Oral non steroidal anti-inflammatories in ankle sprain

Report By: Kevin Mackway-Jones - Consultant
Search checked by Dhurga Gnanasegaram - Senior Clinical Fellow
Institution: Manchester Royal Infirmary
Date Submitted: 1st March 2000
Last Modified: 17th April 2009
Status: Blue (submitted but not checked)

Three Part Question

In [young patients with ankle sprain] do [non-steroidal anti-inflammatory agents] aid in [reduction in pain and recovery of function]?

Clinical Scenario

A 35 year old man has suffered an injury to his left ankle. X-ray criteria are fulfilled but no bony injury is revealed. Outpatient treatment is to be undertaken

Search Strategy

Medline OVID search engine; 1966 - JUL 1997;
(exp ANKLE or exp ANKLE INJURIES or exp ANKLE JOINT or exp LATERAL LIGAMENT , ANKLE) and exp SPRAINS AND STRAINS or SPRAIN ti,ab,sh) and (exp ANTI-INFLAMMATORY AGENTS or ANTI-INFAMMATORY ti,ab,sh)

Search Outcome

42 papers of which 31 not relevant to the problem and 1 relevant but of insufficient quality for inclusion

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Viljakka T and Rokkannen P 1983 Finland	119 adult patients (18-65) with stable sprains of the ankle. Placebo vs oxyphenbutazone vs clonixin	PRCT	Clinical assessment at 5-7 days (pain, tenderness, swelling, limitation of movement)	Clonixin treatment more favourable (p<0.01)	Also carried out non-randomised trial of two different bandaging techniques. No table of cross-over.
Viljakka T and Rokkannen P 1983 Finland		PRCT	Swelling at 5-7 days (plethysmograph)	Swelling less with clonixin vs oxyphenbutazone (P<0.05) but no difference between either drug and control
Andersson S et al 1983 Sweden	100 adult (> 16) patients with sprains of the ankle Crossover trial Ibuprofen vs placebo and standard vs durable elasticity bandage	PRCT	Swelling (plethysmograph) at 1 and 2 weeks	No significant difference
			Pain at 1 and 2 weeks	No significant difference
			Requirement for pain relief	No difference
McLatchie GR et al 1985 UK	100 adult (> 16) patients with sprains of the ankle Crossover trial Ibuprofen vs placebo and standard vs durable elasticity bandage	PRCT	Clinical assessment at 3 and 7 days (joint tenderness, muscle movement, overall severity of injury and match fitness)	Tenderness significantly less at 7 days (P< 0.01) in treatment groups.	Many results not reported.
McLatchie GR et al 1985 UK		PRCT	Patient assessment at 3 and 7 days (worst and least pain, nocturnal pain relief and impairment of function)	Significantly more training possible (P< 0.01) at 3 and 7 days in treatment groups.	Many results not reported.
Aghababian RV 1986 USA	40 adult (18-51) patients with grade 2 ankle sprains without severe pain Difusinal vs acetaminophen (paracetomol) with codeine	PRCT	Clinical assessment at 3, 5 and 7 days (pain, tenderness, swelling and limitation of motion).	No difference	Non blinded
Aghababian RV 1986 USA		PRCT	Patient assessment of therapy	89% rated difusinal excellent or very good vs 38%.	Non blinded
Dupont M et al 1987 Canada	67 adult (> 16) patients with stable ankle sprains Ibuprofen vs placebo	Controlled trial	Pain at 1, 4 and 8 days	No significant difference	No evidence of randomisatation
			Edema (circumference) at 1, 4 and 8 days	No significant difference
			Functional incapacity at 1, 4 and 8 days	No significant difference
Finch WF et al 1989 USA	50 adult (16-55) patients with stable acute sprains and strains of the ankle Fluribroprofen vs difusinal	PRCT	Pain at 7 and 14 days	Significantly (P <0.05)decreased pain on passive motion at day 7 for fluribroprofen	No power study
			Ankle discolouration at 7 and 14 days	No significant difference
			Joint swelling at 7 and 14 days	No significant difference
Moran M 1990 Peru	108 adult (18-63) patients with moderate to severe ankle sprains Diclofenac vs piroxicam vs placebo	PRCT	Swelling (plethysmograph) at 1, 3 and 7 days	Significant reduction (P<0.0001) at day 3 for both active treatments vs placebo
Moran M 1990 Peru		PRCT	Pain at 1, 3 and 7 days	Significant reduction in pain at rest on day 1 (P<0.0001) and day 3 (P=0.0035 - 0.0067) for diclofenac and piroxicam respectively vs placebo
Bahamonde LA and Saavedra H 1990 Chile	92 adult (15-72) patients with a stable mild to severe unilateral ankle sprain Diclofenac vs piroxicam vs placebo	PRCT	Swelling (plethysmograph) at 0, 2 and 6 days	No significant difference
			Pain at 0, 2 and 6 days	Significant (P<0.0002 - 0.0001) reduction in pain in diclofenac group vs piroxicam and placebo at 2 days.
			Investigators overall assessment of efficacy at 6 days	Diclofenac significantly (P<0.001) more often rated excellent than piroxicam or placebo
Moran M 1991 Peru	60 adult patients with ankle sprains Diclofenac vs ibuprofen vs placebo	PRCT	Swelling (plethysmograph) at days 1, 3 and 7	Significant reduction in swelling over time in both treatment groups. Significant (P=0.0001) reduction in diclofenac group vs both other groups at day 3.
			Tenderness at 1, 3 and 7 days	Significant (P<0.005) reduction at day 3 in both treatment groups
			Pain at 1, 3 and 7 days	Significant (P<0.05) reduction in pain in both treatment groups at days 1 and 3.
Dreiser RL and Riebenfeld D 1993 France	60 adult (18-66) patients with traumatic distortion of the ankle with moderate or severe pain Nimesulide vs placebo	PRCT	Functional impairment at 0, 4 and 8 days	Treatment significantly (P<0.01) better than placebo at day 4	High withdrawal from placebo group at day 4 due to lack of efficacy made day 8 analysis poor
			Pain at 0, 4 and 8 days	Treatment significantly (P<0.01) better than placebo at day 4 and 8
			Joint swelling at 0, 4 and 8 days	No significant difference

Comment(s)

There are a number of small PRCTs in this area from all around the world. Many use different drugs and different doses of the same drug. Many use different outcome measures. Most use pain and many use swelling. Most have a 3-4 day assessment and a 7 day assessment. Metanalysis may be possible

Editor Comment

Update awaited

Clinical Bottom Line

There appears (metanalysis awaited) to be a significant reduction in pain when NSAIs are compared to placebo; however the only paper to compare NSAIs with another analgesic found that analgesia per se has this effect

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

Viljakka T , Rokkannen P . The treatment of ankle sprain by bandaging and antiphlogistic drugs. Ann Chir et Gynaecol 1983;72:66-70
Andersson S, Fredin H, Lindberg H et al Ibuprofen and compression bandage in the treatment of ankle sprains Acta Orthop Scand 1983;54:322-325
McLatchie GR Allister C, MacEwen C et al Variable schedules of ibuprofen for ankle sprains Br J Sports Med 1985;19:203-206
Aghababian RV Comparison of Difusinal and Acetaminofen with Codeine in management of grade 2 ankle sprain Clin Ther 1986;8:520-526
Dupont M, Beliveau P, Theriault G The efficacy of antiinflammatory medication in the treatment of the acutely sprained ankle Am J Sports Med 1987;15:41-45
Finch WF, Zananga P, Mickelson MM et al A double-blind comparison of fluriprofen with difusinal in the treatment of acute ankle sprains and strains Curr Med Res Opin 1989;11:409-416
Moran M An observer-blind comparison of diclofenac potassium, piroxicam and placebo in the treatment of ankle sprains Curr Med Res Opin 1990;12:268-274
Bahamonde LA, Saavedra H Comparison of the analgesic and anti-inflammatory effects of diclofenac potassium versus piroxicam versus placebo in ankle sprains J International Med Res 1990;18:104-111
Moran M. . . Double-blind comparison of diclofenac potassium, ibuprofen and placebo in the treatment of ankle sprains J International Med Res 1991;19:121-130
Dreiser RL, Riebenfeld D A double-blind study of the efficacy of nimesulide in the treatment of ankle sprain in comparison with placebo Drugs 1993;46(Suppl 1):183-186