Abstract
To assess the impact of rehabilitation on healing and recurrence rate of ankle sprain, 1 year apart, 111 patients, who suffered an ankle sprain (67 men and 44 women; 17 mild sprains, 67 medium and 27 severe), were included by emergency physicians of four emergency rooms (ER) of Finistère. The physician was free to prescribe, or not, further investigations. He prescribed systematically to patients RICE (rest, ice, compression, elevation) protocol, put an ankle brace, and gave a prescription of standardized rehabilitation. The prescription was the same for the four ER. All patients were recalled to 1 year. Of the 111 patients initially included, 21 patients were excluded for lack of response after three phone calls. In the end, 90 patients were assessable (56 men and 34 women), mean age 31.4 ± 12.6 years (range 15–55) at the time of initial trauma. Emergency physicians had diagnosed, initially, 16 mild sprains (17.8%), 56 medium sprains (62.2%) and 18 severe sprains (20%). Of the 90 patients, 73 patients have been rehabilitated (81.1%). Of the 44 accidents of everyday life, 31 were rehabilitated (70.5%). Of the 27 sports accidents, 25 were rehabilitated (92.6%). Of the 19 work-related injuries, 17 were rehabilitated (89.5%). There is no significant relationship between rehabilitation and no recurrence ( P = 0.45) nor between rehabilitation and full recovery of the ankle ( P = 0.59). Conclusion: We find no association between rehabilitation and prevention of recurrence, nor between rehabilitation and healing of patients. However, our study is limited by the small size of the non-rehabilitated group.
Résumé
Pour évaluer l’impact de la rééducation sur la guérison et le taux de récidive d’entorse de cheville, à un an, 111 patients, victimes d’une entorse de cheville, (67 hommes et 44 femmes ; 17 entorses bénignes, 67 moyennes et 27 graves), ont été inclus par les médecins urgentistes de quatre services d’accueil–urgences (SAU) du Finistère. Le médecin était libre de prescrire ou pas des examens complémentaires. Il prescrivait systématiquement au patient le protocole RICE ( rest, ice, compression, elevation ), posait une attelle semi-rigide et remettait une ordonnance de rééducation standardisée. Cette prescription était la même pour les quatre SAU. Tous les patients inclus ont été rappelés à un an. Sur les 111 patients inclus, 21 patients ont été exclus faute de réponse après trois appels téléphoniques. Au final, 90 patients ont été évaluables (56 hommes et 34 femmes) âgés en moyenne de 31,4 ans ± 12,6 ans (extrêmes de 15 à 55 ans) au moment du traumatisme initial. Les médecins urgentistes avaient diagnostiqué, initialement, 16 entorses bénignes (17,8 %), 56 entorses moyennes (62,2 %) et 18 entorses graves (20,0 %). Sur les 90 patients, 73 patients ont fait leur rééducation (81,1 %). Sur les 44 accidents de la vie quotidienne, 31 ont été rééduqués (70,5 %). Sur les 27 accidents sportifs, 25 ont été rééduqués (92,6 %). Sur les 19 accidents de travail, 17 ont été rééduqués (89,5 %). Il n’y a pas de lien significatif entre la rééducation et l’absence de récidive ( p = 0,45), ni entre la rééducation et la guérison complète de la cheville ( p = 0,59). Conclusion : Nous ne trouvons pas d’association entre la rééducation et la prévention des récidives, ni entre la rééducation et la guérison des patients. Toutefois, notre étude est limitée par la faible importance de l’effectif de la population non rééduquée.
1
English version
Because of its frequency and its cost, ankle sprain represents a real public health problem. It is the most frequent reason for consultation in current trauma, in emergency departments as well as in private practice. Its daily incidence is evaluated at one per 10,000 , with an annual incidence peak, between 15 and 19 years, of 7.2 per 1,000 . It represents 25% of the sports accidents . With 6,000 sprains a day in France, the daily cost can be evaluated at approximately 1.2 million Euros, although a real estimation does not exist in our country . In a study performed in the United States, the cost of this pathology was evaluated at 3.65 billion dollars for the year 2003 . In the Netherlands, the cost is evaluated at 360 Euros per sprain . Actually, the real cost of these sprains is difficult to assess, since the expense items are numerous and different: if it is easier to assess the expenses generated by the treatment of acute sprain (consultations, imaging, medical, functional, or even surgical treatment, as well as sick leave following the accident), it is more difficult to assess the cost related to sequelae of these sprains (5 to 40% according to the studies), either in sportspersons or in the general population . These sequelae may generate new medical (analgesic treatment) or surgical (potential intervention) expenses, rehabilitation and socio-professional costs (extended sick leave, or even disablement); they may also entail a recurrence of the sprain with its related expenses. A better knowledge of mean-term evolution, 1 year, of ankle sprains is therefore important. Since the consensus conference in emergency medicine of 1995 (updated in 2004), functional treatment is privileged, following the application of the RICE (rest, ice, compression, elevation) protocol . This functional treatment is superior to plastered immobilization and to surgery regarding work and sports resumption . It includes immobilization, preferentially using a semi-rigid brace, and rehabilitation . In a previous study conducted in 2009 , we showed that the observance of rehabilitation by the patients suffering from ankle sprain was excellent, which was not the case for other pathologies . In this work, the emergency physicians of the four emergency units in Finistère, France, had included patients with ankle sprain. The only exclusion criterion was the occurrence of a previous sprain on the same ankle during the last 12 months. For each patient, the emergency physician completed an inclusion form with the patient’s demographic data, the cause of the trauma (sports accident, work-related accident, daily-life accident) and the severity degree of this sprain (mild, moderate, severe). The physician was free to prescribe, or not, further examinations. Then the physician prescribed the RICE protocol, placed a semi-rigid brace on the ankle, and gave the patient a standardized rehabilitation prescription ( Appendix 1 ). The choice of the physiotherapist was free. All included patients were called back by phone between day 60 and day 90, by a unique physician who was not involved in the inclusions, in order to answer a questionnaire on brace wearing, rehabilitation treatment, and level of healing. This study demonstrated an excellent observance for rehabilitation by the patients suffering from ankle sprain (92 patients, i.e. 82.9%, had done their rehabilitation having started 13.8 days after the accident), good observance by the private physiotherapists for respecting the medical prescription, but absence of significant correlation between rehabilitation, in general, and healing of this ankle sprain within the 60 to 90 days post-injury. In view of the major risk of recurrence within the 12 months following the trauma , it was necessary to perform a new study on the follow-up at 1 year of our population.
The objective of this new work is therefore two-fold:
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to assess the impact of rehabilitation, at 1 year, on the “healing” of the patient;
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to assess the impact of rehabilitation, at 1 year, on the recurrence rate of sprain.
1.1
Material and methods
1.1.1
Population
One hundred and eleven patients (67 males and 44 females; 17 mild, 67 moderate, and 27 severe sprains), whose characteristics have been published in a first work were included by the emergency physicians of four emergency units in Finistère, France. The physician was free to prescribe, or not, further examinations. The RICE protocol was systematically prescribed to the patient, a semi-rigid brace (Aircast ® ) placed, and a standardized rehabilitation prescription given to the patient. This prescription was identical in the four emergency units. All included patients who had been called by phone between day 60 and day 90 for a first study were called back at 1 year.
1.1.2
Methods
1.1.2.1
Phone survey
The patients were contacted by phone 1 year following the initial trauma, by one and only physician who was not involved in the first study, in order to know:
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through an adapted Foot and Ankle Outcome Score (FAOS) questionnaire, the level of recovery in comparison with pre-trauma status;
- •
whether a sprain recurrence had occurred in this ankle.
Patients were excluded from the study in case of no answer after three phone calls.
1.1.2.2
Modified FAOS
The FAOS is a score validated for arthrosis and other pathologies of the ankle . The FAOS explores the ankles according to five items:
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symptoms (seven questions);
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pain (nine questions);
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capacities for daily life activities (17 questions);
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capacities for sports activities (five questions);
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quality of life (four questions).
The patient chooses between five adjectives to qualify a characteristic of the injured ankle (for example, for pain: non/minimal/moderate/severe/extreme). These adjectives are graded from 0 to 4, allowing each item to be given a score out of 100, 100 being the equivalent of a normal ankle. So far the existing versions of the FAOS were available in English, German, Turkish, Iranian, Swedish and Portuguese. We first translated it in French, and then we modified it on three points:
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numerical scale: we preferred a numerical scale for the answers to questions 0 to 10 (0 = absence of signal; 10 = signal permanently present). We considered this scale to be better adapted to the oral understanding of the questionnaire by the patient;
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number of questions: we have limited to five the number of questions of the item capacities for daily life activities, as we felt some of them to be redundant;
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additional question: we asked the patients to assess their level of sequelae on a scale graded 0 to 10 (0 = no sequelae).
The phoned questionnaire ( Appendix 2 ) required nine to 14 minutes according to the patients. The scores were then entered on a spreadsheet, allowing calculation of the score for each item as well as the FAOS calculation for each patient.
1.1.3
Statistical analyses
The data were entered using SPSS (17.0, Chicago, IL). The statistical tests used were the Chi 2 or the Fisher’s exact test when needed for the discrete variables, and the Mann and Whitney test for the continuous variables. The P < 0.05 values were considered as significant.
1.2
Results
1.2.1
Population
Of the 111 patients included in the first study, 21 were excluded for lack of answer after three phone calls. Finally, 90 patients were included, an answer rate of 81.0% compared to the first study: 56 males (62.2%) and 34 females (37.7%), of a mean age of 31.4 ± 12.6 years (range 15–55) at the time of initial injury. Ankle trauma was caused by an accident of daily life in 44 (44.9%) patients (seven severe sprains, 29 moderate, and eight mild), a sports accident in 27 (30.0%) patients (eight severe sprains, 15 moderate, and four mild), and by a work-related accident in 19 (21.1%) patients (three severe sprains, 12 moderate, and four mild). A total of 16 mild sprains (17.8%), 56 moderate sprains (62.2%) and 18 severe sprains (20%) was initially diagnosed by the emergency physicians.
1.2.2
Rehabilitation
1.2.2.1
Patient’s observance
Of the 90 patients finally included, 73 patients had rehabilitation done (81.1%) versus 17 (18.9%) who did not go to a physiotherapist. Of the 44 daily life accidents, 31 had rehabilitation (70.5%). Of the 27 sports accidents, 25 had rehabilitation (92.6%). Of the 19 work-related accidents, 17 had rehabilitation (89.5%).
1.2.2.2
Impact of rehabilitation on healing and recurrence of ankle sprains
Of the 73 patients who had rehabilitation, 36 (49.3%) patients consider their recovery to be total (FAOS at 100), 29 (39.7%) have sequelae, 6 (8.2%) had a sprain recurrence, 1 (1.4%) presented a bimalleolar fracture and 1 patient had ankle surgery because of persistent pain ( Tables 1 and 2 ).
| Rehabilitation | No rehabilitation | Total | P | Significant | |
|---|---|---|---|---|---|
| Healed | 36 | 8 | 44 | 0.589 | No |
| Sequelae | 29 | 6 | 35 | 0.789 | No |
| Fracture | 1 | 1 | 2 | a | b |
| Recurrence | 6 | 2 | 8 | 0.454 | No |
| Surgery | 1 | 0 | 1 | a | b |
| Total | 73 | 17 | 90 | ||
a Non calculated, sample size too small.
| Sprain | Healing | Sequelae or complications | Total |
|---|---|---|---|
| Mild | 7 | 9 | 16 |
| Moderate | 30 | 25 | 55 |
| Severe | 7 | 12 | 19 |
| Total | 44 | 46 | 90 |
Of the 17 patients without rehabilitation, eight (47%) considered they are completely healed, six (35.3%) patients have sequelae, two (11.8%) had a sprain recurrence, and one (5.9%) a bimalleolar fracture.
There is no significant link ( Table 1 ) between:
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rehabilitation and absence of recurrence ( P = 0.454);
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rehabilitation and complete healing of the ankle ( P = 0.589).
The mean delay before start of rehabilitation is of 11.29 days in the patients without recurrence, and of 25 days in the patients presenting with a recurrence ( P = 0.067). If a difference of delay can be noted between the two populations, this difference is however not significant.
Of the 44 healed patients, seven had initially a mild sprain, 30 a moderate sprain, and seven had a severe sprain.
Of the 46 non-healed patients, 35 have sequelae (29 rehabilitated and six non-rehabilitated), eight of whom initially with mild sprain, 18 with moderate sprain, and nine with severe sprain. Of the eight patients who had a sprain recurrence, five had initially a moderate sprain, and three a severe sprain. The two bimalleaolar fractures occurred on two ankles with moderate sprain. The ankle with surgery for important residual pain had a mild sprain.
Thus we note no link between the severity of the sprain and the occurrence of sequelae or complications ( Table 2 ).
1.2.2.3
Sequelae of the non-healed patients (outside recurrence, fractures and surgery).
The 35 patients with sequelae complained mainly about the impact of their sprain, for ideal scores at 100:
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on their quality of life (mean “quality of life” score: 60.24);
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on their sports activities (mean “sports capacities” score: 73.47).
The mean scores (symptoms, pain, life capacities, sports capacities, quality of life, and total FAOS) are presented in Table 3 . We find no significant link between rehabilitation and each of these scores.
| Items | Rehabilitation | No rehabilitation | P | Significant |
|---|---|---|---|---|
| Symptoms | 92.23 (± 13.02) | 88.04 (± 18.38) | 0.764 | No |
| Pain | 93.46 (± 11.31) | 89.65 (± 15.27) | 0.450 | No |
| Capacities daily life | 93.01 (± 13.47) | 92 (± 16.25) | 0.846 | No |
| Sports capacities | 87.38 (± 18.96) | 81.75 (± 23.97) | 0.471 | No |
| Quality of life | 78.94 (± 25.96) | 78.59 (± 24.97) | 0.929 | No |
| FAOS | 89.01 (± 14.95) | 86.01 (± 18.22) | 0.873 | No |
1.3
Discussion
1.3.1
Population
Of the 111 patients included in our first study , 90 patients (81%) are included in this new study, which allows, in our opinion, a good evaluation of the effects of rehabilitation at 1 year on an ankle sprain. These 90 patients, of a mean age of 31.4 years, are mainly men (62.22%). Our population differs from many studies on the ankle sprain (w34) since the daily life accidents represent 44.89% of the causes of sprain, and sports only 26.67%. The sportspersons of our region go, perhaps, less frequently to the emergency units than the general population, and may consult in other structures specialized in sports traumas. On the other hand, since our survey focused only on patients consulting in emergency units, often at day 0 of the trauma, there may be a bias in the evaluation of the severity of the sprains, as it is preferable to perform a differed examination in order to establish a diagnosis of severity.
1.3.2
Rehabilitation
1.3.2.1
Observance by the patient
We showed, in our first study , the very good observance of rehabilitation by the patient; here, 81.1% of the 90 patients consulted a physiotherapist. This difference of patient number between rehabilitated groups and non-rehabilitated groups (73 versus 17) may create a bias in our study, which is usual in cohort studies.
1.3.2.2
Modified FAOS
In our opinion, the FAOS appeared to be the most adapted to our population, reflecting the general population of Finistère, France. The validity and reliability of the test have been shown in several studies with a good inter- and intra-observer reproducibility for the chronic problems of ankles. However, a systematic review of the evaluation tools for patients with chronic instability of the ankle finds in the FAOS a floor effect and a ceiling effect (which was also found in the other tools), and considers the Foot and Ankle Disability Index (FADI) and the Functional Ankle Ability Measure (FAAM) as the most appropriate for these patients. We considered the FADI little adapted to a phoned questionnaire. As far as the FAAM is concerned, nearly a third of its questions are mainly aimed to a sportspeople population, which is not the case of ours.
Therefore it seems that no consensus score exists for the follow-up at 1 year of ankle sprains, and our FAOS modification removes the “validated” characteristics of this score. However, it enables a solid approach of the evaluation of the trauma, especially for a phoned data collection by an only investigator.
In addition to the subjective criteria according to the FAOS questionnaire, we looked into an objective criterion, which is the recurrence of ankle sprain.
1.3.2.3
Impact of rehabilitation on healing and recurrence
Rehabilitation seems essential in the treatment of ankle sprain. Treatment by rehabilitation is hence almost systematically prescribed, in France, by the physicians managing acute ankle sprain . However, in our study, we find no significant link between rehabilitation in general and the healing felt by the patient at 1 year from the initial trauma. This is in accordance with a recent literature review where no superiority is found for rehabilitation, performed by a physiotherapist on a conventional treatment (without rehabilitation prescription), be it at immediate, short, medium or long term . A randomized study by van Rijn carried out, like our own study, on a 1-year follow-up, doesn’t find either, a significant link between rehabilitation and decreased recurrence risk or between rehabilitation and the healing felt by the patient at 1 year from the initial trauma. On the contrary, a literature review of 2010 shows that rehabilitation would be beneficial to healing and to reintroduction of sports, with limited proof and studies subject to numerous biases. Our study, performed with a questionnaire, is close to that of Konradsen et al. . But the latter extends over 7 years, with a greater proportion of mild sprains (39% versus 18% in ours). In spite of all, this study shows, like ours, that there is no correlation between the severity of the sprain and the frequency of sequelae.
Our work does not show any significant link between rehabilitation and prevention of recurrence at 1 year, a link which is however found in other literature articles . If our previous study showed the interest of proprioception in the healing at 3 months of an ankle sprain, we don’t find a significant link between proprioception and prevention of recurrence in the present study, in disagreement with what can be found in literature , even if these studies focus on a sportspeople population, unlike ours, coming from the general population. Other criteria may also influence the contribution of a treatment by rehabilitation, particularly the delay between the trauma and the start of rehabilitation. In our study, the mean delay before starting rehabilitation is of 11.29 days in the patients having presented no recurrence, and of 25 days in the patients having presented a recurrence, but this difference is not significant ( P = 0.067). And yet, immediate rehabilitation seems to prompt a faster recovery of the functions of the ankle without any recurrence on a 16-week follow-up .
1.3.2.4
Patients’ evolution
Regarding the evolution of the ankle sprains at 1 year, 49% of our patients consider their ankle to be totally healed. Conversely, we find a persistence of pain in 37% of the patients, with a mean pain of about 1.85 out of 10 (minimum: 0.2; maximum: 5), a recurrence rate of 8.9% and a residual instability in 48% of our patients. These results are in accordance with all the literature recently reviewed by van Rijn ( Table 4 ).
| Our study | Literature review | |
|---|---|---|
| Pain at one year | 37% | 5 to 33% |
| Sprain recurrence rate | 8.9% at 1 year | 3 to 34% (period of 2 weeks to 8 years) |
| Instability | 48% at 1 year (47% NR; 48% R) | 0 to 33% (HQ) 7 to 53% (LQ) (period of 2 weeks to 8 years) |
| Total recovery | 49% at one year | 36 to 85% at 3 years |
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