We thank Dr. Zhang Jun for underlining the clinical importance of our level I evidence. He notes existing controversies regarding the optimal treatment for the management of ankle sprains, particularly around basic components of the initial phase of management using PRICE (protection, rest, ice, compression, and elevation) and the use of immobilization. Our trial population was confined to those with grades I and II sprains for whom there is evidence that rigid immobilization with casts or bracing is not indicated.1 Those provided rigid casts or braces were not enrolled as trial participants. We did permit protection with the short term use of walking aids and elastic wraps and the later use of functional taping, as required. The progression from rest through full activity was based on a participant’s progression through the four stages of recovery as per Figure 1 in our paper and is supported by level A evidence.2,3 Use of crutches or a cane, when required, was recommended for 2-4 days only. Use of ice water application was recommended for 15 minutes every 2-4 hours for the first 2 days post-injury. Elevation was recommended to address swelling in the first 2-4 days.
This reader also asked our opinion improving recovery over that seen in our participants. Our paper does report a lower than expected rate of excellent recovery with the standardized course of physiotherapy provided, a course we believe is similar to that provided to most referred for this injury. We do not provide direction on how to improve on the rate of recovery we report, as doing so would be speculative. We assessed “excellent recovery” using a threshold score of 450/500 on the Foot and Ankle Outcome Score (FAOS), as dictated by our protocol. Future research might relate a range of FAOS scores to objective recovery to determine whether the threshold used is too high. In our conclusion we also recognize that there is potential for future work to examine physiotherapy interventions that use different strategies or levels of intensity than provided to our participants. These too would need to be evaluated with the rigour of a clinical trial.
Dr. Zhang Jun also asked of our experience with diagnostic imaging. Our institutions apply the Ottawa Ankle Rules4 in making decisions on the need for a radiograph series of the foot and ankle. In our trial, radiographs were obtained in 84% of cases. This rate is somewhat higher than the approximate 2/3rds rate reported by the developers of the ankle rules. Of note, we recruited one in three eligible patients presenting with an ankle sprain and it is likely that those interested in participating were those with more significant signs of injury.
1. Kerkhoffs GMMJ, Rowe BH, Assendelft WJJ, Kelly KD, Struijs PAA, van Dijk CN. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002(3):CD003762. doi: 10.1002/14651858.CD003762.
2. Kaminshi TW, Hertel J, Amendola N, et al. National Athletic Trainers’ Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Training 2013;48:528-545.
3. Lin CW, Hiller CE, deBie RA. Evidence-based treatment for ankle injuries: A clinical perspective. J Man Manip Ther. 2010; doi: 10.1179/106698110X12595770849524.
4. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. JAMA 1993;269:1127-32.
Competing interests:
No competing interests
01 February 2017
Robert J Brison
MD
Dr. Lucie Pelland, Dr. Brenda Brouwer
Queen's University @ Kingston, Canada
76 Stuart Street, Kingston General Hospital, Kingston, ON. Canada. K7L 2V7
Rapid Response:
Response to Dr. Zhang Jun
We thank Dr. Zhang Jun for underlining the clinical importance of our level I evidence. He notes existing controversies regarding the optimal treatment for the management of ankle sprains, particularly around basic components of the initial phase of management using PRICE (protection, rest, ice, compression, and elevation) and the use of immobilization. Our trial population was confined to those with grades I and II sprains for whom there is evidence that rigid immobilization with casts or bracing is not indicated.1 Those provided rigid casts or braces were not enrolled as trial participants. We did permit protection with the short term use of walking aids and elastic wraps and the later use of functional taping, as required. The progression from rest through full activity was based on a participant’s progression through the four stages of recovery as per Figure 1 in our paper and is supported by level A evidence.2,3 Use of crutches or a cane, when required, was recommended for 2-4 days only. Use of ice water application was recommended for 15 minutes every 2-4 hours for the first 2 days post-injury. Elevation was recommended to address swelling in the first 2-4 days.
This reader also asked our opinion improving recovery over that seen in our participants. Our paper does report a lower than expected rate of excellent recovery with the standardized course of physiotherapy provided, a course we believe is similar to that provided to most referred for this injury. We do not provide direction on how to improve on the rate of recovery we report, as doing so would be speculative. We assessed “excellent recovery” using a threshold score of 450/500 on the Foot and Ankle Outcome Score (FAOS), as dictated by our protocol. Future research might relate a range of FAOS scores to objective recovery to determine whether the threshold used is too high. In our conclusion we also recognize that there is potential for future work to examine physiotherapy interventions that use different strategies or levels of intensity than provided to our participants. These too would need to be evaluated with the rigour of a clinical trial.
Dr. Zhang Jun also asked of our experience with diagnostic imaging. Our institutions apply the Ottawa Ankle Rules4 in making decisions on the need for a radiograph series of the foot and ankle. In our trial, radiographs were obtained in 84% of cases. This rate is somewhat higher than the approximate 2/3rds rate reported by the developers of the ankle rules. Of note, we recruited one in three eligible patients presenting with an ankle sprain and it is likely that those interested in participating were those with more significant signs of injury.
1. Kerkhoffs GMMJ, Rowe BH, Assendelft WJJ, Kelly KD, Struijs PAA, van Dijk CN. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002(3):CD003762. doi: 10.1002/14651858.CD003762.
2. Kaminshi TW, Hertel J, Amendola N, et al. National Athletic Trainers’ Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Training 2013;48:528-545.
3. Lin CW, Hiller CE, deBie RA. Evidence-based treatment for ankle injuries: A clinical perspective. J Man Manip Ther. 2010; doi: 10.1179/106698110X12595770849524.
4. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. JAMA 1993;269:1127-32.
Competing interests: No competing interests