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Optimizing Outcomes & Reducing Costs for Ankle Sprains: New Evidence on the Impact of Delayed Care (PHYSICIAN UPDATE: March 2022)

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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE March 2022 Optimizing Outcomes & Reducing Costs for Ankle Sprains: New Evidence on the Impact of Delayed Care by Karen Napierala MS, AT, PT, CAFS CURRENT EVIDENCE Rhon DI, Fraser JJ. et al.“Delayed Rehabilitation Is Associated With Recurrence and Higher Medical Care use After Ankle Sprain Injuries in the United States Military Health System. JOSPT, 51(12), 2021 2021;619-627. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Clinical Scenario...What would you do? A 24 year old male comes into your office after a 2nd time ankle inversion MOI with local swelling and pain. Non weight bearing AROM inversion and plantarflexion are limited/painful and dorsiflexion is significantly limited. His gait is antalgic with considerable favoring. Plain radiographs are (-) for fracture. Anterior Drawer test is mild Grade iI laxity. The patient is eager to return to activity as soon as possible, including work on the 2nd floor office building with a mix of sitting/walking/stairs, resuming fitness running and singles tennis league, and has three children aged 3 months to 5 years . I would prescribe… RICE and gradual activity return as able - call if problems. Rest in boot x 1-2 weeks + RICE and then go back to activity gradually - call if problems. PT with Class IV laser, early motion/proprioception work and wb progression activity. FU 4 wks if needed. Crutches PWB until gait normalized, simple HEP exercise sheet of generic ankle exercises, return to activity as symptoms allow. FU in office 6 weeks. SUMMARY: A retrospective cohort study of US MIlitary Health System beneficiaries (active duty/retired, family, etc) seeking care for an ankle sprain between 2010-2012 using only data available with both 12mo look-back and 12mo follow up data, resulting in 24,502 cases. Cases were grouped into receiving rehabilitation and no rehabilitation. Using medical and financial billing records, the effects of timing of rehabilitation on injury recurrence and injury-related medical care costs and visits were measured up to one year after injury. Approximately 1 in 4 people received rehabilitation. The probability of a recurrent ankle sprain increased for each day that rehabilitation wasn’t provided during the first week and plateaued for the next 2 months, becoming 2x (OR = 1.97) greater for those receiving PT at 8-12 weeks vs those starting rehab within 4 weeks. The total cost were also greater (OR = 1.13) for those delaying rehab vs early rehab, up to $1400 per episode. Overall recurrence and costs were less for those not obtaining rehabilitation, however, likely contributing factors such as severity and activity goals were not studied, among others. Data did include stratification considering other military duty related and medical comorbidity effects on recurrence and costs. The conclusion was that the earlier the musculoskeletal rehabilitation care started directly after the ankle sprain occurs the lower the chance of recurrence, as well as the downstream ankle-related medical costs. Early care is also important based on the other studies showing over 33% of ankle sprains go on to become chronically unstable. We believe not only early care is necessary but high quality care that includes discerning biomechanical assessment and customized manual therapy/exercise. There are many potential contributing factors for ankle sprain recurrence that are also related to optimizing recovery from a current episode that are not necessarily part of traditional therapy approaches. Our anecdotal experience supports research showing progression to CAI in what seems to be a significant number of patients who themselves and/or their providers viewed an early ankle sprain in a “routine” or sometimes dismissive way. Many factors related to faster/better recovery and prevention of recurrence are controllable. Background: In the US military, 329,702 enlisted members and 30,554 family members received care for ankle sprains over a 9 year time frame from 2006-2015. Many studies show that after two weeks the pain has retracted. Studies have shown 5-33% of ankle sprains have some pain after one year and that 15-54 % didn't recover after 3 years. Recurrence may happen up to 8 years after the initial injury. Over 33% of these sprains have been shown to become chronic ankle Instabilities (CAI) cases. College students with CAI averaged 2100 less steps per day. Total financial burden (adjusted for inflation) of ankle sprains can range from $11.7M to $90.0M per year. Early treatment for other musculoskeletal disorders has been proven effective. The authors studied time to begin rehabilitation on ankle sprain recurrence or future use of medical care for that ankle. Methods: This retrospective cohort study includes all beneficiaries (all active and retired military members, their families and other affiliated beneficiaries) of the US military Health System seeking care for an ankle sprain over a two year period from 2010-2012(with 12mo look-back 2009 to look-forward 2012 range limits). The 39,340 total cases resulted in 24,502 individuals diagnosed with an ankle sprain injury having a full 12-month look-back and follow up. Groups were divided into those with and without rehabilitation following an ankle injury which they sought formal care. Rehabilitation was identified by cases with medical encounters that included medical billing codes for therapeutic exercise, therapeutic activities, manual therapy, and modalities. Not all rehabilitation was from a physical therapist. There was a sub group for direct military clinic care, or civilian network clinic setting since the costs would be different. Considerations were given for comorbidities including: cardiometabolic factors, chronic pain dx, insomnia, depression, anxiety, concussion/ traumatic brain injury and PTSD. Findings: There were 6150 individuals who sought care for ankle sprains and received rehabilitation and 16,325 who did not have rehabilitation (27.4% who sought care received rehab and 72.6% who sought care did not)! Delayed rehabilitation was linearly associated with increasing probability of recurrence (after adjusting for comorbidities.) The probability of recurrence in the rehab groups increased each day during the first week post injury that treatment was not sought. It then plateaued until the first month, then increased again the second/ third months. Individuals who received physical rehab between 8 and 12 weeks had 1.97 greater odds of recurrence compared to those who received immediate physical rehab within 4 weeks. Delayed rehabilitation was linearly associated with a greater number of ankle-related medical visits.Of all the comorbidities, a chronic pain related diagnosis amplified the amount of visits they were seen in a medical office (by at least 10 visits). This translated to $292 to $2268 per cse for ankle sprains with delayed rehabilitation. Individuals in the non rehab group were 32% less likely to resprain. They hypothesized that these people chose far less risky activities and were much less active following the first sprain. (especially when they had chronic pain, or PTSD). Author's Conclusion: There is a greater chance of ankle sprain recurrence, chronic ankle issues, and increased cost to the system and individuals when rehabilitation for the sprain is delayed. THE PEAK PERFORMANCE PERSPECTIVE: Ankle sprains are one of the most common musculoskeletal injuries that occur. These injuries are seen in primary care, orthopedic, and podiatric physician office regularly. Not only patients but also providers all run the risk of thinking, “It's only an ankle sprain - rest it and go back in a week” …but is that the best option now and in the long run for our patients? For perspective, there are a few key facts to be aware of. Ankle sprains were the primary reason for lost (military) duty days in 2017 - 2018. Recurrence may happen for up to 8 years after the initial injury. Chronic ankle instability occurs in up to 40% of individuals with that first time lateral ankle sprain. The financial burden to the military is 11.7M to 90.9M per year! Military ankle sprain numbers have been shown to be similar to the active civilian population in their response to this injury. This study shows that what we do with them not only affects the patient's lifestyle in the future, but both their own financial costs and the total cost on the insurance system. So how do we as physicians and therapists make our decisions on how to treat? I am seeing a 50 year old male now who has had low back and L knee pain for years. During the initial history he reported the L ankle was sprained repeatedly in high school - with only a “walk it off “ rehabilitation that was popular then. He never regained his normal ankle dorsiflexion, and was left with a host of issues including inability to squat appropriately on his L leg due to that lack of dorsiflexion. His compensation happened to be extreme pronation during squatting. This led to decreased balance, subsequent increases of tibial and femoral internal rotation during WB activity that produced a “dynamic valgus” collapsing of his knee,( resultant patello-femoral pain, and quad weakness) his hip(glut medius weakness and poor pelvic control), and eventually affected his back. If the ankle was treated appropriately initially, 30 years of knee and hip abnormal mechanics may have been prevented. There are internal and external contributors to the ankle sprains. You can get yourself faster, more nimble and able to avoid these, External factors such as a tree root , rocks, uneven surfaces, or another player's ankle all can cause excess motion and sometimes means, no matter how perfect your anatomy is or how well trained your balance and agility and strength may be, you're probably going to sprain that ankle. Internal factors (biomechanics) are really the key place that changes can be made to reduce risk and optimize recovery. Good therapy should include looking at the biomechanics and functional patterns of the entire lower extremity. What is the cause for the injury? Have they returned to full ROM without aberrant planes of motion compensating for the lack of normal motion? Is there poor mobility that can cause the ankle to more frequently “live” near that injury risk position? Here are some key things we’d screen for (outside the typical ankle ROM, strength, etc) : Lack of dorsiflexion in subtalar neutral (needed for late gait phase mechanics). Without proper ankle sagittal plane motion, the ankle will choose to compensate into other planes (such as transverse, or frontal in abnormal amounts) or in the sagittal plane via early heel rise, reducing the area of contact for inherent stability. The ability for the ankle to help dissipate forces with jumping, running, and and cutting relies on all three levels (hip, knee, and ankle) to adjust the speed of deceleration when gravity is accelerating you towards the ground. Foot alignment/structure. An uncompensated rearfoot varus(stiffly inverted NWB and WB) or a compensated forefoot valgus (supinated foot with higher arch - including inversion tendency) - both especially concerning since 94% were lateral or inversion sprains. Limited Calcaneal eversion. The subtalar joint’s ability to “load” into eversion/pronation upon hitting the ground in walking or other movements/athletics allows you adaptation to uneven surfaces. Frequently we see ankle sprain patients unable to evert in general, meaning they are living that much closer to inversion (ie risk). Hip retroversion and/or cocca valga will also set an individual up for the foot to be an inverted position and can predispose an individual to ankle sprains A pronated foot oddly enough may also predispose someone to ankle sprains. A prolonged everted position may negatively impact the proprioceptive awareness of excessive inversion and also be less reactive at the peroneals due to the delayed stretch reflex. We’ve seen numbers of these in the clinic where patients or providers first expected the patient to describe a deltoid or eversion MOI sprain but instead they did experience an uncontrolled inversion episode. Prior concussions or balance issues lead individuals to be less apt to adapt to quick changes of direction, or the surface you are moving on. Proprioception - generic and inversion control specific. Oftentimes balance testing identifies a more general lacking of neurologic sensorimotor mechanoreceptor system function such as with eyes closed or dominant eye closed with head up mini squats, but the ability also to specifically control for frontal and transverse plane loading into inversion/supination must be determined. Left untreated these sprains can bring on secondary issues. The example of the 50 year old with a 30 year old ankle sprain is far from out of the ordinary. Studies show that many ankle sprains “feel “ better in 2 weeks. Once they feel better there is a tendency and risk as a clinician and certainly as the patient to think that they “are” better. But we look at the “being better” as an objective, measurable thing rather than simply a feeling the patient has. We want them to have enough motion to be able to handle the unexpected, or live out their dreams, not just be able to walk on a flat surface for 20 minutes. College students left untreated with subsequent ankle issues were found to walk 2100 steps fewer than their intact ankle cohorts. It’s key that good therapy help take them from “feeling better” to “being better”. That requires simply starting with physical therapy early, as Rhon et al found. The next key is that quality care will include actually looking for the biomechanical issues that predispose them to “living in a box” of safety and limitation. Especially for athletes and for active lifestylers the goal must be instead be to help them be capable of performing “outside the box” of safety and of constrained motions and loading where risks are always kept low, so they can return confidently to the activities they love but do so with less risk of recurrence. The following case exemplifies the benefits of early rehab following an ankle sprain. THE PEAK PERFORMANCE EXPERIENCE: Terry said: “ I am playing volleyball on a high level with minimal to no issues. I can jump and land indoors. The stiffness I had in my ankles is gone!” History: Terry was a high school volleyball middle hitter. She had to jump high, and land hard. If the set and/or her approach was off then she’d have to tolerate landing off balance on one leg, risking inversion forces. She injured her ankle during volleyball when she landed on an opponent’s foot, causing a rapid inversion - she heard a “pop” and immediately had difficulty walking and could not play. Plain films were (-). She used crutches for a week. PT began three days after the incident. Objective: Pain limited R squat to 50 plantarflexed (ie no dorsiflexion on the R). Symptoms were localized to the anterior talofibular ligament and the peroneal tendon below the lateral malleolus. (*=pain) Initial Eval Re-Eval STJn WB Dorsiflexion -5 R/ 21 L 19 R / 21 L Single leg squat knee angle Unable to do / L 55 R 65 / L 70 Calf raise 2 R/ 24 L 28 R/ 30 L 3” quad dom step down (eccentric ) Unable * 10 # front racked R/ 22 L / 24 Single leg hop 10 sec R/unable L/ 14 B 15 16 reps Lateral lunge Unable * 15# low reach R 19x L 21x Single leg balance rotation 15 sec Unable R 6x L 8x Med/lat 3 step directional change 15 sec 8 feet distance unable* 10 reps Key Findings: Treatment: Terry began ROM in PT 3 days post injury. She received manual grade 1-2 mobilization in pain free ROM. She began AROM and dorsiflexion with strap assist. She followed with 3 dimensional WB soleus/ gastroc stretches in available pain free ROM. She was able to do Partial WB calf raise that week, as well as proprioceptive balance training static, and dynamically progressed to full WB Eyes closed within a week. She started regaining strength within a week and began uneven surface/ BAPS, and stepping soon after that. We used Rock tape to ease the swelling and provide stability as she progressed. After 2 weeks: She was able to join in practice limited to serve receive and serving. She practiced swing skills standing at the net. Outcome: By 4 weeks she had been doing enough agility/ strength and proprioception that she went back to playing with an ankle brace on and no limitations You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

April 1, 2022
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