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A case review of how we manage ankle sprains in children

Introduction

Injuries to ankles present commonly in clinical osteopathic practice and are a huge medical and socioeconomic problem 1. They account for 3 – 5 % of all visits to Accident & Emergency departments in the UK and acute ankle sprains make up 15 – 20% of all sports injuries 2,3.  Ankle sprains peak between the ages of 15 – 19 years and are more common in women than men 4,5. The tendency towards a higher incidence in women may be due to the increased looseness around the ankle ligaments in comparison to men, leaving the ankle less stable and therefore vulnerable to injury 6.

Most ankle injuries (80%) occur to the outside of the ankle and happen whilst landing from a jump when the foot twists underneath the person (supinated). The 3 ligaments that support the outside of the ankle (from from front to back) are the anterior talofibular (ATFL), calcaneofibular (CFL) and posterior talofibular ligaments (PTFL)

 

Lateral Ankle Ligaments

Ankle sprains are graded from 1 – 3, according to their severity with a Grade 1 meaning a mild stretching of the ligaments without joint instability; grade 2 meaning a partial rupture of the ligaments with mild instability of the joint; and grade 3 meaning a complete rupture of the ligaments with instability of the joint 7. The ATFL is the first or only ligament to sustain injury in 97% of cases 8.

For this blog post, I will run through how we would assess and manage an ankle in the hypothetical case set out below.

Presentation

A 12 year old female presented at a private osteopathic clinic with her mother and younger sister. She complained of left lateral ankle pain, swelling and bruising. The onset of the symptoms were one day previous whilst landing awkwardly on the trampoline at home in her garden. She reported that her foot twisted underneath her and she felt something “go” in her ankle. Her mother had told her to not walk on it and she had taken some infant paracetamol which had slightly helped reduce the pain. She could weight bear and walk with associated pain.

History

She had ‘twisted her ankle’ 2 months previously, to a lesser degree, and the symptoms had resolved without seeking any professional advice or treatment. She appeared otherwise well and healthy. Her and her mother were concerned about the high demands the school placed on her to compete in trampolining competitions. As well as the immediate control and recovery from her pain, they asked for advice on how to approach her school in order to regulate her physical activities whilst there.

Examination, Evaluation, Clinical Findings & Diagnosis

Taking into account the information gained from the verbal case history, it was important to rule out any breaks in the ankle bones as this would need referral for x-ray. Icing a Sprained Ankle with Ice PackThe patient was observed weight bearing and her ability to walk was observed over a short distance. Palpation was carried out in accordance with the Ottawa Ankle Rules (OAR) bilaterally 9. As well as adults, the OAR have been proven in children over 5 to be an effective decision making tool for screening for rboken ankles and therefore prevent unnecessary radiation exposure in non-fracture cases.10,11 The use of a tuning fork to put some vibration through the joint has shown to be a useful adjunct for improving the OAR even further 12.

Having ruled out the need for immediate onward referral, the patient was then examined on both ankles, knees and hips. Both sides are often examined in an osteopathic clinic, even though only one side may be affected. This is because it is useful to see what the normal for that individual is. In this case, findings in the hips, knees and right ankle were normal. Sometimes we have ‘special tests’ that implicate certain structures around joints. The special tests used in this case are the anterior drawer and talar tilt. Significant looseness in the ligaments was picked up on both sides, with the left ankle producing pain in both the tests. The mode of onset and clinical findings led to working diagnosis of a grade 2 ankle sprain being made, with the majority of the damage being to the ATFL.

Osteopathic Management and Treatment 

The initial focus was to reduce the bruising and inflammation surrounding the joint whilst at the same time keep some movement through the area to encourage blood flow and drainage. Some gentle ankle joint movement was carried out  and the patient was given RICE (rest, ice, compression, elevation) instructions. Gentle, non weight bearing ankle movement was encouraged. On the 4 day follow up, the swelling had significantly reduced. There was pain particularly on palpation of the ATFL and in passive inversion of the left ankle. Further ankle joint movement was performed. Wobble board exercises given to do at home.

Discussion and Technical Analysis

The patient was advised to follow the RICE procedure as this was, at the time, the most up to date thinking on the treatment in the initial phase of acute ankle sprains. Although the RICE protocol is given still commonly as advice for patients within osteopathic and other healthcare settings, there is little supporting evidence to suggest this combination of interventions has a justifiable therapeutic effect 8. The most up to date understanding of the healing of ligamentous tissue suggest a proportionate amount of loading at an early stage will produce a faster recovery. An updated acronym P.O.L.I.C.E. (protection, optimal loading, ice, compression and elevation) has been suggested to include the understanding relating to the benefits of joint loading in ligament injury recovery 13. Our role as osteopaths becomes increasingly valuable with the introduction of optimal loading into the treatment protocol for acute ankle sprains as it is up to the individual practitioner to decide on what ‘optimal’ is for that specific patient. Too much loading would mean risking further injury and too little may slow the healing process.

Sprained Ankle Osteopathic TreatmentThis patient was not given any specific advice on analgesic and anti inflammatory medications as it was deemed not within the remit of an osteopath. It may have been beneficial to ask her mother to seek the advice of a pharmacist as, if the pain was preventing ‘optimal loading’ then an analgesic may be of use. Non-steroidal anti inflammatories (NSAIDS) are commonly prescribed following an acute ankle sprain and studies have shown that the benefits of using NSAIDS outweigh any negative effects 14. However, an osteopathic viewpoint may consider the function of inflammation as being a part of the body’s natural healing response and therefore trying to reduce this mechanism is to take a part of the recovery process away.

Recurrent ankle sprains are commonplace and lead to significant chronic ankle instability which in turn leads to early degenerative change. The longevity of an injury free period depends on strengthening the muscular and proprioceptive control surrounding the ankle. It is was of critical importance in the management of this patient that a thorough and achievable management plan was implemented in order to have an injury free return to trampolining. The factors that were considered in formulating this were both of a home based exercise type and a strapping and bracing type for use during more demanding activities. A recent study has shown that the more cost effective approach to preventing recurrent ankle sprains is through the wearing of an ankle brace, rather than focusing on neuromuscular training 15. As this case review focuses on private practice a wobble board and resistance band programme were given as well as a semi rigid ankle brace. The patient was reviewed regularly over the rehabilitation period so as to ascertain that the intensity of the exercises maintained an ‘optimal loading’.

Another factor that was considered was whether the patient was likely to comply with the home exercises given. In this case it was decided that between the patient’s motivation, analog with her parents, there would be a high level of patient compliance. It is important for us as osteopaths to consider patient compliance, as it is a waste of time prescribing home exercises if they will not be completed. A study has shown that patient non or partial compliance can be as high as 54% 16.

It was apparent at an early stage that in this case, that there were high demands and expectations placed on the patient, both from her parents and school in order to return to competitive trampolining. There is little published within any ankle guidelines with regards timeframes for the return to exercise post grade 2 ankle sprains. This is probably due to massive variations within the individual. The individual clinical judgement in this case was that she should avoid bounding type activities for 3 weeks with a view to trampolining in 5 weeks. In reality, this patient returned to trampolining, using her ankle brace in 4 weeks with no ankle pain present.

Summary and Conclusion

This case demonstrates the complexities involved in the management of a paediatric acute sprained ankle. Its has shown that the OAR in conjunction with the use of a tuning fork are a low cost yet highly valuable tool for screening for ankle fractures. Patient compliance with home exercises was high in this case which produced a successful outcome. It must be something that is always considered by the osteopath as it is key the preventing chronic ankle instability. The new concept of optimal loading requires skilled clinical judgement. Osteopaths, with their expert understanding of biomechanics are in a prime position to utilise this concept to produce a positive outcome in the treatment of the paediatric sprained ankle.

References

1. Kerkhoffs, G.M., van den Bekerom, M., Elders, L.A., van Beek, P.A., Hullegie, W.A., Bloemers, G.M., de Heus, E.M., Loogman, M.C., Rosenbrand, K.C., Kuipers, T., Hoogstraten, J.W., Dekker, R., Ten Duis, H.J., van Dijk, C.N., van Tulder, M.W., van der Wees, P.J & de Bie, R.A. (2012) Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 46, 854-860. Available from: http://bjsm.bmj.com/content/46/12/854.full.pdf+html [Accessed 30th September 2016].

2. Cooke, W.M., Lamb, S.E., Marsh, J., Dale, J. (2003) A survey of current consultant practice of treatment of severe ankle sprains in emergency departments in the United Kingdom. Emerg Med J. 20, 505–507. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726246/pdf/v020p00505.pdf [Accessed 30th September 2016].

3. Petersen, W., Rembitzki, I.V., Koppenburg, A.G., Ellermann, A., Liebau, C., Brüggemann, G.P., Best, R. (2013) Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg. 133(8): 1129–1141. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718986/ [Accessed 30th September 2016].

4. Tiemstra, J.D. (2012) Update on acute ankle sprains. Am Fam Physician. 85 (12) 1170-6 Available from: http://www.aafp.org/afp/2012/0615/p1170.pdf [Accessed 30th September 2016].

5. Beynnon, B.D., Renström, P.A., Alosa, D.M., Baumhauer, J.F., Vacek, P.M. (2001) Ankle ligament injury risk factors: a prospective study of college athletes. Journal of Orthopaedic Research 19, 213-220 Available from: http://onlinelibrary.wiley.com/doi/10.1016/S0736-0266(00)90004-4/epdf [Accessed 30th September 2016].

6. Wilkerson, R.D. & Mason, M.A. (2000) Differences in Men’s and Women’s Mean Ankle Ligamentous Laxity. Iowa Orthop J. 20, 46–48. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888743/ [Accessed 30th September 2016].

7. BMJ Best Practice. (2015) Ankle sprain: the effects of non-steroidal anti-inflammatory drugs. Available from: http://bestpractice.bmj.com/best-practice/evidence/background/1115.html [Accessed 1st September 2016].

8. Van den Bekerom, M. P. ., Struijs, P. A. ., Blankevoort, L., Welling, L., van Dijk, C. N., & Kerkhoffs, G. M. M. . (2012). What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? Journal of Athletic Training, 47(4), 435–443 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396304/pdf/i1062-6050-47-4-435.pdf [Accessed 4th October 2016]

9. Stiell, I. (1996). Ottawa ankle rules. Canadian Family Physician, 42, 478–480.

10. Clark, K.D. & Tanner, S. (2003) Evaluation of the Ottawa ankle rules in children. Pediatr Emerg Care. 19.2. 73-8

11. Libetta, C., Burke, D., Brennan, P., & Yassa, J. (1999). Validation of the Ottawa ankle rules in children. Journal of Accident & Emergency Medicine, 16(5), 342–344

 

12. Dissmann, P. D., & Han, K. H. (2006). The tuning fork test—a useful tool for improving specificity in “Ottawa positive” patients after ankle inversion injury. Emergency Medicine Journal - EMJ, 23(10), 788–790.

13. Bleakley, C.M., Glasgow, P., MacAuley, D. (2012) PRICE needs updating, should we call the POLICE? Br J Sports Med 46:220–21 Available from: http://bjsm.bmj.com/content/46/4/220.full.pdf [Accessed 4th October 2016].

14. Van den Bekerom, M.P., Sjer, A., Somford, M.P., Bulstra, G.H., Struijs, P.A.A., Kerkhoffs, G.M.M.J. (2014) Non-steroidal anti-inflammatory drugs (NSAIDs) for treating acute ankle sprains in adults: benefits outweigh adverse events. Knee Surg Sports Traumatol Arthrosc  23: 2390

15. Janssen, K.W., Hendriks, M.R.C., Mechelen, W. van, Verhagen, E., (2014) The Cost-Effectiveness of Measures to Prevent Recurrent Ankle Sprains Results of a 3-Arm Randomized Controlled Trial. Am J Sports Med 42, 1534–1541. Available from: http://ajs.sagepub.com/content/42/7/1534.full.pdf+html [Accessed 6th September 2016]

16. Hupperets, M.D.W., Verhagen, E.A.L.M., Mechelen, W. van, (2009). Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ 339, b2684.

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