence of ankle sprain was indoor/court sports, with a cumulative incidence rate of 7 per 1,000 exposures or 1.37 per 1,000 athlete exposures and 4.9 per 1,000 h. Low-quality studies tended to underestimate the incidence of ankle sprain when compared with high-quality studies (0.54 vs 11.55 per 1,000 exposures). Ankle sprain prevalence period estimates were similar across sub-groups. Lateral ankle sprain was the most commonly observed type of ankle sprain.

CONCLUSIONS

Females were at a higher risk of sustaining an ankle sprain compared with males and children compared with adolescents and adults, with indoor and court sports the highest risk activity. Studies at a greater risk of bias were more likely to underestimate the risk of ankle sprain. Participants were at a significantly higher risk of sustaining a lateral ankle sprain compared with syndesmotic and medial ankle sprains.

Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes

BACKGROUND

Although several reconstruction procedures for chronic lateral ankle instability using autografts have been reported, all have recommended postoperative immobilization and a nonweightbearing period.

HYPOTHESIS

Reconstructive surgery with a gracilis autograft using an interference fit anchoring system for chronic lateral ankle instability enables early accelerated rehabilitation and recovery with a return to activity without requiring immobilization.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 33 patients (33 feet) who underwent reconstruction of the anterior talofibular ligament with a gracilis autograft using interference screws were included; 15 were followed for 4 weeks with postoperative cast immobilization (group I), while 18 were followed with accelerated rehabilitation without immobilization (group A). Clinical and radiological results were evaluated based on the Karlsson and Peterson score, talar tilt angle, anterior displacement of the talus on stress radiography, and time between surgery and return to full athletic activity.

RESULTS

The mean Karlsson and Peterson scores before and 2 years after surgery were the following: for group I: 62.3 ± 4.7 (range, 54-72) and 94.4 ± 7.1 (range, 76-100), respectively (P < .001), and for group A: 64.1 ± 4.8 (range, 57-70) and 91.7 ± 7.7 (range, 74-100), respectively (P < .001). The mean difference in the talar tilt angle compared with the contralateral side and mean displacement of the talus on stress radiography before and 2 years after surgery were the following: for group I: 8.7° ± 2.6° and 7.7 ± 1.8 mm and 3.8° ± 1.5° and 4.0 ± 1.6 mm, respectively, and for group A: 10.5° ± 3.4° and 8.7 ± 2.1 mm and 4.3° ± 1.8° and 4.3 ± 1.2 mm, respectively. Radiography revealed significantly improved postoperative outcomes in both groups (P < .0001). No significant differences in the score and any parameters on stress radiography were evident at 2 years after surgery between the groups. The mean time between surgery and return to full athletic activity was significantly higher in group I (18.5 ± 3.5 weeks) than in group A (13.4 ± 2.2 weeks) (P < .0001). No cases of reinjury were reported, and no differences in athletic performance ability were observed between the groups.

CONCLUSION

Patients in group A returned to full athletic activity 5 weeks earlier than those in group I, demonstrating the advantage of accelerated rehabilitation after surgery.

Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments

The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians.

Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries

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

LEVEL OF EVIDENCE

Level IV.

Eminence-based medicine versus evidence-based medicine: when can the athlete with a sprained ankle return to play?

When can the athlete with a sprained ankle to return to play? The medical literature provides no definitive answer to this question, so we surveyed 500 experts in sports medicine, and asked them if they agree with the following statement: "For patients with an acute ankle injury, the ability to hop on the sidelines is sufficient evidence to allow the athlete to return to the field." Overall, the experts did not endorse this statement. Further, a review of the medical literature failed to lend support for the statement. Taken together, some level V (expert opinion) evidence emerges, namely, that a patient's ability to successfully complete the hop test is not necessarily sufficient evidence to allow a return to play. That finding does not mean that a physician must shun the test; rather, the conclusion is that it cannot be relied on in isolation. The hop test, used in context with other findings, along with a consideration of the risks and benefits of continued play, may help the physician on the field reach a reasonable conclusion. To date, however, there is no single, easily applied test that can correctly determine whether an athlete is safe to return to the field.

Predicting functional recovery after acute ankle sprain

Introduction

Ankle sprains are among the most common acute musculoskeletal conditions presenting to primary care. Their clinical course is variable but there are limited recommendations on prognostic factors. Our primary aim was to identify clinical predictors of short and medium term functional recovery after ankle sprain.

Methods

A secondary analysis of data from adult participants (N = 85) with an acute ankle sprain, enrolled in a randomized controlled trial was undertaken. The predictive value of variables (age, BMI, gender, injury mechanism, previous injury, weight-bearing status, medial joint line pain, pain during weight-bearing dorsiflexion and lateral hop test) recorded at baseline and at 4 weeks post injury were investigated for their prognostic ability. Recovery was determined from measures of subjective ankle function at short (4 weeks) and medium term (4 months) follow ups. Multivariate stepwise linear regression analyses were undertaken to evaluate the association between the aforementioned variables and functional recovery.

Results

Greater age, greater injury grade and weight-bearing status at baseline were associated with lower function at 4 weeks post injury (p<0.01; adjusted R square=0.34). Greater age, weight-bearing status at baseline and non-inversion injury mechanisms were associated with lower function at 4 months (p<0.01; adjusted R square=0.20). Pain on medial palpation and pain on dorsiflexion at 4 weeks were the most valuable prognostic indicators of function at 4 months (p< 0.01; adjusted R square=0.49).

Conclusion

The results of the present study provide further evidence that ankle sprains have a variable clinical course. Age, injury grade, mechanism and weight-bearing status at baseline provide some prognostic information for short and medium term recovery. Clinical assessment variables at 4 weeks were the strongest predictors of recovery, explaining 50% of the variance in ankle function at 4 months. Further prospective research is required to highlight the factors that best inform the expected convalescent period, and risk of recurrence.

Treatment of acute ankle ligament injuries: a systematic review

BACKGROUND

Lateral ankle sprains are common musculoskeletal injuries.

OBJECTIVES

The objective of this study was to perform a systematic literature review of the last 10 years regarding evidence for the treatment and prevention of lateral ankle sprains.

DATA SOURCE

Pubmed central, Google scholar.

STUDY ELIGIBILITY CRITERIA

Meta-analysis, prospective randomized trials, English language articles.

INTERVENTIONS

Surgical and non-surgical treatment, immobilization versus functional treatment, different external supports, balance training for rehabilitation, balance training for prevention, braces for prevention.

METHODS

A systematic search for articles about the treatment of lateral ankle sprains that were published between January 2002 and December 2012.

RESULTS

Three meta-analysis and 19 articles reporting 16 prospective randomized trials could be identified. The main advantage of surgical ankle ligament repair is that objective instability and recurrence rate is less common when compared with non-operative treatment. Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. For non-surgical treatment, long-term immobilization should be avoided. For grade III injuries, however, a short period of immobilization (max. 10 days) in a below knee cast was shown to be advantageous. After this phase, the ankle is most effectively protected against inversion by a semi-rigid ankle brace. Even grades I and II injuries are most effectively treated with a semi-rigid ankle brace. There is evidence that treatment of acute ankle sprains should be supported by a neuromuscular training. Balance training is also effective for the prevention of ankle sprains in athletes with the previous sprains. There is good evidence from high level randomized trials in the literature that the use of a brace is effective for the prevention of ankle sprains.

CONCLUSION

Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. The indication for surgical repair should be always made on an individual basis. This systematic review supports a phase adapted non-surgical treatment of acute ankle sprains with a short-term immobilization for grade III injuries followed by a semi-rigid brace. More prospective randomized studies with a longer follow-up are needed to find out what type of non-surgical treatment has the lowest re-sprain rate.

National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes

OBJECTIVE

To present recommendations for athletic trainers and other allied health care professionals in the conservative management and prevention of ankle sprains in athletes.

BACKGROUND

Because ankle sprains are a common and often disabling injury in athletes, athletic trainers and other sports health care professionals must be able to implement the most current and evidence-supported treatment strategies to ensure safe and rapid return to play. Equally important is initiating preventive measures to mitigate both first-time sprains and the chance of reinjury. Therefore, considerations for appropriate preventive measures (including taping and bracing), initial assessment, both short- and long-term management strategies, return-to-play guidelines, and recommendations for syndesmotic ankle sprains and chronic ankle instability are presented.

RECOMMENDATIONS

The recommendations included in this position statement are intended to provide athletic trainers and other sports health care professionals with guidelines and criteria to deliver the best health care possible for the prevention and management of ankle sprains. An endorsement as to best practice is made whenever evidence supporting the recommendation is available.

Management of acute lateral ankle ligament injury in the athlete

PURPOSE

Inversion injuries involve about 25 % of all injuries of the musculoskeletal system and about 50 % of these injuries are sport-related. This article reviews the acute lateral ankle injuries with special emphasis on a rationale for treatment of these injuries in athletes.

METHODS

A narrative review was performed using Pubmed/Medline, Ovid and Embase using key words: ankle ligaments, injury, lateral ligament, ankle sprain and athlete. Articles related to the topic were included and reviewed.

RESULTS

It is estimated that one inversion injury of the ankle occurs for every 10,000 people each day. Ankle sprains constitute 7-10 % of all admissions to hospital emergency departments. Inversion injuries involve about 25 % of all injuries of the musculoskeletal system, and about 50 % of these injuries are sport-related. The lateral ankle ligament complex consists of three ligaments: the anterior talofibular ligament, the calcaneofibular ligament and the posterior talofibular ligament. The most common trauma mechanism is supination and adduction (inversion) of the plantar-flexed foot.

CONCLUSION

Delayed physical examination provides a more accurate diagnosis. Ultrasound and MRI can be useful in diagnosing associated injury and are routine investigations in professional athletes. Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures. RICE therapy is the treatment of choice for the first 4-5 days to reduce pain and swelling. Initially, 10-14 days of immobilization in a below the knee cast/brace is beneficial followed by a period in a lace-up brace or functional taping reduces the risk of recurrent injury. Acute repair of the lateral ankle ligaments in grade III injuries in professional athletes may give better results.

The challenge of obtaining information necessary for multi-criteria decision analysis implementation: the case of physiotherapy services in Canada

BACKGROUND

As fiscal constraints dominate health policy discussions across Canada and globally, priority-setting exercises are becoming more common to guide the difficult choices that must be made. In this context, it becomes highly desirable to have accurate estimates of the value of specific health care interventions.Economic evaluation is a well-accepted method to estimate the value of health care interventions. However, economic evaluation has significant limitations, which have lead to an increase in the use of Multi-Criteria Decision Analysis (MCDA). One key concern with MCDA is the availability of the information necessary for implementation. In the Fall 2011, the Canadian Physiotherapy Association embarked on a project aimed at providing a valuation of physiotherapy services that is both evidence-based and relevant to resource allocation decisions. The framework selected for this project was MCDA. We report on how we addressed the challenge of obtaining some of the information necessary for MCDA implementation.

METHODS

MCDA criteria were selected and areas of physiotherapy practices were identified. The building up of the necessary information base was a three step process. First, there was a literature review for each practice area, on each criterion. The next step was to conduct interviews with experts in each of the practice areas to critique the results of the literature review and to fill in gaps where there was no or insufficient literature. Finally, the results of the individual interviews were validated by a national committee to ensure consistency across all practice areas and that a national level perspective is applied.

RESULTS

Despite a lack of research evidence on many of the considerations relevant to the estimation of the value of physiotherapy services (the criteria), sufficient information was obtained to facilitate MCDA implementation at the local level.

CONCLUSIONS

The results of this research project serve two purposes: 1) a method to obtain information necessary to implement MCDA is described, and 2) the results in terms of information on the benefits provided by each of the twelve areas of physiotherapy practice can be used by decision-makers as a starting point in the implementation of MCDA at the local level.

Possible effects of mobilisation on acute post-operative pain and nociceptive function after total knee arthroplasty

BACKGROUND

Experimental studies in animals, healthy volunteers, and patients with chronic pain suggest exercise to provide analgesia in several types of pain conditions and after various nociceptive stimuli. To our knowledge, there is no data on the effects of exercise on pain and nociceptive function in surgical patients despite early mobilisation being an important factor to enhance recovery. We therefore investigated possible effects of mobilisation on post-operative pain and nociceptive function after total knee arthroplasty (TKA).

METHODS

Thirty patients undergoing TKA under standardised anaesthesia and analgesia underwent an exercise (mobilisation) strategy on the first post-operative morning consisting of 25-m walking twice, with a 20-min interval. Pain was assessed at rest and during passive hip and knee flexion before, and 5 and 20 min after walk, as well as during walk. Nociceptive function (pain threshold and tolerance) was assessed with pressure algometry and an electrical stimulus.

RESULTS

Pain at rest (supine) and during hip and knee flexion was significantly reduced 5 min (P < 0.03) and 20 min (P < 0.003) after walk compared with before walk, and pain was reduced during the second walk compared with the first walk (P < 0.034). Knee pain pressure threshold (P = 0.002) but not tolerance (P = 0.27) was increased following walk compared with before walk.

CONCLUSION

This first exploratory hypothesis-generating pilot study suggests mobilisation to promote analgesic effects after TKA calling for future studies with a randomised, controlled design on exercise dose-response effects in post-surgical patients.

Management of chronic ankle pain using joint mobilization and ASTYM® treatment: a case report

Treatment of ankle sprains predominately focuses on the acute management of this condition; less emphasis is placed on the treatment of ankle sprains in the chronic phase of recovery. Manual therapy, in the form of joint mobilization and manipulation, has been shown to be effective in the management of this condition, but the combination of joint mobilization and manipulation in tandem with ASTYM® treatment has not been explored. The purpose of this case report is to chronicle the management of a patient with chronic ankle pain who was treated with manual therapy including manipulation and ASTYM treatment. As a result of a fall down stairs 6 months previously, the patient sustained a severe ankle sprain. The soft tissue damage was accompanied by bony disruptions which warranted the patient spending 3 weeks in a walking boot. At the initial evaluation, the patient reported difficulty with descending stairs reciprocally and not being able to run more than 4 minutes on the treadmill before the pain escalated to the level that she had to stop running. After five sessions of therapy consisting of joint mobilization, manipulation and ASTYM, the patient was able to descend stairs and run 40 minutes without pain.

What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?

CONTEXT

Ankle sprains are common problems in acute medical care. The variation in treatment observed for the acutely injured lateral ankle ligament complex in the first week after the injury suggests a lack of evidence-based management strategies for this problem.

OBJECTIVE

To analyze the effectiveness of applying rest, ice, compression, and elevation (RICE) therapy begun within 72 hours after trauma for patients in the initial period after ankle sprain.

STUDY SELECTION

Eligible studies were published original randomized or quasi-randomized controlled trials concerning at least 1 of the 4 subtreatments of RICE therapy in the treatment of acute ankle sprains in adults.

DATA SOURCES

MEDLINE, Cochrane Clinical Trial Register, CINAHL, and EMBASE. The lists of references of retrieved publications also were checked manually.

DATA EXTRACTION

We extracted relevant data on treatment outcome (pain, swelling, ankle mobility or range of motion, return to sports, return to work, complications, and patient satisfaction) and assessed the quality of included studies. If feasible, the results of comparable studies were pooled using fixed- or random-effects models.

DATA SYNTHESIS

After deduction of the overlaps among the different databases, evaluation of the abstracts, and contact with some authors, 24 potentially eligible trials remained. The full texts of these articles were retrieved and thoroughly assessed as described. This resulted in the inclusion of 11 trials involving 868 patients. The main reason for exclusion was that the authors did not describe a well-defined control group without the intervention of interest.

CONCLUSIONS

Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults. Treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of each option, and must be based on expert opinions and national guidelines.

The ANKLE TRIAL (ankle treatment after injuries of the ankle ligaments): what is the benefit of external support devices in the functional treatment of acute ankle sprain? A randomised controlled trial

Background

Acute lateral ankle ligament injuries are very common problems in present health care. Still there is no hard evidence about which treatment strategy is superior. Current evidence supports the view that a functional treatment strategy is preferable, but insufficient data are present to prove the benefit of external support devices in these types of treatment. The hypothesis of our study is that external ankle support devices will not result in better outcome in the treatment of acute ankle sprains, compared to a purely functional treatment strategy. Overall objective is to compare the results of three different strategies of functional treatment for acute ankle sprain, especially to determine the advantages of external support devices in addition to functional treatment strategy, based on balance and coordination exercises.

Methods/design

This study is designed as a randomised controlled multi-centre trial with one-year follow-up. Adult and healthy patients (N = 180) with acute, single sided and first inversion trauma of the lateral ankle ligaments will be included. They will all follow the same schedule of balancing exercises and will be divided into 3 treatment groups, 1. pressure bandage and tape, 2. pressure bandage and brace and 3. no external support. Primary outcome measure is the Karlsson scoring scale; secondary outcomes are FAOS (subscales), number of recurrent ankle injuries, Visual Analogue Scales of pain and satisfaction and adverse events. They will be measured after one week, 6 weeks, 6 months and 1 year.

Discussion

The ANKLE TRIAL is a randomized controlled trial in which a purely functional treated control group, without any external support is investigated. Results of this study could lead to other opinions about usefulness of external support devices in the treatment of acute ankle sprain.

Trial registration

Netherlands Trial Register (NTR): NTR2151

Functional treatment after surgical repair for acute lateral ligament disruption of the ankle in athletes

BACKGROUND

There have been several reports showing 20% to 40% failure after nonoperative functional treatment for acute lateral ligament disruption of the ankle.

HYPOTHESIS

Functional treatment after primary surgical repair has the advantage of decreasing the failure rate in comparison with functional treatment alone.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 132 feet of 132 patients were included in this study. Of these, 78 patients were treated with functional treatment alone (group F), and the remaining 54 patients were treated with functional treatment after primary surgical repair (group RF). The clinical results were evaluated using the Japanese Society for Surgery of the Foot Ankle-Hindfoot scale (JSSF) score, measuring the talar tilt angle and the anterior displacement of the talus in stress radiography, and noting the elapsed time between the injury and the return to the full athletic activity with no external supports.

RESULTS

The mean JSSF scores at 2 years after injury were 95.6 ± 5.0 points in group F and 97.5 ± 2.6 points in group RF (P = .0669). The differences of the talar tilt angles compared with the contralateral side and displacement of the talus on stress radiography at 2 years after injury were 1.1° ± 1.5° and 3.6 ± 1.6 mm in group F, and 0.8° ± 0.9° and 3.2 ± 0.8 mm in group RF, respectively (P = .4093, .1883). In group F, 8 cases showed fair to poor results, with JSSF scores below 80 points and instability at 2 years after injury. In group RF, 9 cases (9.4%) showed dorsum foot pain along the superficial peroneal nerve, which disappeared within a month. The time elapsed between the injury and the patient's return to full athletic activity without any external supports was 16.0 ± 5.6 weeks in group F and 10.1 ± 1.8 weeks in group RF (P < .0001).

CONCLUSION

Nonoperative functional treatment alone and functional treatment after primary surgical repair showed similar overall results after acute lateral ankle sprain, but functional treatment alone had an approximately 10% failure rate and a slower return to full athletic activity. The authors recommend that treatment be tailored to suit each individual athlete.

Racial, ethnic, and insurance status disparities in use of posthospitalization care after trauma

BACKGROUND

Posthospitalization care is important for recovery after trauma. Disadvantaged populations, like racial or ethnic minorities and the uninsured, make up substantial percentages of trauma patients, but their use of posthospitalization facilities is unknown.

STUDY DESIGN

This study analyzed National Trauma Data Bank admissions from 2007 for 18- to 64-year-olds and estimated relative risk ratios (RRR) of discharge to posthospitalization facilities--home, home health, rehabilitation, or nursing facility--by race, ethnicity, and insurance. Multinomial logistic regression adjusted for patient characteristics including age, sex, Injury Severity Score, mechanism of injury, and length of stay, among others.

RESULTS

There were 136,239 patients who met inclusion criteria with data for analysis. Most patients were discharged home (78.9%); fewer went to home health (3.3%), rehabilitation (5.0%), and nursing facilities (5.4%). When compared with white patients in adjusted analysis, relative risk ratios of discharge to rehabilitation were 0.61 (95% CI 0.56, 0.66) and 0.44 (95% CI 0.40, 0.49) for blacks and Hispanics, respectively. Compared with privately insured white patients, Hispanics had lower rates of discharge to rehabilitation whether privately insured (RRR 0.45, 95% CI 0.40, 0.52), publicly insured (RRR 0.51, 95% CI 0.42, 0.61), or uninsured (RRR 0.20, 95% CI 0.17, 0.24). Black patients had similarly low rates: private (RRR 0.63, 95% CI 0.56, 0.71), public (RRR 0.72, 95% CI 0.63, 0.82), or uninsured (RRR 0.27, 95% CI 0.23, 0.32). Relative risk ratios of discharge to home health or nursing facilities showed similar trends among blacks and Hispanics regardless of insurance, except for black patients with insurance whose discharge to nursing facilities was similar to their white counterparts.

CONCLUSIONS

Disadvantaged populations have more limited use of posthospitalization care such as rehabilitation after trauma, suggesting a potential improvement in trauma care for the underprivileged.

Effectiveness of additional supervised exercises compared with conventional treatment alone in patients with acute lateral ankle sprains: systematic review

OBJECTIVE

To summarise the effectiveness of adding supervised exercises to conventional treatment compared with conventional treatment alone in patients with acute lateral ankle sprains.

DESIGN

Systematic review. Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, Cinahl, and reference screening.

STUDY SELECTION

Included studies were randomised controlled trials, quasi-randomised controlled trials, or clinical trials. Patients were adolescents or adults with an acute lateral ankle sprain. The treatment options were conventional treatment alone or conventional treatment combined with supervised exercises. Two reviewers independently assessed the risk of bias, and one reviewer extracted data. Because of clinical heterogeneity we analysed the data using a best evidence synthesis. Follow-up was classified as short term (up to two weeks), intermediate (two weeks to three months), and long term (more than three months).

RESULTS

11 studies were included. There was limited to moderate evidence to suggest that the addition of supervised exercises to conventional treatment leads to faster and better recovery and a faster return to sport at short term follow-up than conventional treatment alone. In specific populations (athletes, soldiers, and patients with severe injuries) this evidence was restricted to a faster return to work and sport only. There was no strong evidence of effectiveness for any of the outcome measures. Most of the included studies had a high risk of bias, with few having adequate statistical power to detect clinically relevant differences.

CONCLUSION

Additional supervised exercises compared with conventional treatment alone have some benefit for recovery and return to sport in patients with ankle sprain, though the evidence is limited or moderate and many studies are subject to bias.