Bread and Butter

Bread, butter……and food for thought!

Fall sports in the USA  — sometimes in my clinics at this time of year I feel like I am swamped in concussions.  There will be stretches in a morning that I go from room to room, each one a different variant of this all-too-common injury.

But overall, in truth, the bulk of my patient encounters this time of year are of the musculoskeletal (MSK) variety.  It may not ‘feel’ that way, but when my hospital ‘numbers gal’ crunches the data, we’re still running at > 50 % MSK for patient visits.

And ankle sprains are definitely in that mix.

Ankle injuries, like knee injuries, concussions, and fractures, are part of the ‘bread and butter’ of my practice at the Division of Sports Medicine at Nationwide Children’s Hospital (NCH).  And one of the things I love about the Clinical Journal of Sport Medicine are the multiple original research articles the journal publishes that give me insight into the management of these common injuries.

I recently wrote a blog post about the four original research articles focused on concussion in our just-published September 2016 issue.  In this current post, I want to draw your attention to some more original research being published ‘ahead of print’: “Current Trends in the Management of Lateral Ankle Sprains in the United States.”

I found this to be a very interesting read using a “Big Data” approach to look at how this common injury, lateral ankle sprain (LAS), is managed in the USA.  The authors queried a database of national health insurance records for 2007 to 2011 and identified 825,718 patients with the diagnosis of LAS.  After applying select exclusion criteria (e.g. those with associated fractures,), they analyzed 725,927 isolated patients with LAS.

The authors found that 36% of all LAS occurred in patients < 20 years old (my patient mix at NCH), and that the number of patients with LAS decreased ‘exponentially’ with age (the 60+ crowd represented < 5% of the total).  Some of the more notable findings:  fully 2/3 (67.8%) received radiographs, and for treatment — 9% received a brace, and only 6.8% received physical therapy (PT) within 30 days of their diagnosis.

Ankle bracing was looked at in the study, but not taping.

I think these two findings in particular should challenge us as clinicians.

First, though we cannot know in detail what the physical examination status was for the 700K LAS patients at time of initial evaluation, it strains credulity, I think, to consider that 67.8% of them met Ottawa Ankle Rules criteria.  Talk about a knowledge translation gap!  I believe the rules have been around for a good 20+ years [I did a Google scholar search on that, anyone is welcome to comment on this and let me know what they consider to be the first, the ‘Ur’ reference for the rules].  The rules have a very high sensitivity (approaching 100%).  Does anyone remember the mnemonic SnOUT? [ SnOUT = a negative finding in a highly sensitive test rules ‘out’ the problem].  I think this result reinforces for me what I need to be thinking about in my evaluations of LAS on the sideline and in the training room — apply those rules, and I’ll surely minimize my use of radiographs, saving cost and radiation exposure.

Second, the authors make a great case for the residual functional deficits that can linger for some time after a LAS. They specifically mention the evidence “…that patients with LAS are less physically active throughout their lifetime and (have) decreased health-related quality of life.”  LAS are not the benign injury we may always think them to be, and it is arguable they need some form of rehab.  I would note, again, that we cannot know in detail what access these patients had to PT, but to think that less than 7% received PT within the first month of injury……

In my own clinics, we often prescribe home rehab, and do a brief tutorial and give a handout to patients with LAS; we also prescribe PT to many.  I am not so sure how compliant my patients are with their home rehab, and I know that I get a lot of ‘no-shows’ for my prescribed PT.  Perhaps if I ‘put the hammer down’ a bit as a clinician–emphasized a bit more of the consequences of a poorly rehabbed LAS–I might get more patient ‘buy in’ to the concept of the necessity for PT/rehab to achieve a fully recovery.

LAS — bread and butter injuries, no doubt.  And this new research article — food for thought, indeed.