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Ankle sprains are very common, both in the Emergency Room and working as a resident with the Orthopedic Foot & Ankle Surgeon. Physical Therapy is a common treatment recommendation.

When that patient returns for a review, a patient will report that Physical Therapy did not seem to help as much as we anticipate. Not an uncommon finding.

Pain medication, rest & ice may be a better option for the ankle-sprain patient, according to the findings of a Canadian Level 1 evidence study.

"We do note that 43% of participants in the physiotherapy arm and 38% in the control arm had not reached excellent recovery by six months; this being lower than anticipated."

http://www.bmj.com/content/355/bmj.i5650

 

Not sure this should be surprising based on the physio intervention?:

Treatment sessions were 30 minutes in length and were augmented by standardised home exercise plans of active ankle range of motion exercises, isometric strengthening, and resistance exercise, using therapeutic elastic resistance bands or body weight. A home exercise programme was recommended based on each patient’s functional recovery. Icing was used when swelling persisted, but no manual therapies or immobilisation (for instance, taping) or brace devices were used. The treatment plan was implemented by one of three assigned physiotherapists, with a single therapist providing all treatment for an individual participant, whenever possible. At each session, the therapist assessed each individual’s stage of recovery and recorded compliance with appointments and home exercise programmes.

What it does show is the on going level of problem ankle sprains can cause.

 

Ya, maybe .... this is Level 1 evidence and not to be dismissed too lightly. Where was the evidence to suggest the treatment protocol adopted in this study has no merit? Like most good quality research a study raises more questions than it can hope to answer. Your assumption, that additional therapy might change the outcome, remains to be proven.

We would regularly supplement our treatments with ankle braces, of various stiffness. Didn't seem to make too much of a difference.

 

Sorry for that duplication. What I was going to say was I see many many sprains and it might serve to make better sense when these studies are done on sprains and follow up to separate out those who may become chronic and those who will not from these studies. Perhaps I did not word that properly but in order to make sense would not separating out those with a laterally deviated sub talar axis from the rest not make sense? Then perhaps finding out what the degree of sub talar axis lateral deviation means to this issue and what in what population. Am I off on that?

Thanks

 

Hi Dieter
Sorry if misunderstood. I didn't mean to dismiss the study. All of the treatments were things you commonly find in practice so fair game to look at them and see what effect they have.

My question was from a clinical point of view how and why we expect these things to make a significant difference. For instance, if we get someone doing some resistance work, does this load the tissue more/in a better way/in a functionally relevant way from their normal return to activity would anyway.

I would anticipate some manual therapies might have more effect but as you say, that's for another study

 

Manual therapies ie mobilization have been shown to reduce healing time in lateral ankle sprains pretty sure I read that somewhere here, and see that with patients I treat - depending on the type and severity of Sprain

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3103112/ may be of some interest

 

All useful information and opinion. I would not have expected a patient to fare better from home care than PT and speculate this finding might be related to the patient population that was studied. The authors comment on the fact their study population had a high retention rate, i.e. a highly motivated group. A similar study performed elsewhere might have a different outcome.

From the research I would have liked to know a more detailed analysis to understand better the primary complaints when conservative care has failed, i.e. pain, ankle instability, nerve irritation, stiffness etc. Assuming this data was collected.

For the attending Doctor this patient becomes more interesting. Not uncommon to find talar dome osteochondral defects, peroneal tendon tears, and persistent ATFL/CFL pathology. Clinical evaluation, MRI and XR stress tests can point to the problem. Pathology that cannot be manipulated or strapped out of existence.

 

I know n=1 is hardly representative, but as a long-time sufferer of ankle sprains since rupturing my ant talo-fibular ligament when 12 years old, I've always followed the RICE principles with immobilisation in a cam walker boot for a week or two following injury. Usually normal function is restored after 3-4 months. However, last time I sprained the ankle badly was in the middle of a long walk in the hills at the top of a 3,700' peak and 12 miles back to the car. I didn't remove the boot and it took 8 hours for the return trip - the first three at a snails pace, but by the time I was back at the start, I was weightbearing reasonably pain free.. The next few days delivered the usual bruising and oedema but I kept mobilising the ankle thoroughly and didn't use the cam-walker. Ankle function was normal and asymptomatic after 4 weeks.

Yes - I'm aware there are a number of variable factors - but it did feel better, quicker - to the point that I will take the same approach next time.

 

Mark,

Kudos to you for putting up with this recurrent problem. A surgical solution would not be inappropriate. We have good results with the Internal Brace :

https://www.arthrex.com/foot-ankle/internalbrace-ligament-augmentation-repair-technique

 

I keep well away from hospitals, Dieter. Too many people die there, from the most innocuous things too!

 

.... and quite right too. Try an ambulatory surgery center instead.