Olympics, Exercise and Ankle Injuries
The excitement and success of the Olympics and Paralympics seems
to have had a positive effect on the nation.
Cycling to and from the practice each day I’ve noticed a visible
increase in the number of people out exercising. This can only be a good thing for the health
of the nation, but it does come with consequences: people seeing their GPs with
musculoskeletal injuries.
This week I’ve had a run of sprained ankles coming in from
people with a variety of shapes, sizes and athletic ability. I always feel my management of acute injuries
is a little basic, despite (or possibly because of) spending almost a year
doing T&O jobs as a junior doctor. It
turns out that the ability to consent 90 year old ladies for a
hemi-arthroplasty while ignoring all co-morbidities has little relevance to the
general practice MSK case mix.
So, is there more to
it than rest, ice, compression and elevation?
With fortuitous timing a leaflet included with this months
BJGP from Arthritis Research UK on Sports and Exercise Medicine1 contained
an interesting piece on management of acute inversion ankle sprains.
These are the most common ankle injury, resulting in a
lateral ligament sprain. So what do they
recommend?
- Initially use the Ottawa rules to decide whether XR is required
a.
The Ottawa rules recommended XR is only
necessary if there is any pain in the malleolar zone and either tenderness at
the posterior edge or tip of lateral or medial malleolus, base of the 5th
metatarsal or navicular or inability to bear weight both immediately on injury
and at review.
b.
Anterior malleolus tenderness doesn’t count for
the rules – presumably its more likely to be ligament-related pain
c.
The leaflet has a very good diagram of the rules
– click
here
2.
- Advise “PRICED” – like RICE but elongating the acronym to include things you’ll tell the patient to do anyway
a.
Protect – clean any other wounds, splint if
broken, etc.
b.
Rest
c.
Ice
d.
Elevation
e.
Drugs – simple analgesia +/- anti-inflammatory
- Review after 72 hours and re-examine – initially the ankle is usually too painful to manage a meaningful examination
a.
3 key tests here – the latter two assess portions
of the lateral ligament
i.
Assess proprioception – can they stand on one
foot? – this can be significantly compromised by an ankle injury and increases
the risk of re-injury.
ii.
Anterior draw test – assesses the anterior talofibular
ligament (ATFL – see the pic below) – stabilise the leg, put a hand behind the
heel and pull forwards – feel for laxity, no ‘end-feel’ implies a grade 3 sprain
(complete tear); compare to the uninjured side
iii.
Talar tilt test – assesses the calcaneofibular
ligament (CFL)– stabilise the leg, then invert the hind foot – again, feel for
laxity, comparing to the uninjured side
1.
CFL injuries confer a worse outcome (the ATFL
always goes first then the CFL so it’s a multiple injury) - the paper suggests
that onward referral may be needed if the CFL is damaged.
2.
ATFL damage alone can be managed conservatively.
3.
But reading Clinical Sports Medicine2
(the definitive sports medicine textbook), they cite a 2002 Cochrane review
concluding that there was insufficient evidence to recommend surgery over
conservative treatment for grade 3 ankle sprains – but conservative Rx here
implies management by a sports medicine team.
4.
Early physio may be helpful in more severe
injuries.
- Rehabilitation – can start at this review – in fact all the stages are likely to overlap
a.
Explain the injury may take 6-12 weeks to heal
b.
Get the patient exercising the ankle
i.
Encourage range of movement – get them to write
the alphabet with their toe
ii.
Improve eversion strength – using an elastic
fitness band looped around a chair leg, evert against resistance – the aim is
for low power, high reps – 3 sets of 10 bd
iii.
Improve proprioception – may be the most
important part – initially practice balancing on the affected leg and building
up the duration, then try on more unstable surfaces – ideally a wobble board,
but a pillow will do
iv.
Arthritis Research UK has a great patient leaflet
so all this – click
here
- Return to sport
a.
Start when the pain has settled, full range of
movement, eversion strength is good and proprioception is at least as good as
the other leg. Start easy and build up
slowly.
b.
Clinical Sports Medicine highlights the benefits
of strapping for any athlete with a significant injury for 6-12 months
post-injury. There are lots of common
methods, but the simplest is stirrups – put anchor tape circumferentially
around the lower leg then with the foot in a neutral position apply stirrups
under the hind foot from medial to lateral until stable.
So, at the very least I have a better idea of what I’m
testing, why I’m testing it and which patients are at risk of worse outcomes
and may benefit from more intensive treatment.
The Hands On series from Arthritis Research UK is aimed at GPs and well
worth a read – click here.
My appraisal’s looming and I remember part of my PDP being
improvement in MSK – I’ll keep looking for primary care management of acute
injuries. Anyone who’s interested in
more Facebook or Tweet us and I blog it when I find it. For all you MSK GPwSI’s out there send us
your tips!
Enjoy the weekend, the Paralympics promises masses more of
exciting sport and hopefully medals.
Neal
References:
2.
P Brukner, K Khan. Clinical Sports Medicine, 3rd edition. Lateral ligament injuries, pages 617-622
