Inversion ankle sprains are one of the most common injuries in sports, with occurrence rates ranging from 0.68 to 3.85 sprains per 1000 person-days of exposure.4,5,18,19 Although these injuries are often considered minor, they can lead to persistent disability in athletes.12 Early treatment of syndesmosis sprains includes immobilization and early functional treatment; however, the indications for these treatments are controversial.
We asked whether a difference exists between time to return to preinjury level of activity in patients who receive early functional treatment compared to patients who have their ankles immobilized. We hypothesized early functional treatment leads to a quicker return to activity. We also asked whether a difference exists between the two groups in terms of patient satisfaction, presence of subjective instability, and rate of reinjury. We hypothesized early functional treatment improves these outcomes as well.
MATERIALS AND METHODS
We searched PubMed from inception to December 2005 for articles with textwords “ankle sprain,” “lateral,” and “inversion” and for the MeSH subject heading, “Lateral Ligament, Ankle”. MeSH stands for medical subject heading and is a controlled vocabulary of terms used to categorize Medline entries. “Lateral” and “inversion” were combined using a Boolean OR operator and this result was combined with “ankle sprain” using a Boolean AND operator. The search identified 595 articles. EMBASE was then searched using the terms “ankle” and “sprain” as exploded search terms and textwords, and “lateral” and “inversion” as textwords combined with a Boolean OR operator. These terms were combined with a Boolean AND operator to identify 535 articles. We reviewed abstracts to identify articles which might represent the highest level of evidence, and these 19 articles were retrieved for review.
The studies were independently reviewed by two individuals (MHJ and ASA). Studies were reviewed for methodological quality and excluded if less than 80 percent of patients were available for followup and if studies were not randomized, controlled trials. In addition, studies had to compare immobilization with some form of early functional treatment for inclusion.
Nineteen studies were identified for review; nine studies were excluded because they failed to include immobilization as an intervention,1,2,13,14,16,17,22-24 and one study was excluded because it did not differentiate foot instability from ankle instability.11 Two studies had short followup of only three months, but we included these studies because they provided sufficient followup for us to address our primary research question of time to return to preinjury activity. Nine of the 19 studies identified were randomized controlled trials which compared immobilization to early functional treatment (Table 1).3,6-10,15,20,21
Five studies3,6-8,20 reported the number of days to return to work or sport, and 95% confidence intervals were calculated for each study (Table 2). One study3 showed a longer time to return to sport in the functional treatment group compared with the immobilization group (43 days versus 38 days), although there was overlap of the confidence intervals. The remaining four studies showed a shorter average time to return to sport or work in the functional treatment groups, and two studies6,8 showed a marked difference between the groups. Immobilization consisted of a cast or plaster splint, and time of immobilization ranged from 10 days to 6 weeks. Eighty-three to 100% of patients were available for followup at a duration of 3 months to 3.8 years (Table 1).
Five studies reported the percentage of patients able to return to work or sport.8-10,15,21 Rate of return ranged from 67% in the immobilization group of one study21 to 100% in both groups of another study.10 Only one study demonstrated a substantial relative risk of 1.26 (95% CI, 1.02-1.55).21 When data for 414 patients were pooled, the relative risk was 1.06 (95% CI, 0.98-1.15).
Five studies6,8-10,15 reported the presence of subjective instability. Two studies9,15 reported more complaints of subjective instability in the functional treatment group while three studies reported more patients with subjective instability in the immobilization groups versus the functional treatment groups. In these studies, the relative risk for subjective instability ranged from 0.50 to 1.68 for the functional treatment groups versus the immobilization groups. When the data were pooled for 477 patients, the relative risk was 1.01 (95% CI, 0.72-1.42) (Table 3).
Six studies3,6,8-10,15 reported the reinjury rate at final followup, and in all studies except one9 the reinjury rate was lower for the functional treatment group than for the immobilization group. The relative risk of reinjury for functional treatment versus immobilization ranged from 0.5 to 1.26, and relative risk in pooled data from 598 patients was 0.81 (95% CI, 0.58-1.12) (Table 3).
Two studies reported on patient satisfaction, noting only patients were satisfied or unsatisfied. Cetti et al8 reported 18% of patients in the immobilization group and 5% of patients in the functional treatment group were satisfied with their final result. Moller-Larsen et al21 reported 20% of subjects in the immobilization group and 15% of the patients in the functional treatment group were satisfied with their final result (Table 3). When data were pooled, the relative risk of satisfaction was 0.60 (95% CI, 0.30-1.18) for functional treatment versus immobilization.
Inversion ankle sprains are a common injury and can lead to recurrent injury and persistent disability. Initial treatment has included immobilization and early functional treatment. We undertook a systematic review of the literature comparing immobilization with early functional treatment to determine whether early functional treatment lessens time to return to preinjury activity, reinjury rate, and presence of subjective instability after injury.
We note several limitations. Although nine randomized, controlled trials were identified which compared immobilization and functional treatment in the acute management of inversion ankle sprains, there was substantial variation in the type and duration of immobilization and in the mode of functional treatment employed. In addition, the studies did not have large numbers of subjects or comprehensive, uniform methods for measuring outcomes.
Despite these limitations, this systematic review demonstrates a trend toward earlier return to preinjury activity in patients undergoing early functional treatment. Although studies seem to favor early functional treatment in terms of recurrent instability and reinjury, the pooled data do not demonstrate a substantial difference in these outcomes. The two studies evaluating patient satisfaction8,21 suggest patients are slightly more satisfied with immobilization compared with functional treatment; however, the concerning aspect of these data is the low overall satisfaction rate, which is not greater than 20% in any group.
Future investigations of the acute treatment of inversion ankle sprains should aim to evaluate various methods of early functional treatment with the goals of hastening return to activity, decreasing reinjury and subjective instability, and ultimately increasing patients' overall satisfaction with treatment.
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