Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial

SE Lamb , JL Marsh, JL Hutton, R Nakash , MW Cooke

Background

Severe ankle sprains are a common presentation in emergency departments in the UK. We aimed to assess the effectiveness of three different mechanical supports (Aircast brace, Bledsoe boot, or 10-day below-knee cast) compared with that of a double-layer tubular compression bandage in promoting recovery after severe ankle sprains.

Methods

We did a pragmatic, multicentre randomised trial with blinded assessment of outcome. 584 participants with severe ankle sprain were recruited between April, 2003, and July, 2005, from eight emergency departments across the UK. Participants were provided with a mechanical support within the first 3 days of attendance by a trained health-care professional, and given advice on reducing swelling and pain. Functional outcomes were measured over 9 months. The primary outcome was quality of ankle function at 3 months, measured using the Foot and Ankle Score; analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN37807450.

Results

Patients who received the below-knee cast had a more rapid recovery than those given the tubular compression bandage. We noted clinically important benefits at 3 months in quality of ankle function with the cast compared with tubular compression bandage (mean difference 9%; 95% CI 2·4—15·0), as well as in pain, symptoms, and activity. The mean difference in quality of ankle function between Aircast brace and tubular compression bandage was 8%; 95% CI 1·8—14·2, but there were little differences for pain, symptoms, and activity. Bledsoe boots offered no benefit over tubular compression bandage, which was the least effective treatment throughout the recovery period. There were no significant differences between tubular compression bandage and the other treatments at 9 months. Side-effects were rare with no discernible differences between treatments. Reported events (all treatments combined) were cellulitis (two cases), pulmonary embolus (two cases), and deep-vein thrombosis (three cases).

Interpretation

A short period of immobilisation in a below-knee cast or Aircast results in faster recovery than if the patient is only given tubular compression bandage. We recommend below-knee casts because they show the widest range of benefit.

The Lancet, Volume 373, Issue 9663, Pages 575 – 581, 14 February 2009 – abstract

doi:10.1016/S0140-6736(09)60206-3

Filed under: Injuries, Joints

Iliotibial Band Syndrome in Runners: Innovations in Treatment.

Fredericson, Michael; Wolf, Chuck

Iliotibial band syndrome (ITBS) is the most common cause of lateral knee pain in runners. It is an overuse injury that results from repetitive friction of the iliotibial band (ITB) over the lateral femoral epicondyle, with biomechanical studies demonstrating a maximal zone of impingement at approximately 30° of knee flexion. Training factors related to this injury include excessive running in the same direction on a track, greater-than-normal weekly mileage and downhill running. Studies have also demonstrated that weakness or inhibition of the lateral gluteal muscles is a causative factor in this injury. When these muscles do not fire properly throughout the support phase of the running cycle, there is a decreased ability to stabilise the pelvis and eccentrically control femoral abduction. As a result, other muscles must compensate, often leading to excessive soft tissue tightness and myofascial restrictions. Initial treatment should focus on activity modification, therapeutic modalities to decrease local inflammation, nonsteroidal anti-inflammatory medication, and in severe cases, a corticosteroid injection. Stretching exercises can be started once acute inflammation is under control. Identifying and eliminating myofascial restrictions complement the therapy programme and should precede strengthening and muscle re-education. Strengthening exercises should emphasise eccentric muscle contractions, triplanar motions and integrated movement patterns. With this comprehensive treatment approach, most patients will fully recover by 6 weeks. Interestingly, biomechanical studies have shown that faster-paced running is less likely to aggravate ITBS and faster strides are initially recommended over a slower jogging pace. Over time, gradual increases in distance and frequency are permitted. In the rare refractory case, surgery may be required. The most common procedure is releasing or lengthening the posterior aspect of the ITB at the location of peak tension over the…

Sports Medicine; 2005, Vol. 35 Issue 5, p451-459

Full text available in through MTABC member only website under the research tab and then library.

Note new information on ITB movement in ther article by Fairclough, J et al

Filed under: Knee, Review article, Running

The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome.

Fairclough, J; Hayashi, K; Toumi, H; Lyons, K et al

Iliotibial band (ITB) syndrome is a common overuse injury in runners and cyclists. It is regarded as a friction syndrome where the ITB rubs against (and ‘rolls over’) the lateral femoral epicondyle. Here, we re-evaluate the clinical anatomy of the region to challenge the view that the ITB moves antero-posteriorly over the epicondyle. Gross anatomical and microscopical studies were conducted on the distal portion of the ITB in 15 cadavers. This was complemented by magnetic resonance (MR) imaging of six asymptomatic volunteers and studies of two athletes with acute ITB syndrome. In all cadavers, the ITB was anchored to the distal femur by fibrous strands, associated with a layer of richly innervated and vascularized fat. In no cadaver, volunteer or patient was a bursa seen. The MR scans showed that the ITB was compressed against the epicondyle at 30° of knee flexion as a consequence of tibial internal rotation, but moved laterally in extension. MR signal changes in the patients with ITB syndrome were present in the region occupied by fat, deep to the ITB. The ITB is prevented from rolling over the epicondyle by its femoral anchorage and because it is a part of the fascia lata. We suggest that it creates the illusion of movement, because of changing tension in its anterior and posterior fibres during knee flexion. Thus, on anatomical grounds, ITB overuse injuries may be more likely to be associated with fat compression beneath the tract, rather than with repetitive friction as the knee flexes and extends.

Journal of Anatomy; Mar2006, Vol. 208 Issue 3, p309-316,

Full text available in through MTABC member only website  under the research tab and then library.

Filed under: Injuries, Knee