Plaster casts are better for ankle sprains

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BBC News are reporting:
http://news.bbc.co.uk/1/hi/health/7886619.stm

Seems like the podiatry philosophy of 'restricted motion' may have more validity than the physiotherapy approach of 'get things moving'.

Something I always suspected for lower limb injuries.

LL

 

Not only lower-limb...but virtually any acute injury.

BTW, what is the "podiatry approach"? I thought most podiatry approaches were inversio-philic or eversio-phobic?


This physiotherapy approach of "move it or lose it", "no pain no gain" is all brawn and no brain; and such an approach has been robotically drilled into the profession and students alike. Its all about movement...its all about strength, but there is nil regard for healing.

As a practicing clinician, I have had the evidence-based-practice and hence the profession tell me for years/decades that you don't immobilise it...

I have never accepted evidence based practice, irrespective of the statistical significance levels and epitome of methodology. To consider it, it first has to be clinically significant, pass the test of common-sense...and mirror what you see in the clinical setting.


Anyhow, strapping with tape is just as cost-effective and allows earlier asymptomatic weightbearing (compared to plaster) in most typical cases. Oh, but hang on EBP tells me strapping doesn't have any mechanical effect after 20 minutes.igs:


Ron
Physiotherapist (Masters) & Podiatrist

 

Ron

Glad to hear you buck the normal physiotherapy approach.

I agree, most podiatrists seem to have some great fundamental issue with actually pronating/everting the foot - probably down to not really getting that not evert foot is pronated...duh!

Because podiatrists tend to immobilise and shut down motion with orthoses and various techniques (eg I fit a tonne of CAM walkers) - this tends to raise the ire of physio's who are focussed on movement/flexibility and strength - when most of the time the foot/ankle just needs a bit of a holiday. This study is useful in supporting this approach...

LL

 

I love that last line of yours.



Ron
Physiotherapist (Masters) & Podiatrist

 

Thanks Ron - I use it almost every day. I think patients understand that concept rather easily when they have an overuse or acute injury.

LL

 

Here's the abstract:

 

The pendulum of immobilization vs motion for treatment of foot and lower extremity injuries swings back and forth every few decades, depending on the specialty. Judicious use of periods of bracing and/or immobilization for weightbearing activities during the acute phase along with early non-weightbearing range of motion, then non-weightbearing and weightbearing exercise used along with gradually limiting the bracing of the joint over time seems to have worked best for the quarter century that I have been treating patients with these injuries.

 

Severe sprains ..........CAM vs PLASTER vs FIBERGLASS.................

Regrettably there is more to the medical delivery system then what works best for the patient.

On a purely logistic level, it's certainly less time consuming and less labor intensive to merely place a patient who needs immobilization in a CAM walker vs a plaster or fiberglass cast.
( I can't recall the last time I used plaster vs fiberglass for a walking type cast.)

I'm in the USA, but I see the study quoted the price of a plaster cast as 16 pounds (or euros I assume) - that certainly isn't enough to cover the cost of materials and time it takes to apply it and the mess you're left with afterwards plus the time to remove it (free of charge apparently.) In addition, you need a shower protector for the cast and a cast shoe or walking heel. These are not free either.

Plus, how "happy" is the patient familiar with a CAM walker going to be when you slap a heavy plaster cast on their foot and tell them they'll get it off when they return in 2 week?

In this day and age, I just don't (no matter what any study may find) anyone actually applying a plaster cast to each patient with a "severe" sprain when they can take 1/10 of the time and charge 20 times more by having an assitant dispense a CAM walker.

Steve

 

>>Judicious use of periods of bracing and/or immobilization for weightbearing activities during the acute phase along with early non-weightbearing range of motion, then non-weightbearing and weightbearing exercise used along with gradually limiting the bracing of the joint over time seems to have worked best for the quarter century that I have been treating patients with these injuries.<<

I concur with this approach having been on both sides of the fence both as a patient and a clinician treating sports injuries.

I do have questions about the study. What was the patient population like? Treating athletes, the nine month outcome wasn't nearly as important as the 1, 2, and 3 month outcomes. Were the effects of immobilization vs. a CAM walker, an aircast, etc. study further up the kinetic chain - knee, hip, pelvis, spine?

In support of the physiotherapists on the forum, it's not a " no pain no gain" situation in rehab. One works within pain free ROM initially and expands to patient tolerance (as Dr. Kirby so eloquently explained.) Using the brawn vs. brain drill instructor approach, especially with patients who aren't really body-aware, is to invite exacerbation of the initial injury.