Tertiary rehabilitation in acute ankle sprain caused by sports training

Abstract

BACKGROUND:

An ankle sprain is a common joint sprain in sports injury, which is closely related to its physiological position and anatomical characteristics, and may progress into chronic ankle instability after improper early treatment or premature exercise.

OBJECTIVE:

To analyze the tertiary rehabilitation effect of acute lateral ankle sprain caused by sports training.

METHOD:

Ninety-six athletes with acute lateral ankle sprain diagnosed from January 2019 to June 2020 were included and divided into the control group and the rehabilitation group using the random number table grouping method, with 48 cases in each group. The two groups received standardized treatment, and the rehabilitation group additionally received tertiary rehabilitation. The American Orthopedic Foot and Ankle Society (AOFAS ) scores, degree of ankle swelling, pain, and re-injury rate were compared between the two groups.

RESULTS:

The AOFAS scores of the two groups increased after treatment ( $P<$ 0.05). The degree of swelling in both groups after treatment was improved ( $P<$ 0.05). The Visual Analogue Scale (VAS) scores in both groups declined two weeks after treatment, with lower results observed in the rehabilitation group The two groups showed similar results of the follow-up visit ( $P<$ 0.05).

CONCLUSION:

Rehabilitation exercise on acute lateral ankle sprain effectively relieves ankle swelling and pain.

Keywords

Sports training acute lateral ankle sprain tertiary rehabilitation sports injury rehabilitation

1. Introduction

An ankle sprain is a common joint sprain in sports injury, which is closely related to its physiological position and anatomical characteristics [1, 2]. The ankle joint is a weight-bearing joint that directly touches the ground [3]. It is flexible and stable [4, 5] and integral to daily movements such as walking, running, and jumping. In ankle sprains, lateral ankle sprains caused by varus are most frequently seen [6]. Ankle sprains may progress into chronic ankle instability due to improper early treatment or premature exercise without systematic rehabilitation training [7, 8, 9]. POLICE is a commonly used treatment method after an acute ankle sprain with a promising effect, which includes Protect, Optimal loading, Ice, Compression, and Elevation. Traditional Chinese medicine adopts the concept of “combination of movement and static, equal emphasis on muscles and bones, internal and external treatment, and doctor-patient cooperation”, and uses tertiary rehabilitation to achieve remarkable results in ankle sprains [10]. This study collected the data of 96 athletes with acute lateral ankle sprain caused by sports training from January 2019 to June 2020 and discussed the effect of tertiary rehabilitation on functional recovery after an acute ankle sprain.

2. Materials and methods

2.1 Sample size analysis

In this study, it was determined prospectively that $\alpha=$ 0.05 (two-sided), $1-\beta=$ 0.9, and that the standard deviation would be 1.2 according to the two group subsets. Forty-five participants were required for each group (1:1 allocation). Therefore, a total of 96 patients were identified as research subjects and 48 patients were randomly selected to perform the rehabilitation exercises.

2.2 Randomization and blinding

In this study, the concealed allocation was conducted and all patients were randomly divided into 2 groups with Random Allocation Software (version 1.0) after the basic information assessment. In addition, a blind experiment was conducted on the subjects. The intervention sessions were delivered separately to maintain the blind experiment.

2.3 Inclusion and exclusion criteria

Inclusion criteria: (1) Patients with a clear history of lateral ankle sprain (within 3 days), resulting in ankle swelling, pain, and dysfunction of movement; (2) The degree of injury was Degree I or II confirmed by Ankle Joint MRI, with no open injury [11]; (3) Ankle fracture, fibula subluxation, or dislocation was excluded by X-ray examination; (4) Patients with no use of hormone drugs, and without a history of surgery; (5) Patients with a pain visual acuity score (Visual Analogue Scale) $>$ 0 points; (6) Patients who signed an informed consent form to cooperate with the treatment.

Exclusion criteria: (1) The ankle ligament was completely ruptured and the joint was unstable, for which surgery was required; (2) Patients with broken treatment site or skin diseases; (3) Patients with diseases of the blood system; (4) Patients with primary mental disorders and dementia; (5) Patients with other factors that were not suitable for the group.

The study was approved by the Medical Ethics Committee of Dalian Maritime University (Approval number: LC2018-168/17).

2.4 Methods

The control group received POLICE – the standardized treatment regimen, including Protect, Optimal loading, Ice, Compression, and Elevation. Ice compress was coordinated with the compression dressing and was applied twice for 10 minutes, and once for the compression dressing of the affected limb, with a 10-minute interval between each process (3 times/day). Non-steroid anti-inflammatory drugs were given when necessary.

Based on the POLICE, the rehabilitation group adopted tertiary rehabilitation including early rehabilitation (within 1 week), medium-term rehabilitation (2 $\sim$ 3 weeks), and later rehabilitation (2 weeks later).

Early rehabilitation treatment and training (within 1 week). In this stage, it is appropriate to receive treatment that promotes blood circulation, removes blood stasis, reduces swelling, and relieves pain. The ankle joint was fixed in a neutral position to relax the ligaments on both sides. Ice or cold towels were applied externally to the injured area for 15 minutes, Wu-huang powder or Jin-huang-powder ointment was applied externally, and the injured area was then bandaged. The patients took Taohong Siwu Decoction or Fuyuan Huoxue Decoction which included Medicinal Salvia, Peach Kernel, Safflower, Chuanxiong, Red Peony Root, Panax Notoginseng, Angelica, Rhubarb, Pollen, Corydalis, Bupleurum, and Turmeric. Moreover, the patients were instructed to stay in bed and were prohibited from weight-bearing activities on the injured foot, and the affected limb was elevated to help reduce swelling and pain. If the bruises were obvious, three-edged needle therapy combined with cupping therapy was used to suck out the extravasated blood. If the ligament was severely torn or avulsed, the ankle joint was fixed in a neutral position with a bandage or splint. In traditional Chinese medicine, the pain of acute ankle sprain stems from the block of Qi and meridian, which is defined as “the pain by being blocked”. Various acupuncture and moxibustion therapies can dredge the meridians and dispel blood stasis, to achieve the goal of “no block no pain”. Acupuncture was performed on the following acupoints, including Shenmai, Zhaohai, Taixi, Kunlun, Xiexi, Yanglingquan, and local Ashi. After obtaining the needle reached the appropriate depth where an apparent resistance against the needle can be sensed and the patients may have sensations such as numbness and swelling, the twisting and purging technique was then performed, with purging as the main method.

Medium-term rehabilitation treatment and training (2–3 weeks). In this stage, the treatment should center on relaxing tendons and activating collaterals, warming menstruation, and relieving pain. Hot compress or irradiation with the infrared ultrashort wave was applied to the affected area. On the basis of blood circulation promotion and swelling alleviation, muscle-relieving medicinal herbs were also appropriately added, such as Tenjingrass, Acanthopanax acanthopanacis, Tougucao, Weilingxian, Dipsacus, and Duhuo. For simple ligament contusions and partial ligament tears, manual tendon therapy was performed, which referred to non-weight-bearing activities and mild ankle flexion and extension exercises under bandaging.

Medium-term rehabilitation treatment and training (2–3 weeks). To increase the range of motion of joints, it could effectively prevent joint contracture through manipulation to relax muscles, eliminate edema, and draft joints. In the middle stage of ankle sprain, muscle strength training mainly changes from active flexion and extension of the ankle in a lying position to double foot and single heel lifting. Finally, resistance training were carried out with the aid of an elastic band, and the resistance of the elastic band were gradually increased according to the recovery of muscle strength.

Later rehabilitation treatment and training (2 weeks later). The treatment in this stage ought to relieve pain and restore joint function. Most of the patients in this stage experienced severe or double-ankle ligament injury, early improper treatment, premature activity, or delayed treatment. The swelling of the ankle joint did not improve or even worsened, and a harder lump was formed due to blood stasis. Improper treatment may lead to traumatic arthritis, which compromises the ankle joint movement and triggers frequent pain. The small displacement of the sprained ankle joint could not be reset for a long time, and the loose synovial membrane or ligament embedded in the joint space could not be prolapsed, destroying the mechanical balance of the ankle joint. The rehabilitation methods of ankle sprain included manipulation therapy and functional training. According to the theory of traditional Chinese orthopedics of “separation first for reunion, dynamic and static integration”, through methods such as traction, circling and shaking, pressing, poke, the slightly staggered ankle joint could be reset and the adhesion could be relieved. Furthermore, with the modern rehabilitation joint loosening technique, the ankle joint motion angle could be increased by extending the ligaments and joint capsule around the ankle joint and increasing the extensibility of non-contracting tissues. Rehabilitation training mainly included training of muscle strength, proprioception, and balance function. The drug treatment in this stage mainly adopts traditional Chinese medicine fumigation and washing for warming the meridian and dispelling cold, dredging collaterals, and relieving pain.

2.5 Observational index

The two groups were followed up for 16 weeks. Before treatment, the patients were evaluated with American Orthopedic Foot and Ankle Society (AOFAS) score, degree of ankle swelling, pain, and ankle joint function.

AOFAS score. Before treatment, 1 week, 2 weeks, 3 weeks, and 4 weeks after treatment, the AOFAS score [12] was used, with a total score of 100 points, including 40 points for pain, 50 points for function, 10 points for alignment.

Evaluation of ankle joint swelling degree. The improved ankle joint “8” measurement method [13] was adopted. Methods: From the base of the fifth metatarsal bone to the bottom of the lateral malleolus, to the base of the fifth metatarsal, the perimeter was measured across the bottom of the foot to the tip of the medial malleolus.

Pain assessment. Visual Analogue Scale (VAS) [14] was used in this experiment to assess the pain. A line segment of 10 cm was marked with 0 (no pain) and 10 (severe pain) at both ends. The subjects were asked to rate their pain on a line segment based on their actual feeling.

(4) Reinjury rates were recorded at 16 weeks.

2.6 Statistical analysis

SPSS 22.0 statistical software was used to analyze the data. The normality of variables was investigated by the Shapiro-Wilk test. The measurement data were expressed as mean with SD and the count data were expressed as ( $n$ , %). Basic information was compared by two independent sample $t$ -test (measurement data) and the chi-square test (count data). Outcome measures were compared before and after the treatment using a two-way (group-by-time) mixed-model analysis of variance (ANOVA), with time (baseline and postintervention) as the repeated measure. For all analyses, the alpha level was set at 0.05.

3. Results

3.1 Results of the general data

The data of 117 patients with an acute lateral ankle sprain from January 2019 to June 2020 were assessed for eligibility. Of these, 96 patients met the inclusion criteria, provided consent, and were randomized to the control group ( $n=$ 48) and the rehabilitation group ( $n=$ 48). The basic information of the two groups was comparable without significant difference (all $P>$ 0.05) (Table 1).

Table 1
The general data of the two groups

	Control group ( $n=$ 48)	Rehabilitation group ( $n=$ 48)
Gender (female/male)	17/31	21/27
Age (years)	28.9 (3.7)	27.2 (4.3)
Height (cm)	174.5 (9.5)	169.9 (11.5)
Body weight	77.6 (8.7)	78.2 (9.4)
Time since injury	34.8 (11.5)	30.9 (9.1)
Injured ankle (right/left)	40/8	38/10
Grade of sprain (I/II)	19/29	21/27

Table 2

Results of AOFAS scores

Groups	$n$	Injured	1 week	2 weeks	3 weeks	4 weeks
Control group	48	75.83 $\pm$ 0.86	80.15 $\pm$ 0.86	84.32 $\pm$ 0.64	90.04 $\pm$ 0.48	93.01 $\pm$ 0.47
Rehabilitation group	48	75.82 $\pm$ 1.11	84.13 $\pm$ 1.02	88.74 $\pm$ 0.49	91.32 $\pm$ 0.27	93.82 $\pm$ 0.27
$P$		0.501	0.006	0.001	0.052	0.173
$F$		F time $=$ 168.13; F groups $=$ 17.24; Interaction $=$ 15.13

Note: The multiple $t$ -tests revealed all $P<$ 0.001 among five time-points.

Table 3

Results of the degree of ankle swelling

Groups	$n$	Injured	1 week	2 weeks	3 weeks	4 weeks
Control group	48	1.85 $\pm$ 0.03	1.76 $\pm$ 0.05	1.45 $\pm$ 0.02	0.89 $\pm$ 0.03	0.72 $\pm$ 0.02
Rehabilitation group	48	2.01 $\pm$ 0.05	1.77 $\pm$ 0.04	1.39 $\pm$ 0.05	0.86 $\pm$ 0.04	0.64 $\pm$ 0.04
$P$		0.455	0.438	0.104	0.438	0.462
$F$		F time $=$ 864.12; F groups $=$ 0.15; Interaction $=$ 2.52

Note: The multiple t-tests revealed all P<0.001 among five time-points.

Table 4

Results of pain assessment

Groups	$n$	Injured	1 week	2 weeks	3 weeks	4 weeks
Control group	48	7.15 $\pm$ 1.02	5.41 $\pm$ 1.25	5.41 $\pm$ 0.82	4.51 $\pm$ 0.32	2.01 $\pm$ 1.36
Rehabilitation group	48	7.03 $\pm$ 1.26	5.30 $\pm$ 1.02	2.21 $\pm$ 0.44	1.04 $\pm$ 0.24	0.55 $\pm$ 1.38
$P$		0.423	0.302	0.101	0.010	0.004
$F$		F time $=$ 141.32; F groups $=$ 0.20; Interaction $=$ 2.37

Note: The multiple t-tests revealed all P<0.001 among five time-points.

3.2 Results of AOFAS scores

The AOFAS scores of patients in the two groups were compared and analyzed respectively from 1 week to 4 weeks after treatment, and the results were consistent with the spherical test ( $P<$ 0.05). The AOFAS scores of patients in the two groups increased gradually at four time points after treatment when compared with those at the time of injury ( $P<$ 0.05). Results of AOFAS scores are shown in Table 2.

3.3 Results of the degree of ankle swelling

There was no significant difference in the degree of limb swelling between the two groups from 1 week to 4 weeks after treatment ( $P ï ¼ ž$ 0.05). However, the degree of swelling in the two groups at four time points after treatment was significantly improved compared with that at the time of injury ( $P<$ 0.05). Results of the degree of ankle swelling are shown in Table 3.

3.4 Results of pain assessment

Compared with before treatment, the VAS scores in both groups saw a decline two weeks after treatment ( $P<$ 0.05). One week and two weeks after treatment, the rehabilitation group observed lower VAS scores than the control group ( $P<$ 0.05), which suggested a better performance of pain relief in the rehabilitation group than that in the control group one week and two weeks after treatment. Results of pain assessment are shown in Table 4.

3.5 Results of re-injury rate

The two groups showed similar results of the 16-week follow-up visit, in which two cases (4.17%) of the ankle joint re-injury were found in each group ( $P ï ¼ ž$ 0.05).

4. Discussion

Most acute ankle sprains are caused by the pronation or valvular stress of the ankle joint during plantar flexion, resulting in the anterior talofibular ligament, the calofibular ligament, and the posterior talofibular ligament outside the joint; or the medial deltoid ligament is injured and ruptured in different degrees, which results in local acute pain, swelling, and limited activity [15]. The treatment in modern western medicine for a mild and moderate ankle injury still follows the RICE principle (Rest, Ice, Compression, and Elevation), according to the severity of injury, bandage, elastic support, plaster fixation, severe ligament repair surgery [16, 17]. In 2017, some scholars proposed the POLICE principle to replace the rest with the optimal loading principle [18]. The biomechanical changes in local proprioception, muscle strength, neuromuscular control, and other aspects after joint sprains have captured increasing attention of clinicians, which endorses the principle of POLICE in early loading [19]. It is believed that these rehabilitation exercises should be carried out in wake of the alleviation of the symptoms, to avert the missing of the optimal exercise opportunity.

The results of this paper showed that the AOFAS scores of patients in the two groups were compared and analyzed respectively from 1 week to 4 weeks after treatment, and the results were consistent with the spherical test ( $P<$ 0.05). The AOFAS scores of patients in the two groups increased gradually at four time points after treatment when compared with those at the time of injury ( $P<$ 0.05). The tertiary rehabilitation therapy of traditional Chinese medicine has distinctive characteristics in the treatment of acute ankle sprains, which recognizes the disease from different angles and provides treatment from different levels [20]. Prior studies found that the traditional Chinese medicine method of strengthening bones and tendons combined with external application of Xiaoding ointment can effectively mitigate the symptoms of ankle joint swelling and pain, reasonably improve the motion function of the ankle joint, and reduce dyskinesias. Therefore, this method is considered to possess the advantages of low treatment cost, few side effects, and rapid recovery [21]. In addition, the present study observed no significant difference in the degree of limb swelling between the two groups from 1 week to 4 weeks after treatment ( $P ï ¼ ž$ 0.05). However, the degree of swelling in the two groups at four time points after treatment was significantly improved compared with that at the time of injury ( $P<$ 0.05). Compared with before treatment, the VAS scores in both groups saw a decline two weeks after treatment ( $P<$ 0.05). Moreover, one week and two weeks after treatment, the rehabilitation group observed lower VAS scores than the control group ( $P<$ 0.05), which suggested a better performance of pain relief in the rehabilitation group than that in the control group one week and two weeks after treatment. Tertiary rehabilitation therapy is based on syndrome differentiation, guided by the meridian theory of traditional Chinese medicine, and combined treatment with a variety of methods, which can eliminate local skin blood stasis and abate inflammation, to achieve the effects of promoting qi and blood circulation and reducing inflammation and pain. In previous research, 40 patients with acute ankle sprains were treated with physical therapies such as traditional Chinese acupuncture and massage, and its clinical effects on symptoms such as swelling and pain were observed. Results of the study demonstrate that after the treatment of traditional Chinese medicine physical therapy on patients with acute ankle sprains, the local swelling of the patients is quickly improved, the pain symptoms are mitigated, and the ankle function is substantially optimized [22]. Kim et al. [23] took the rat ankle sprain pain model as the research subjects and used a reproducible and quantifiable pain index as an indicator to study the neural mechanism of electroacupuncture analgesia in persistent pain after an ankle sprain. Their trial revealed that ankle sprain can cause sensitization of spinal cord pain, and acupuncture points can activate the analgesic system mediated by $\alpha$ 2-adrenergic receptors to produce analgesia, and the two groups showed similar results of the 16-week follow-up visit, in which two cases (4.17%) of the ankle joint re-injury were found in each group ( $P ï ¼ ž$ 0.05).

5. Conclusion

In summary, rehabilitation exercise had a promising clinical effect in treating acute lateral ankle sprains, and could effectively relieve ankle swelling and reduce pain.

Footnotes

Conflict of interest

None to report.

Author contributions

Shuyi Li designed the study, Mengqi Ding and Shuyi Li collected and analysed the data. Mengqi Ding wrote and edited the manuscript. All authors read and approved the final version of the manuscript.

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Tertiary rehabilitation in acute ankle sprain caused by sports training

Abstract

BACKGROUND:

OBJECTIVE:

METHOD:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 Sample size analysis

2.2 Randomization and blinding

2.3 Inclusion and exclusion criteria

2.4 Methods

2.5 Observational index

2.6 Statistical analysis

3. Results

3.1 Results of the general data

Table 1 The general data of the two groups

3.3 Results of the degree of ankle swelling

3.4 Results of pain assessment

3.5 Results of re-injury rate

4. Discussion

5. Conclusion

Footnotes

Conflict of interest

Author contributions

References

Table 1
The general data of the two groups