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Ankle Sprains Kevin M Journal ofAthletic Training 1999;34(1):5-10 C by the National Athletic Trainers' Association, Inc www.nata.org/jat Comparison of 3 Methods of External Support for Management of Acute Lateral Ankle Sprains Kevin M. Guskiewicz, PhD, ATC*; Bryan L. Riemann, MA, ATCt; James A. Onate, MA, ATCt * Sports Medicine Research Laboratory, Department of Physical Education, Exercise, and Sport Science, University of North Carolina, Chapel Hill, NC; t Department of Health, Physical, and Recreational Education, University of Pittsburgh, Pittsburgh, PA; * Southeast Raleigh High School, Raleigh, NC Objective: To examine the efficacy of 3 different types of Measurements: We assessed subjects for ankle volume, injury support systems (standard elastic wrap with horseshoe, functional performance, and self-perception of symptoms dur- Aircast Sport Stirrup, and Omni Multiphase orthosis) used in ing the 5 postinjury assessments. treating acute inversion ankle sprains. Results: We found no significant differences among the 3 Subjects: We recruited 30 physically active college-aged groups on measures of volume, level of function, and self- subjects who had sustained a grade 1 + or 2 lateral ankle sprain perception of symptoms. within the previous 24 hours for the study. Conclusions: Our results suggest that none of these meth- Design and Setting: Subjects were randomly placed into ods is superior to the others for reducing swelling, restoring one of 3 groups, the first treated with standard elastic wrap function, or relieving symptoms during the acute management with horseshoe, the second with an Aircast Sport Stirrup, of lateral ankle sprains. and the third with an Omni Multiphase orthosis. Subjects Key Words: focal compression, edema reduction, ankle reported to the athletic training room on days 1, 2, 3, 5, and stirrup 7 postinjury. E dema about the ankle is a naturally occurring phe- produces a consistent pressure around the entire circumfer- nomenon associated with inversion ankle sprains. ence of a limb. It has been described as being most effective While inversion ankle sprains are one of the most in reducing swelling around regularly shaped contours, such frequently occurring injuries among athletes and physically as the leg or thigh, especially when applied in a graduated active people, the optimal method of treatment still remains manner.7'8 In contrast, focal compression with a horseshoe- controversial. Various treatment plans for the management shaped pad is best applied in areas where concavities about of acute ankle injuries have been proposed and are well bony prominences exist. This technique, when combined documented in the literature. 1-6 Most clinicians will agree with circumferential compression, theoretically promotes that functional treatment protocols should involve cryother- lymph drainage by diverting edema in a proximal direction apy, elevation, compression, protection, and nonsteroidal through soft tissue compression under the pad.8'9 Ankle anti-inflammatory medications to control pain and inflam- stirrup braces are believed to offer the medial and lateral mation. There is debate, however, as to which method of joint stability necessary for early ambulation, while provid- best for edema external compression and support is reducing ing increased collateral pressures for promoting removal of and for an return to activity. promoting recovery early edema. It is believed that these orthoses provide variable Until recent advancements made available rigid external of the as soft tissues are support systems offering both stability and focal compres- collateral compression extremity sion, clinicians used an elastic wrap for circumferential compacted between the compressive device and underlying compression, an elastic wrap with a horseshoe pad for focal bone during ambulation.'0 compression, or a rigid stirrup brace offering both stability Debate exists as to whether or not the added cost of the and collateral compression. Circumferential compression manufactured support systems meets the expected cost:benefit ratio in comparison with the standard treatment method involv- ing an elastic wrap and horseshoe. Our purpose, therefore, was Address correspondence to Kevin M. Guskiewicz, PhD, ATC, Sports to determine whether one method of external support for acute Medicine Research Laboratory, CB No. 8700, University of North Carolina, Chapel Hill, NC 27599-8700. E-mail address: gus@email. ankle sprain management was superior in reducing swelling, unc.edu restoring function, or relieving subjective symptoms. Journal of Athletic Training 5 METHODS Procedures Thirty subjects who had sustained acute lateral ankle sprains participated in this study. Qualifying ankle sprains involved suspected stretching or partial tears to the anterior talofibular ligament (grade 1 + or 2). All sprains exhibited mild to moderate instability with an anterior drawer test, moderate point tenderness over the anterior talofibular, calcaneofibular, or anterior tibiofibular ligaments, a sudden onset of edema, and no history of an ankle sprain within the previous 6 months. All prospective subjects were evaluated by one of the 3 investiga- tors, all of whom are certified athletic trainers. The study was approved by the Academic Affairs Institutional Review Board Figure 2. Aircast Sport Stirrup. at the University of North Carolina at Chapel Hill, and subjects reviewed and signed a human subjects informed consent form subjects (10 males, 21.7 ± 3.4 years, ht = 183.9 + 6.3 cm, before participating. wt = 81.5 ± 11.5 kg) were placed in a 7.62-cm (3-inch) We randomly placed subjects into one of 3 groups within 24 single-length elastic wrap and 0.64-cm (0.25-inch) felt horse- a hours after injury, according to predetermined rotation of the shoe. A 15.24-cm (6-inch) horseshoe was custom fit to encircle 3 support systems. Group 1 subjects (8 males and 2 females, the lateral malleolus and divert edema away from the soft 21.4 ± 1.5 years old, ht = 179.1 + 9.4 cm, wt = 78.2 ± 14.2 tissue surrounding the lateral ankle ligaments. Compression kg) were placed in the Multiphase (Omni Scientific, Inc, was administered using a distal to proximal graduated method, Concord, CA) orthosis, which consists of a rigid plastic shell whereby the pressure was greatest distally (Figure 3). The that provides ankle stabilization and inversion control (Figure elastic wrap and horseshoe were applied by one of the 3 1). The unique feature of this orthosis is a built-in focal investigators after each treatment; however, subjects were also compression pad designed to facilitate translocation of edema trained in proper self-application. away from the lateral ankle ligaments. Group 2 subjects (9 Five postinjury assessments were made on all subjects at males and 1 female, 20.2 ± 1.2 years old, ht = 178.6 ± 7.4 days 1, 2, 3, 5, and 7 (same time of day ± 1 hour). In an cm, wt = 75.7 ± 11.5 kg) were placed in the Aircast Sport attempt to ensure consistent procedures and results, subjects Stirrup (Aircast Inc, Summit, NJ). The Aircast Sport Stirrup were assessed by only one of the 3 investigators. The investi- consists of 2 plastic shells aligned with adjustable air bladders gators practiced and piloted the protocol before beginning the that the support ankle both medially and laterally (Figure 2). study. All subjects began a standardized rehabilitation program The bladders are designed to exert alternating pressures during on day 1 postinjury, which involved a progression of range- the and dorsiflexion of plantar flexion locomotion. Both the of-motion, strengthening, and balance exercises. Subjects con- Aircast and were Multiphase braces sized and applied accord- tinued the daily program until their strength reached approxi- to the manufacturers' recommended to ensure ing guidelines mately 90% of the uninvolved extremity and they were able to consistent compression and support. Proper brace application perform straight-ahead jogging without pain and apprehension. was also demonstrated one of the by 3 investigators. Group 3 All subjects wore their respective ankle support during waking Figure 1. Omni Multiphase. Figure 3. Elastic wrap and feft horseshoe. 6 Volume 34 * Number 1 * March 1999 hours, beginning on day 1 postinjury, and abstained from Table 2. Visual Analogue Questions Used for Subjective taking nonsteroidal anti-inflammatory medications or perform- Symptom Assessment ing physical activity involving the lower extremities. A 20- 1. Do you experience pain when walking (or attempting to walk) minute elevation and cryotherapy (ice application using elastic without crutches? compression wrap) treatment followed each rehabilitation and 2. Do you experience pain while sitting or lying down? 3. To what extent is your normal function impaired? assessment session. Subjects were instructed to undergo 2 4. Did you have difficulty sleeping due to pain? additional cryotherapy treatment sessions on assessment days 5. Were you able to walk without limping while wearing the brace? and 3 cryotherapy treatment sessions on nonassessment days. Crutches were required for ambulation until subjects attained level 2 status on the Functional Assessment Scale (Table 1). Although this study was concerned with acute phase manage- ment of the injury, subjects were encouraged to continue rehabilitating their ankles for several days after attaining level 5 status. Visual Analogue Scales Subjects completed a series of visual analogue scales inquir- ing about levels of pain and disability (Table 2). The first 3 scales listed in
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