Bracing superior to neuromuscular training for the prevention of self-reported recurrent ankle sprains: a three-arm randomized controlled trial
Janssen K, van Mechelen W, & Verhagen ALM. British Journal of Sports Medicine. Published Online First November 29, 2013 doi:10.1136/bjsports-2013-092947
Take Home Message: Long-term bracing reduced the incidence of recurrent ankle sprains in comparison with 12 weeks of neuromuscular training following an ankle sprain. A combination of bracing and neuromuscular training also had a mild reduction in comparison with neuromuscular training.
Ankle sprains are very common in the athletic and physically-active population. We can successfully return individuals to activity after an ankle injury; however, we need to more closely investigate our long-term treatment strategies because the risk of a recurrent sprain is doubled after an individual returns to activity. The authors of this randomized clinical trial compared the effectiveness of 3 interventions: 1) an 8 week neuromuscular training program, 2) bracing for 12 months, and 3) a combination of neuromuscular training program with a brace for 8 weeks total. Physically-active individuals between 18 and 70 years of age with a history of a lateral ankle sprain within the 2 months prior to screening were eligible for this study. A total of 340 randomized participants (107 training, 113 brace, 120 combination) completed 12 monthly follow-up forms that asked a participant to report sport participation, recurrent ankle sprains, and adherence to treatment. The authors reported that bracing alone had fewer self-reported recurrent sprains than the training group: 1) bracing alone (15%, 0.5 sprains/1000 hours of sport), 2) training group (27%, 2.5 sprains/1000 hours of sport), and 3) combination group (19%, 0.7 sprains/1000 hours of sport). The authors also reported that there were compliance issues within each group (full compliance: 45% training, 23% bracing, 28% combination) as well as participants who reported adding either a brace or training to their assigned intervention program (~15% of participants).
While this study aims to answer a very interesting question, the results should be interpreted with caution. Clinically, it appears that bracing is the best option post-ankle sprain to reduce the risk of recurrent sprains. Interestingly enough, I believe this study highlights a larger underlying issue of patient compliance. Bracing had the lowest overall compliance, yet the best outcomes. Unfortunately, it is unknown as to what the compliance was over time. It may have been interesting to look at this as well as patient reported reasons for non-compliance. Also, the prescribed training program was only 2 months in duration, while the bracing was for 12 months. A 2 month training program is typical following an ankle sprain; however, perhaps we should consider the value of a longer-term training program for prevention. The combination group was prescribed 2 months of training and brace wearing only. Also, despite a lack of significant findings, the combination training/brace group had lower ankle sprain recurrence than the training only group, comparable to the brace for 12 months group. If the two groups with bracing had high adherence for the first few weeks that then diminished then protection for a few weeks after an injury may be critical to preventing recurring ankle sprains. Overall, this is an interesting study that compares three common treatment strategies after an ankle sprain and highlights that we need to find ways to promote adherence/compliance and further optimize our strategies.
Questions for Discussion: What are your thoughts regarding rehabilitation and/or bracing following an ankle sprain? What are your recommendations for clinically managing ankle sprains over a long term?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban