The twisted ankle

Last week I ran upon a college-aged kid holding his leg rolling around on the ground, obviously in great agony.  "Great," I thought.  Being a doctor can be a huge inconvenience at times.  Like at thanksgiving when Aunt Elda asks about her incontinence, or at my grandfather-in-law's funeral when I'm getting the third degree about the hospital that "killed him".

 

I say "Great" sarcastically.  Anyone in medicine knows that all docs don't know all things.  Furthermore, aanyone gone to med school knows that orthopedics and orthopedic injuries (those involving the bones/ligaments/tendons/muscles) are only known to those appropriate specialties.  LITERALLY, my formal education of the foot consisted of a 50 minute anatomy lecture followed by a 2 hour cadaver dissection that was to include everything below the knee.  And that's not to say I am dumb or went to a dumb school (my board scores are about 95th percentile).

 

Anyway, I kinda know the pathology of an incontinent bladder and can visualize a sprained ankle.  But treatment?  What I say might as well be voodoo.  Most of my education about orthopedic injuries has come from the web, looking at exercise websites, blogs, and the occasional expert opinion.

 

So between breaths I asked the kid if he was ok (a good starting point I thought.  In advanced life support they teach you really obvious things like "if the person can talk then they are doing better than if they can't").  "Yeah, I just have a cramp".  Oh thank God.  "Sorry, there's nothing I can do about that..."  I ran on.  From the looks of things his pride was a little hurt that another male only a few years older was offering him help.

 

It got me thinking that I really don't know how to treat the common athletic ailments any better than the average athlete.  I find myself telling people things like "alternate cold and hot compresses, take advil, elevate it, rest it but keep it active".  What does that mean?  Where did I learn that?  It's all just made up based on hearsay and what may be common sense.

 

So tonight I read a little about ankle sprain, a very common complaint, especially for runners.

 

To not be too redundant, there is a complete review article published in the American Family Practice Journal last year that takes a scientific look at treatment.  It is available free here: http://www.aafp.org/afp/20061115/1714.pdf

 

In summary:

1. There is something called the Ottawa Ankle Rules that is simple way to diagnose severe sprain or ligament tear with reasonable accuracy.  It was designed to sort out who needs xrays and who doesn't, to save the health care system money.  Basically, if you have swelling, bruising, pain, and an "anterior drawer test" (looks at the abnormal laxity of motion around the heel joint) there is 96% risk of a serious tendon/joint injury.  Without all 4 of these things, risk is 14% and declines with declining severity.

2. ICE is the treatment.  Not heat.  There is some (limited) scientific studies that icing ankle injuries not only improves pain but speeds recovery.  HEAT IS NOT RECOMMENDED.

3. Taping a sprained ankle seems to help some, but not greatly.

4. Using compression taping or a brace seems to help.  Lace-up semirigid braces are best.

5. Taping/bracing or icing seems to help EVEN WHEN YOU DON'T HAVE AN INJURY.  You can reduce your risk of injury if you use braces on joints that have old inactive injuries, maybe even to be totally preventative.

6. There is even some evidence that icing non-injured muscles and joints (after workouts) can reduce the risk of injury.

7. Meds: the use of NSAIDS (ie ibuprofen and the like) seem to speed recovery.  Take it not just for pain but for swelling.

8. Research supports avoiding immobilization, ie you don't want to just rest your ankle totally.  Some function is important to recovery.  Of course act within reason; probably walking is enough early on.

9. Surgery, even for severely sprained ankle, is not the first line of therapy.  First try physical therapy / exercise.  Many studies show no long term difference between surgery and physical therapy.