Sports Medicine Research: In the Lab & In the Field: Acute Care Needs to Focus More on Preventing Chronic Ankle Issues (Sports Med Res)


Wednesday, April 12, 2017

Acute Care Needs to Focus More on Preventing Chronic Ankle Issues

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

Feger MA, Glavniano NR, Donavan L, Hart JM, Saliba SA, Park JS, & Hertel J. Clin J Sport Med. 2017; 27:145-152. doi: 10.1097/JSM.0000000000000321

Take Home Message: Most common care after an ankle sprain involved multiple physician visits. Very few patients receive supervised rehabilitation. 

Lateral ankle sprains are one of the most common acute injuries among physically active individuals.  Ankle sprains cause short-term pain and disability and may cause long-term chronic ankle instability and joint damage.  Therefore, the question remains as to how ankle sprains are managed and whether the deficits exist due to initial management or if they develop after recovery from the primary injury.  The authors of this study aimed to describe lateral ankle sprain management within 30 day of injury using a database of national health insurance records in the United States for 2007 to 2011.  Specifically, they focused on diagnosis codes for lateral ankle sprains and excluded people with concurrent fractures, medial sprains, or syndesmotic sprains. Next, the authors evaluated the database to determine how often patients received diagnostic imaging, orthopedic devices, or physical therapy treatments within 30 days of the injury. Overall, 96% (~740,000 injuries) of documented ankle sprains were lateral ankle sprains without foot or ankle fracture.  Two-thirds of them received an ankle x-ray. On average patients with an ankle sprain attended of a little over 4 physician’s visits for each injury.  Less than 7% of patients who suffered a lateral ankle sprain were referred for supervised rehabilitations. Physician visits in addition to the resulting imaging, care, rehabilitation accounted for approximately $152 million in health care costs within the database. Of these costs $124 million were because of physician visits. 

While it may seem that a lateral ankle sprain can be managed conservatively with home exercise programs or patient education, the vast majority of patients are never referred to supervised rehabilitation. This may contribute to chronic ankle instability post ankle sprain.  While returning to normal activities of daily living is successful, the long-term risk of instability should cause us to pay closer attention to the importance of supervised rehabilitation programs.  There were some patients who saw a physical therapist for evaluation, treatment, and rehabilitation.  It is unknown how access to an athletic trainer may affect these numbers.  It would be interesting to see how the financial burden of ankle sprains vary now in comparison to the investigated time (2007 to 2011) when the physician visits were the most expensive component of care.  Healthcare has shifted and allows more direct access visits to physical therapists.  While only a small number of patients went to physical therapy, it would be interesting to see how patient-reported outcomes, recovery times, costs, and reinjury rates compare between those who did and did not complete supervised rehabilitation.  Considering the consequences of poor long-term outcomes, we need to re-evaluate our current treatment paradigm and seek solutions to prevent poor long-term outcomes. The largest focus may need to be on ensuring that our patients receive a supervised rehabilitation program to address their short-term issues and reduce the long-term risks of chronic ankle instability and post-traumatic osteoarthritis. Patient education may also be essential in the performance of maintenance programs or exercises to try to prevent another injury from occurring or from developing these long-term complications. 

Questions for Discussion:  What do you use for post-lateral ankle sprain functional testing to determine clearance?  Are there any areas that you pay specifically attention to when a patient is recovering from a lateral ankle sprain?

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:

Feger, M., Glaviano, N., Donovan, L., Hart, J., Saliba, S., Park, J., & Hertel, J. (2017). Current Trends in the Management of Lateral Ankle Sprain in the United States Clinical Journal of Sport Medicine, 27 (2), 145-152 DOI: 10.1097/JSM.0000000000000321


Christopher Gregory said...

It's amazing to think that in a 4 year span of all documented lateral ankle sprains in this nation wide database that less than 7% of them were even referred for supervised rehabilitation. I speculate that the number is even lower that actually sought out that rehabilitation even with that referral. We know that about 40% of those who sustain a lateral ankle sprain will go on to developing chronic ankle instability and the fact that so few people are being supervised through their recovery process is not aiding that statistic. I wonder how much higher the cost of the initial injury rise above the $124 million and $152 million when the individual will go on to spraining their ankle again and again and continue to seek treatment due to inadequate initial treatment.

I think the first step in preventing these poor outcomes has to be access to proper and reasonable treatment and rehabilitation. Giving an individual who has had a lateral ankle sprain a piece of paper with a couple of ROM and strengthening exercises and expecting them to adhere to them is foolish. Clearly, the accessible to supervised rehabilitation in many parts of the country is difficult. However, if we are to adapt as a health care system to increase quality outcomes, increasing the ability for someone to access adequate care is the first step.

Jeffrey Driban said...

Kyle, great points. It is probably even lower when we consider how many people have an ankle injury and never seek proper evaluation or care. It would be interesting to see the long-term cost benefit of having a patient attend 6 weeks of rehab vs not.

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