Adherence and effectiveness of rehabilitation in acute ankle sprain.
Guillodo Y, Le Goff A, Saraux A. Ann Phys Rehabil Med. 2011 Apr 14. [Epub ahead of print]
Ankle sprains are one of the most commonly encountered musculoskeletal injuries. Early treatment can range from rest/immobilization to early exercise intervention. The purpose of rehabilitation exercises for ankle sprains is to restore mobility, strength, sensorimotor control, and full function. Since re-injury is a common problem after return to activity, early intervention is a critical component to treatment of these injuries. The objective of this study was to assess the adherence to and effectiveness of rehabilitation after an acute ankle sprain. 111 patients (age range 15 to 55 years old; 45% of those initially evaluated) that attended 4 emergency room departments from February to July 2009 and responded to a phone questionnaire 2 to 3 months after the evaluation were included in this study. Initial treatment included prescribed RICE protocol, prescription for analgesics, Aircast ankle brace, and a standardized rehabilitation program (2 to 3 sessions/week for 6 to 8 weeks; including massage, pain management, as well as range of motion, strengthening, and proprioceptive exercises). Participants answered questions on the phone regarding brace use, rehabilitation, and extent of their recovery. Of the 111 participants that answered, 50% of the cases were from everyday accidents, 30% from sports injuries, and 20% from workplace injuries. In terms of severity, 15.3% where diagnosed as a mild sprain, 60.4% as moderate, and 24.3% as severe ankle sprains. At the time of the phone interview, only 55% considered that they had full recovery. 83% of participants reported being compliant with the rehabilitation program and on average started their rehabilitation 14 days after the injury. The results of this study indicated that massage and proprioceptive training were significantly associated with patient perception of recovery. In contrast, brace use, physiotherapy, weight training, and manipulative therapy were not associated with patient perception of recovery at 3 months post injury. It would have been helpful if the authors did not rely solely on patient interviews. Furthermore, a lot of patients did not complete the follow-up questionnaire and it is possible those patients had different levels of compliance or perception of recovery than the patients who answered the questionnaire. The relevant part of this study in my view is the importance of proprioceptive exercise in the recovery process.
The results of this study support the importance of proprioceptive exercises in the management of acute ankle sprains. These results are consistent with other findings in the literature. Sefton et al (JOSPT Feb 2011) demonstrated that 6 weeks of balance training among individuals with chronic ankle instability (CAI) improved dynamic balance and proprioception compared to healthy controls who did not train. Bleakley et al (BMJ May 2010) demonstrated that patients with acute ankle sprains receiving early exercise intervention had improved ankle function and were more active in less time after an injury than patients receiving a standard PRICE protocol. While the early intervention and proprioceptive exercise are critical to recovery, one question is the initial treatment in terms of immobilization, use of brace/boot, and weight bearing status for more significant sprains. It would be interesting to look at pain, function, and recovery (time to return to play or re-injury rate) with 1) different degrees of immobilization early in the injury process or 2) early-intervention proprioceptive/balance training versus late-onset training. The treatment protocol used in my department for more significant sprains typically includes use of a boot and early exercise intervention. The time of boot use varies (from a few days to over one week) with degree of sprain, joint response to rehabilitation, and patient’s pain level. It would be interesting to hear other clinicians’ experience with acute management of ankle sprains.
Written by: Thomas Martin
Reviewed by: Jeffrey Driban
When I first came into the school I am at right now a little over a year and a half ago, I had our girls basketball coach come to me regarding his best player. She was a 15 yo with recurrent right ankle sprains. Upon questioning this girl she also complained of numbness and burning into her lateral foot during the course of playing and previously no one could figure out why.
This athlete wound up tearing her ACL during last season and up to that point had her ankle taped religiously prior to practice/games. In the course of her rehabilitation from the ACL surgery and as she became more functional she resumed her complaints of foot pain and numbness. She also complained of this while stretching her hamstrings and IT Band.
On a follow up visit to the ortho she mentioned these complaints and he ordered nerve conduction velocity testing. The affected peroneal was slightly slower than the unaffected but not enough to recommend anything other than a conservative approach. He ordered orthotics which did not help.
I was very diligent with her in foam rolling the entire length of the peroneals from that point on and eventually the athlete was running upward of a mile and playing basketball without complaint. Time and again she would complain the pain was starting again which coincided with her not having done the foam rolling in some time.
She played all of this past season without complaint or ankle sprain, was an all state caliber athlete (which had nothing to do with me, trust me). All of this was done without a piece of tape touching her ankle all year!
Long story short, many times so much focus is put on the ankle ligament and healing factors associated with that when a sprain occurs. Its important that people realize you cannot sprain anything in isolation! The peroneals are always strained in inversion ankle sprains as well as the peroneal nerve being stretched to boot. I'm not saying I've solved the chronic ankle instability paradigm but in your acute ankle rehabs be cognizant of tissue quality of the peroneals because they can spasm, entrap the peroneal nerve, delay firing of the peroneal muscles and contribute to feelings of instability!
You may not agree and I'd love to hear your thoughts but to see this one athlete go from two extremes of the complaint chart due to a few interventions I'm a believer!
Sorry so long winded thought it was a good story to share!