New in EM 008: Do minor ankle sprains need physiotherapy?

Originally Published on RCEM Learning Podcast June 2017

As part of the RCEM Learning Podcast I record reviews of recent literature with Dave McCreary. We’ve been doing this for about a year now and you can hear them all on the RCEM Learning Podcast each month. I’d like to have them here and searchable on this site too so I’ll be posting the ones I find most relevant here. You can hear the newest ones by subscribing to the free RCEM Learning Podcast. 

Audio:

Authors: Dave McCreary, Andy Neill

Codes: CC21,CAP 33

Clinical Question:

• Do minor ankle sprains need physiotherapy?

Title of paper:

• Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial

Journal

• British Medical Journal 2016

Author

• Robert Brison

Background

• We see lots of low grade sprains in the ED
• Clinical standards for the treatment of them arent well defined
• Physiotherapy is a great but finite resource so we need to know if they add anything to these injuries

Study type

• Parallel group RCT

Patients

• 16 years
• Simple grade I & II ankle sprain
  • Included clinically unimportant avulsion fracture (<3mm displacement)
  • Within 72 hours of injury
• Excluded: multiple injury, other condition limiting mobility, ankle injury requiring immobilisation, unable to accommodate time consuming protocol

Intervention

• Supervised program of physiotherapy plus usual care

Comparison

• Usual care
  • Written instructions for RICE, graduated weight bearing activities

Outcomes

• Primary – proportion of participants reporting excellent recovery
  • Assessed with foot and ankle outcome score (FAOS)
  • Defined as 450/500 at 3 months
  • Difference of 15% increase in absolute proportion of participants with excellent recovery deemed clinically important.
• Secondary:
  • Assessment of excellent recovery at one and six months
  • Change from baseline using continuous scores at 1, 3, 6 months
  • Clinical and biomechanical measures of ankle function at 1, 3, 6 months

Results

• 504 patients randomised
• No significant difference in excellent recovery at 3 months
  • 43% PT group vs 37% usual care
  • Absolute difference 6%, CI 3-15%
• Trend towards benefit PT did not increase in the per protocol analysis and was in opposite direction at 6 months

Bottom Line

• There is no clinically important improvement in functional recovery when providing supervised physiotherapy in addition to standard care for grade I/II sprains presenting within 72 hours of injury.
• I suppose it depends on your institution whether this is something you do anyway, but based on this Ill probably be less inclined to consider it.
• Obviously this doesnt go for the potentially higher grade sprains or the ones you cant assess for stability on initial assessment…and I suppose for professional footy players unless youre really brave…

Further Reading

• I came across this paper on the Broomedocs / first10EM Journal Club Podcast – see the written summary of all their papers here
• You can read the BMJ editorial on this paper here