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The therapist is also often involved in the treatment of the main sequelae of ankle sprain: chronic ankle instability. In recent years, there have been a number of systematic reviews and randomized controlled trials of treatment of ankle sprain, which are considered here. It should be noted that all studies in the acute ankle sprain section are of a non-specific selection of ankle sprain unless stated. Functional support is preferable to immobilization for most ankle sprains.
Functional support involves the use of a removable and variable immobility device and therefore often includes an exercise component in the treatment. A meta-analysis found significant differences in favor of functional support, which included brace, elastic bandage, tape, softcast, or wrap over immobilization.
However, neither Kerkhoffs et al. In contrast to these results, a recent large pragmatic randomized controlled trial comparing immobilization for 10 days in a below-knee cast with tubular bandage, a Bledsoe boot or an Aircast TM brace, found that people with the cast had better clinical benefits at three months post-injury; 14 however, all differences had disappeared by 9 months.
While this study appears to contradict the previous reviews and current practice, it needs to be noted that this study exclusively recruited patients with severe ankle sprain unable to weight-bear for at least 3 days.
In addition, there are a number of limitations that should mitigate decision making during practice. Outcomes were by self-reports so there was no assessor blinding. Therefore, current practice of using functional support rather than immobilization for most ankle sprains should remain in place until follow-up of the latest trial confirms the result.
The type of functional support that is preferable to use may depend on the main outcome desired. A systematic review comparing the use of one type of functional support with another included elastic bandage, tape, semi-rigid support, and lace-up ankle support found them equally effective in reducing pain, swelling, ankle instability, and preventing recurrent sprain.
A more recent comparison of an Aircast ankle brace with elastic support bandage group demonstrated a significant improvement in ankle joint function at 10 and 30 days when using the ankle brace. There is fairly consistent evidence that the use of non-steroidal anti-inflammatory drugs during the first 2 weeks following ankle sprain, administered orally or topically, is more effective than a placebo.
However, the study also reported greater range of motion restriction and mechanical instability in the intervention group in the short term. The extent and quality of the available evidence for the effects of electro-physical agents for treatment of acute ankle sprains are limited.
Ultrasound does not appear to be effective although as the tested dosage range and treatment times are limited, there may be an effect using untested variables. In one study, low-level laser with rest, ice, compression, and elevation RICE was shown to reduce swelling up to 3 days after the treatment when commenced within 8 h of injury and given twice a day, compared with RICE alone, or RICE and placebo laser.
Manual therapy in a number of forms has been shown to have positive effects after acute 23 , 24 and subacute ankle sprain. Following acute ankle sprain, a passive anteroposterior glide of the talus was better at increasing dorsiflexion range of motion than rest, ice, compression, and elevation at the end of the treatment period. Manual therapy also increased ankle function up to 1 month following the treatment.
Maitland anterior—posterior talocrural mobilization with pain-free force at pain-free limit of dorsiflexion;. Three systematic reviews of the effect of exercise compared with usual care concluded that exercise resulted in less risk of recurrent sprain 27 , 28 relative risk: 0. Contrary to the results of previous systematic reviews, van Rijn et al. This finding was consistent regardless of the severity of the sprain. This study and results of previous systematic reviews suggest that exercise may be beneficial in reducing the risk of recurrent sprain.
The main interventions for chronic ankle instability are external ankle supports and exercise. The use of external ankle supports has been the subject of two systematic reviews, 33 , 34 which concluded, with fairly strong evidence, that the use of supports during sporting activity results in a decreased risk of recurrent ankle sprain.
A combination of factors may contribute to chronic ankle instability, including diminished neuromuscular control, proprioception and postural control deficits, muscle weakness, impaired joint position sense, and ligament laxity. A common clinical thought is that wobble board or disk training is the essential component, but there is no direct evidence to support this. The management of ankle fracture usually involves surgical or conservative fracture reduction, followed by a period of immobilization and rehabilitation.
More often, rehabilitation for ankle fracture starts after the immobilization period. Recently, there has been one systematic review 45 and one Cochrane review 46 on treatments for rehabilitation after ankle fracture. Most of the randomized controlled trials examining treatment for ankle fracture during the immobilization period included only subjects who had had surgical rather than conservative orthopedic management.
However, the use of a removable type of immobilization combined with early exercise may also lead to a higher rate of adverse events. These adverse events were generally minor e. The higher rate of adverse events indicates that this treatment needs to be applied judiciously in clinical practice, for example, only in patients who are able to comply with the regimen. The use of a compression stocking in addition to a cast, or electro-physical agents ultrasound, electrical muscle stimulation or interferential during the immobilization period did not improve outcomes after surgical fixation.
Since the publication of these reviews, one additional randomized controlled trial has been published; it investigated the effects of an orthosis that allowed some ankle movement after surgical fixation. However, one case of impaired wound healing required surgical revision in the treatment group. Treatments prescribed for ankle fracture after the immobilization period typically include exercise, manual therapy, progression of mobility, and a gradual increase in activities.
Kaltenborn-based manual therapy including traction and gliding mobilization to the talocrural and talocalcaneal joints, and other hypomobile lower limb joints;. We further investigated the effectiveness of manual therapy large amplitude anterior—posterior glides of the talus in a randomized controlled trial of 94 participants. These findings were consistent regardless of the severity of fracture.
Furthermore, although the overall costs did not differ between groups, participants in the treatment group incurred more out-of-pocket costs. Our findings may only apply to the specific manual therapy technique used; however, there is some evidence in recurrent ankle sprain showing that different techniques do not lead to a difference in outcomes. Thus, current evidence on treatments for ankle fracture after the immobilization shows that the addition of stretching or manual therapy to exercises did not enhance outcomes.
This suggests that treatment for ankle fracture after the immobilization should be focused on a progressive and structured exercise program. Studies on factors that can predict or influence outcome in ankle fracture may assist clinicians in allocating treatment resources and advising patients according to the expected prognosis.
Factors found to be associated with outcomes after ankle fracture include the type of orthopedic management surgical or conservative , 11 , 53 — 57 fracture severity, 11 , 54 , 58 — 64 ankle range of motion, 54 , 65 and pain While ankle fracture managed surgically achieves better anatomical reduction than conservative means, 53 , 55 , 56 the implication of this on clinical outcomes is unclear with some authors finding no difference between surgical or conservative management, 11 , 53 , 56 some favoring surgical management, 55 and others favoring conservative management.
Classifying fracture severity according to the number of malleoli fractured appears to provide a more reliable prediction of outcome. Unimalleolar fracture has been consistently shown to be associated with better outcomes than bimalleolar or trimalleolar fracture. Evidence-based treatment of acute ankle sprain should consist of functional support, possibly augmented by non-steroidal anti-inflammatory drugs in the early phases after injury. Manual therapy may also provide very short-term benefits after ankle sprain.
Recent studies showed the additional benefits of exercise, particularly balance exercises, in reducing the risk of a recurrent sprain. The use of electro-physical agents does not appear to enhance, and may even negate, outcomes. After ankle fracture, current evidence supports an early introduction of activity to enhance outcomes.
This can be administered via the commencement of exercise or weight-bearing during the immobilization period in patients who will comply with this treatment regimen. After the immobilization period, adding adjunct treatments to a comprehensive exercise program may not improve outcome, and hence the focus of the treatment should be on exercise. One way takes seconds. Another way may take up to 1 minute. Both kinds of stretches seem to improve ankle flexibility.
However, we do not know how well they work to improve pain and disability in individuals following ankle sprains. The purpose of this research is to find out which physical therapy treatments work best for people with ankle sprains.
To start the study, subjects will be asked to fill out some forms that ask about their ankle problem. Subjects will receive an examination by a physical therapist that includes gentle movements of the feet and legs to test their flexibility, strength, and balance. Subjects will then be assigned to 1 of 3 treatments to be provided by a separate physical therapist.
They will not get to choose their group. All 3 groups will receive ankle stretching by the physical therapist. The groups will differ in how much and how fast the stretch will be. The first group will have an ankle stretch that lasts seconds. The second group will have a stretch that lasts 1 minute. The third group will have their foot held without any stretching. After stretching, all subjects will receive the same kind of exercise program. Study-related treatment will last 5 sessions over 4 weeks, with 2 sessions for stretching within the 1st week and 1 session per week for the 3 following weeks for the exercise program.
After 1 week and 4 weeks, subjects will fill out the same forms as at the initial examination. The treatment part of the study will then be finished. After 6 months, 1 year, and 2 years from enrollment in the study, subjects be asked to fill out many of the same forms that ask about their ankle problem.
We think subjects that get a stretch will have a better outcome than subjects that get ankle holding. To test our idea, we will compare how subjects in each group tell us they are doing with their ankle problem on the Foot and Ankle Ability Measure at 1 week, 4 weeks, 6 months, 1 year, and 2 years following entry into the study.
Since the way a person thinks and feels about their injury may have something to do with how much they improve during physical therapy, we will also measure these factors to find out if they affect the results of this study. Arms and Interventions. With the subject in a seated position on a treatment table and the lower extremity of interest stabilized to the table with a belt, a single standardized treating investigator will grasp the foot of interested with the thenar eminences on the foot's plantar surface, which is similar to the positioning used for the active comparator groups.
With the subject in a seated position on a treatment table and the lower extremity of interest stabilized to the table with a belt, a single standardized treating investigator will grasp the foot of interested with the thenar eminences on the foot's plantar surface. Outcome Measures.
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