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Three Part Question

In [patients with an ankle sprain] is [physiotherapy a useful adjunct to simple RICE instructions] at [speeding time to recovery]?

Clinical Scenario

A twenty year old man attends the emergency department, having sustained an inversion injury slipping off a kerb. Clinical examination by an Emergency Nurse Practitioner in the minor injuries unit reveals tenderness to the lateral malleolus, and you suspect an anterior talo-fibular ligament sprain. You prescribe a double-tubigrip bandage and advise him to follow "Rest, Ice, Compression and elevation", (RICE) instructions. You wonder whether it is worthwhile referring him to the physiotherapist in addition to this, to speed up his return to normal activity.

Search Strategy

Medline 1966-week 3/09/04 using the OVID interface.
[exp ankle injuries OR (ankle.mp AND {exp soft tissue injuries OR exp "sprains and strains"})] AND [exp Physical Therapy Techniques OR physiotherapy.mp OR manipulation.mp] AND [controlled clinical trial.pt OR randomized controlled trial.pt OR review, academic.pt] LIMIT to human AND English.

Search Outcome

Altogether 38 papers were found of which 32 were irrelevant to the study question. An additional paper was found via reference checking. The remaining 6 papers and one systematic review are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pasila et al 1978 Finland	300 patients randomised to either Diapulse, Curapulse or placebo therapy sessions	RCT	Strength measurements, range of movement; swelling	No significant differences found	Power settings of diathermy lower than previous studies
Wester et al 1996 Denmark	48 patients randomised to RICE alone or RICE + "wobble board" training	RCT	Swelling, reliance on support, activity	No significant differences found	22% dropout rate No data on use of NSAIDS affecting outcome
			Subjective opinion	Fewer recurrent sprains on treatment group (p<0.05)
Karlsson et al 1996 Sweden	86 patients <24 hours injury randomised to either compression pads and mobilisation training or compression bandage and crutches	RCT	Validated orthopaedic scoring scale for instability, pain, swelling, stiffness, activities	No significant differences found	Only difference between groups was more aggressive treatment in the first week.
Holme et al 1999 Denmark	92 patients 5 days post injury randomised to either RICE and exercise sheet or additional supervised 1 hour twice weekly physiotherapy sessions	RCT	Position sense. Isometric testing. Postural control.	No significant differences found	Questionable whether groups were comparable - significantly more positive anterior drawer signs in the experiment group.
			Patient interview	Reduced incidence of re-injury (7% vs 29%, n=65) in following 12 months
Green et al 2001 Australia	41 patients within 72 hours of injury randomised to RICE or RICE + passive manipulation every 2/7 for 2/52	RCT	Angle of dorsiflexion that produced pain. Gait characteristics	No significant differences found	Multiple assessors for goniometry Small sample size Sports tape also applied Clinical relevance of results?
			Return to work	1.5 days quicker to return to normal walking. 0.7 days quicker to return to running. 1.2 days quicker to return to sport
Van Der Windt 2001 Netherlands	Total of 572 patients (5 trials) - placebo or "sham ultrasound"	Systematic Review	General improvement. Pain, swelling, functional disability, range of motion.	No significant differences found for any outcome measure at 7 to 14 days of follow up. Pooled relative risk for general improvement was 1.04 (CI 0.92 to 1.17)	4 of the trials were "of modest methodological quality"
Wilson DH, 1972, UK	40 patients all within 36 hrs of acute injury, randomised to either "diapulse" or placebo with exercise advice	RCT	Swelling, pain and disability	Significant improvements in pain and disability noted, but not swelling	Small numbers (20 to each arm) Randomisation not clear Outcome measures not taken beyond three days post injury

Comment(s)

A number of different techniques are described, all of which purport to be of benefit in therapy for acute ankle sprains. These include passive manipulation, ultrasound, short-wave diathermy, and "wobble-board" training amongst other exercise regimes. There does however appear to be a paucity of evidence as to the effectiveness of any of these methods at the present time nor is there clear demarkation as to their effectiveness according to the 3 grades of injury which help to classify muscle and ligament damage equivalent to any loss of function, strength, fibre damage and instability of the affected joint.

Clinical Bottom Line

Based on the current best evidence, home mobilisation facilitated by simple written instructions is suitable for the management of ankle sprains, and active physiotherapy offers no additional benefit.

References

1. Pasila M, Visuri T, Sundholm A. Pulsating shortwave diathermy: value in treatment of recent ankle and foot sprains. Archives of Physical Medicine and Rehabilitation. 1978;59(8):383-6.
2. Wester JU, Jespersen SM, Nielsen KD et al. Wobble board training after partial sprains of the lateral ligaments of the ankle: a prospective randomised study. Journal of Orthopaedic and Sports Physical Therapy. 1996;23(5):332-6.
3. Karlsson J, Eriksson BI, Sward L. Early functional treatment for acute ligament injuries of the ankle joint. Scandinavian Journal of Medicine and Science in Sports. 1996;6(6):341-5.
4. Holme E, Magnusson SP, Becher K et al. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scandinavian Journal of Medicine and Science in Sports. 1996;9(2):104-9.
5. Green T, Refshauge K, Crosbie J et al. A randomised control trial of a passive accessor joint mobilisation on acute ankle inversion sprains. Physical Therapy. 2001;81(4):984-993.
6. Van Der Windt DA, Van Der Heijden GJ, Van Den Berg SG et al. Ultrasound therapy for acute ankle sprains [Cochrane Review]. Cochrane Library. Issue 4, 2002. Oxford: Update Software.
7. Wilson DH. Treatment of soft-tissue injuries by pulsed electrical energy. BMJ 1972;2(808):269-70.