Exploring influences and risk of bias of studies on return to sport and work after lateral ankle sprain:A systematic review and metaanalysis

BACKGROUND Lateral ankle sprains are the most common traumatic musculoskeletal injuries of the lower extremity,with an incidence rate of 15%-20%.The high incidence and prevalence highlights the economic impact of this injury.Ankle sprains lead to a high socioeconomic burden due to the combination of the high injury incidence and high medical expenses.Up to 40%of patients who suffer from an ankle sprain develop chronic ankle instability.Chronic instability can lead to prolonged periods of pain,immobility and injury recurrence.Identification of factors that influence return to work(RTW)and return to sports(RTS)after a lateral ankle sprain(LAS)may help seriously reduce healthcare costs.AIM To explore which factors may potentially affect RTW and RTS after sustaining an LAS.METHODS EMBASE and PubMed were systematically searched for relevant studies published until June 2023.Inclusion criteria were as follows:(1)Injury including LAS or chronic ankle instability;(2)Described any form of treatment;(3)Assessment of RTW or RTS;(4)Studies published in English;and(5)Study designs including randomized controlled clinical trials,clinical trials or cohort studies.Exclusion criteria were:(1)Studies involving children(age<16 year);or(2)Patients with concomitant ankle injury besides lateral ankle ligament damage.A quality assessment was performed for each of the included studies using established risk of bias tools.Additionally quality of evidence was assessed using the GRADEpro tool in cases where outcomes were included in the quantitative analysis.A best evidence synthesis was performed in cases of qualitative outcome analysis.For all studied outcomes suitable for quantitative analysis a forest plot was created to calculate the effect on RTW and RTS.RESULTS A total of 8904 patients were included in 21 studies,10 randomized controlled trials,7 retrospective cohort studies and 4 prospective cohort studies.Fifteen studies were eligible for meta-analysis.The overall RTS rate ranged were 80%and 83%in the all treatments pool and surgical treatments pool,respectively.The pooled mean days to RTS ranged from 23-93 d.The overall RTW rate was 89%.The pooled mean time to RTW ranged from 5.8-8.1 d.For patients with chronic ankle instability,higher preoperative motivation was the sole factor significantly and independently(P=0.001)associated with the rate of and time to RTS following ligament repair or reconstruction.Higher body mass index was identified as a significant factor(P=0.04)linked to not resuming sports or returning at a lower level(median 24,range 20-37),compared to those who resumed at the same or higher level(median 23,range 17-38).Patients with a history of psychological illness or brain injury,experienced a delay in their rehabilitation process for sprains with fractures and unspecified sprains.The extent of the delayed rehabilitation was directly proportional to the increased likelihood of experiencing a recurrence of the ankle sprain and the number of ankle-related medical visits.We also observed that 10%of athletes who did return to sport after lateral ankle sprain without fractures described non-ankle-related reasons for not returning.CONCLUSION All treatments yielded comparable results,with each treatment potentially offering unique advantages or benefits.Preoperative motivation may influence rehabilitation after LAS.Grading which factor had a greater impact was not possible due to the lack of comparability among the included patients.

Acute ankle sprain in athletes:Clinical aspects and algorithmic approach

Acute ankle sprain is the most common lower limb injury in athletes and accounts for 16%-40%of all sports-related injuries.It is especially common in basketball,American football,and soccer.The majority of sprains affect the lateral ligaments,particularly the anterior talofibular ligament.Despite its high prevalence,a high proportion of patients experience persistent residual symptoms and injury recurrence.A detailed history and proper physical examination are diagnostic cornerstones.Imaging is not indicated for the majority of ankle sprain cases and should be requested according to the Ottawa ankle rules.Several interventions have been recommended in the management of acute ankle sprains including rest,ice,compression,and elevation,analgesic and anti-inflammatory medications,bracing and immobilization,early weight-bearing and walking aids,foot orthoses,manual therapy,exercise therapy,electrophysical modalities and surgery(only in selected refractory cases).Among these interventions,exercise and bracing have been recommended with a higher level of evidence and should be incorporated in the rehabilitation process.An exercise program should be comprehensive and progressive including the range of motion,stretching,strengthening,neuromuscular,proprioceptive,and sport-specific exercises.Decision-making regarding return to the sport in athletes may be challenging and a sports physician should determine this based on the self-reported variables,manual tests for stability,and functional performance testing.There are some common myths and mistakes in the management of ankle sprains,which all clinicians should be aware of and avoid.These include excessive imaging,unwarranted non-weightbearing,unjustified immobilization,delay in functional movements,and inadequate rehabilitation.The application of an evidence-based algorithmic approach considering the individual characteristics is helpful and should be recommended.

Risk factors for chronic ankle instability after first episode of lateral ankle sprain:A retrospective analysis of 362 cases

Background:Chronic ankle instability(CAI) is a common sequela following an acute lateral ankle sprain(LAS).To treat an acture LAS more effectively and efficiently,it is important to identify patients at substantial risk for developing CAI.This study identifies magnetic resonance imaging(MRI) manifestations for predicting CAI development after a first episode of LAS and explores appropriate clinical indications for ordering MRI scans for these patients.Methods:All patients with a first-episode LAS who received plain radiograph and MRI scanning within the first 2 weeks after LAS from December 1,2017 to December 1,2019 were identified.Data were collected using the Cumberland Ankle Instability Tool at final follow-up.Demographic and other related clinical variables,including age,sex,body mass index,and treatment were also recorded.Univariable and multivariable analyses were performed successively to identify risk factors for CAI after first-episode LAS.Results:A total 131 out of 362 patients with a mean follow-up of 3.0± 0.6 years(mean ± SD;2.0—4.1 years) developed CAI after first-episode LAS.According to multivariable regression,development of CAI after first-episode LAS was associated with 5 prognostic factors:age(odds ratio(OR)=0.96,95% confidence interval(95%CI):0.93-1.00,p=0.032);body mass index(OR=1.09,95%CI:1.02-1.17,p=0.009);posterior talofibular ligament injury(OR=2.17,95%CI:1.05-4.48,p=0.035);large bone marrow lesion of the talus(OR=2.69,95%CI:1.30-5.58,p=0.008),and Grade 2 effusion of the tibiotalar joint(OR=2.61,95%CI:1.39-4.89,p=0.003).When patients had at least 1 positive clinical finding in the 10-m walk test,anterior drawer test,or inversion tilt test,they had a 90.2% sensitivity and 77.4% specificity in terms of detecting at least 1 prognostic factor by MRI.Conclusion:MRI scanning is valuable in predicting CAI after first-episode LAS for those patients with at least 1 positive clinical finding in the10-m walk test,anterior drawer test,and inversion tilt test.Further prospective and large-scale studies are necessary for validation.

Forty-three Cases of Acute Lumbar Sprain Treated by Acupuncture Plus Kinesitherapy

Acute lumbar sprain is commonly encountered among the young and middle-aged. It often occurs at the lower part of the back, which seriously hinders the daily life and work of the patients because of the severe pain. The author has treated 43 cases of acute lumbar sprain by needling Weizhong (BL 40), Houxi (SI 3) and Yaotongdian (EX-UE7) plus kinesitherapy and obtained satisfactory therapeutic results. A report follows.

Thirty Cases of Acute Lumbar Sprain Treated by Acupuncture Combined with Point-Injection at Tianzhu

In recent years, the authors have treated 30 cases of acute lumbar sprain by acupuncture combined with point medicinal injection at Tianzhu (BL 10), and obtained quite good therapeutic results, as is reported in the following.

THERAPEUTIC EFFECTS OF ELECTROACUPUNCTURE PLUS POINT-PENETRATION FOR CHRONIC ANKLE JOINT SPRAIN

Objective: To observe clinical therapeutic effects of electroacupuncture plus point-penetration for chronic ankle joint sprain. Methods: 76 patients were randomly divided into treatment group (n=43) and control group (n=33).In teatment group, penetration needling from Qiuxu (丘墟 GB 40) to Zhaohai (照海 KI 6) was performed, combined with electrical stimulation for 30 min. Patients of control group were ordered to take Antinfan (50 mg,b.i.d.),supplemented with local external application of Votalin cream (b.i.d.).After 14 treatments (two courses), the therapeutic effect was assessed. Results: Following two courses of treatment, of the 43 cases and 33 cases in treatment and control groups,33 (76.7%) and 15 (45.5%) were cured, 4 (9.3%) and 7 (21.2%) had marked improvement in their symptoms, 3 (7.0%) and 2 (6.1%) had improvement, and 3 (7.0%) and 9(27.3%) failed, with the effective rates being 93.0% and 72.7% respectively. The therapeutic effect of treatment group was significantly superior to that of control group (P<0.05). Conclusion: Penetrative needling plus EA is significantly superior to medication in relieving chronic ankle spain patient’s clinical symptoms and signs.

OBSERVATION ON THERAPEUTIC EFFECTS OF ACUTE SPRAIN OF SOFT TISSUE TREATED BY ACUPUNCTURE AT PRESSURE PAIN POINTS

In the present paper,70 cases of acute sprain of soft tissue were treated withacupuncture at pressure pain points on the lateral of the second metacarpal bone.Results showedthat the cure rate was 58.6％ and the total effective rate was 94.3％.Also,its mechanisms werestudied preliminarily.The present therapy is simple,convenient,easy to operate and it producesrapidly desired effects with a higher cure rate,so it is suited to be popularized clinically.

FINGER PRESSURE PLUS MOXIBUSTION FOR TREATMENT OF 30 CASES OF ACUTE LUMBAR SPRAIN

In the present paper,30 cases of acute lumbar sprain are treated with finger pressuretherapy and moxibustion therapy.Results show that 21 cases are cured,4 markedly effective and 5effctive.This combined treatment has no sufferings to the patient,is safe,simple and easy to be ac-cepted by patients.

Acupuncture Combined with Plucking Muscle Method for Treatment of 48 Cases of Acute Lumbar Sprain

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Most ankle sprain research is either false or clinically unimportant:A 30-year audit of randomized controlled trials

Background:Lateral ankle sprain is the most common musculoskeletal injury.Although clinical research in this field is growing,there is a broader concern that clinical trial outcomes are often false and fail to translate into patient benefits.Methods:We audited 30 years of experimental research related to lateral ankle sprain management(n=74 randomized controlled trials)to determine if reports of treatment effectiveness could be validated beyond statistical certainty.Results:A total of 77%of trials reported positive treatment effects,but there was a high risk of false discovery.Most trials were unregistered and relied solely on statistical significance,or lack of statistical significance,rather than on interpreting key measures of minimum clinical importance(e.g.,minimal detectable change,minimal clinically important difference).Conclusion:Future clinical trials must adopt higher standards of reporting and data interpretation.This includes consideration of the ethical responsibility to preregister their research and interpretation of clinical outcomes beyond statistical significance.

Patients’perspectives on the conventional synthetic cast vs a newly developed open cast for ankle sprains

BACKGROUND Orthopedic physicians typically apply a cast to immobilize a body part that has been injured.There have been no significant structural changes or advances in synthetic casts since the development of the modern cast.The Opencast®is a recently developed type of cast that allows ventilation and direct visual inspection of the skin to avoid cast-related complications.Although this novel cast appears to have more benefits than the conventional synthetic cast,its clinical efficacy and advantages have not been established.AIM To investigate the clinical efficacy and advantages of the newly developed Opencast®based on patients’perspectives in those with ankle inversion injury.METHODS A specifically designed questionnaire consisting of 19 items was used to compare patients’opinions and concerns of the Opencast®and the conventional synthetic cast.The items were focused on subjective patient satisfaction,discomfort,and adverse effects while wearing the cast.Patients with an ankle inversion injury diagnosed as a high-grade ankle sprain were enrolled.The subjects were randomized and instructed to fill the questionnaire after wearing a synthetic cast or an Opencast®for 2 wk.They were then required to fill the questionnaire again,after switching to the alternative type of cast for 2 more weeks.RESULTS A total of 22 subjects participated in the study.The synthetic cast appeared to be more rigid and stable than the Opencast®,but there was no significant difference in the amount of pain relief.The likelihood of adverse effects when wearing the synthetic cast was significantly higher.Patient satisfaction tended to be rated higher after wearing the Opencast®.Opencast®showed more subjective vulnerability than the synthetic cast,but there was no significant difference in the redo rate.Patients were more anxious about removal of the synthetic cast than of the Opencast®.CONCLUSION The results indicate that the Opencast®could replace the conventional synthetic cast as it offers increased patient satisfaction,which would in turn increase compliance to treatment.

ACUTE WAIST SPRAIN TREATED BY ACUPUNCTURING DONGSHI ACUPOINT

Acute waist sprain is a local injury of themuscle, fascia and ligament in the waist due tosudden overstretch by external force beyond thenormal physiological limit. Acute waist spraincan lead to cicatrix adhesion, loss of normal tis-sue function and chronic waist pathologicalchanges without timely and effecthe treatment.Long time treatment without cure will affectboth work and daily life.

1st degree acromioclavicular sprain, elevated 1st rib, or both? A case study of a rodeo cowboy

Objective: To present a case of a rodeo cowboy who suffered a seemingly routine 1st degree acromioclavicular (AC) sprain. The AC sprain was exacerbated by an elevated 1st rib. Background: Saddle bronc riding is one of three rough stock events in North American rodeo and the least common event for injury relative to bull riding and bareback riding. Shoulder injury in rodeo rough stock events make up 9.3% of all injuries. Approximately 28% of injuries in rodeo are considered minor sprains. The professional cowboy was thrown from his horse landing on the tip of his shoulder. The cowboy presented with a routine 1st degree AC sprain based on the Tossey and Rockwood definitions. Differential Diagnosis: Due to the mechanism of injury and forces produced with the cowboy being thrown to the ground, elimination of serious neck injury was critical. A scanning examination revealed some neck dysfunction. A cervical rotation, lateral flexion special test confirmed the additional elevated 1st rib in addition to the 1st degree AC sprain. Treatment: A chiropractic adjustment of the 1st rib reduced pain in the AC joint from a 6/10 to 1/10 immediately. Subsequently, the patient iced and was treated with one other 1st rib adjustment at a later date. Uniqueness: There were no cases of 1st degree AC sprains with an associated elevated first rib in the literature. It was very unique to relieve to the patient’s shoulder symptoms so dramatically in a short period of time with manual therapy to the first rib. Conclusions: It is important to follow a thorough history and physical examination of patients who suffer from a 1st degree AC sprain. The use of a scanning examination will help identify the primary source of pain (i.e. neck and/or shoulder). Manual therapy of the 1st rib may be useful in the treatment.

Clinical Study on Puncturing Houxi (SI 3) Toward Hegu (LI 4) plus Lumbar Movement for Acute Lumbar Sprain

Objective： To observe the therapeutic efficacy of puncturing Houxi （SI 3） toward Hegu （LI 4） plus lumbar movement in treating acute lumbar sprain. Methods： A total of 212 patients with acute lumbar sprain were randomized into two groups. There were 106 subjects in the observation group who were treated with puncturing Houxi （SI 3） toward Hegu （LI 4） plus lumbar movement; the other 106 patients in the control group were treated with puncturing Houxi （SI 3） toward Hegu （LI 4） alone. Therapeutic efficacy was evaluated after 2 treatment courses. Results： The total effective rate was 95.3% in the observation group versus 88.7% in the control group, and the difference was statistically insignificant between the two groups （P〉O.05）. However, in comparing the treatment times for achieving recovery and effectiveness, differences between the two groups were statistically significant （both P〈O.05）, indicating that integrated use of acupuncture and exercise is faster in realizing therapeutic effectiveness. Conclusion： By selecting fewer acupoints, puncturing Houxi （Sl 3） toward Hegu （LI 4） is effective in treating acute lumbar sprain, and with the help of lumbar movement, it can achieve even better treatment effect.

Acupuncture treatment on 31 cases of obsolete lateral malleolus joint sprain

Objective To observe the clinical effect of acupuncture on the obsolete lateral malleolus joint sprain. Methods Thirty-one cases of patients with obsolete lateral malleolus joint sprain were selected. Jiexi （解溪 ST 41） were penetrated to Shenmei （申脉 BL 61）, and Yanglingquan （阳陵泉 GB 34） was applied. The needles were retained for 30 min, and the treatment was performed only once, with follow-up visit after 1 month. Results All the patients were cured after treatment, and without relapse on the follow-up visit after 1 month. Conclusion The clinical effect of acupuncture on the obsolete lateral malleolus joint sprain is remarkable.

Acupuncture-movement therapy for acute lumbar sprain: a randomized controlled clinical trial

OBJECTIVE： Several studies have reported that acupuncture is effective for treatment of acute lumbar sprain, but they neglected to consider that acupuncture cannot remarkably improve lumbar activity. We performed a randomized controlled trial to evaluate the effect of acupuncture-movement therapy versus conventional acupuncture in the trea ment of acute lumbar sprain. METHODS： Sixty patients were randomized into four groups： the acupuncture-movement （AM） group, sham acupuncture-movement （SAM） group, conventional acupuncture （CA） group, and physical therapy （PT） group. Patients in the AM group were treated with acupuncture at Yintang （EX-HN 3） and exercise of the lumbar region during acupuncture. Patients in the SAM group were treated with sham acupuncture at Yintang （EX-HN 3） and exercise of the lumbar region during sham acupuncture. Con- ventional acupuncture was performed in the CA group, and physical therapy was applied in the PT group. Each treatment lasted for 20 min. Patients were assessed before and after treatment using a visual analogue scale （VAS） and the Roland Morris Questionnaire （RMQ）. RESULTS： The VAS and RMQ scores in the AM group were significantly lower after than before treatment （P 〈 0.01）. The AM group reported lower RMQ scores in after-treatment and 24 h after treatment and lower VAS score in 24 h after treatment in comparison with those of the CA, SAM, and PT groups （P 〈 0.05）. CONCULSlON： Acupuncture-movement therapy is effective for treating acute lumbar sprain with a persistent pain-relief and remarkable improvement of lumbar activity. Movement, that is, lumbar exercise during acupuncture, enhances the effect of acupuncture.

增加着地时足外展角度可降低慢性踝关节不稳者内翻损伤的风险

背景:慢性踝关节不稳者在着地时易发生踝关节内翻扭伤,适度增大着地时足外展角度有助于减少踝关节内翻扭伤的发生,但尚无研究直接论证。目的:探讨着地时增加足外展角度对有无慢性踝关节不稳者着地过程中踝内翻角度、角度峰值时刻及角速度峰值的影响。方法:共招募了60名受试者,其中慢性踝关节不稳者30名,非慢性踝关节不稳者30名。使用模拟扭伤装置进行下落跳测试,该装置中的活动平台可向前翻转24°、向内侧翻转15°,从而模拟踝关节内翻扭伤时的足部位置。受试者需要在两种着地状态下进行下落跳测试,即自然着地和外展着地,后者的足外展角度更大,约为前者的150%以上。使用12摄像头三维红外动作捕捉系统记录运动学数据,采用双因素重复测量方差分析和Spearman相关分析进行数据分析。结果与结论:①下落跳时的内翻角度峰值(P<0.001,η^(2)p=0.270)、内翻角速度峰值(P=0.015,η^(2)p=0.098)和内翻角度峰值时刻(P<0.001,η^(2)p=0.260)均存在显著的状态主效应;内翻角速度峰值存在显著的组别主效应(P=0.029,η^(2)p=0.080);②慢性踝关节不稳组与非慢性踝关节不稳组受试者着地时的足外展角度与踝内翻角度峰值(P=0.021,r=-0.310;P=0.042,r=-0.278)、内翻角度峰值时刻(P=0.018,r=-0.312;P=0.021,r=-0.309)均存在显著的负相关关系;慢性踝关节不稳组受试者着地时的足外展角度与内翻角速度峰值(P=0.021,r=-0.312)之间也存在显著的负相关关系;③提示增加着地时的足外展角度可以减小慢性踝关节不稳及非慢性踝关节不稳人群着地过程中的内翻角度峰值、内翻角速度峰值,提前内翻角度峰值时刻,从而降低踝内翻扭伤的风险。

Clinical Observation on Effect of FU＇s Subcutaneous Needling for Acute Lumbar Sprain

Objective： To observe the clinical effect of FU＇s subcutaneous needling on acute lumbar sprain. Method： One hundred acute lumbar sprain cases were randomly allocated into a treatment group and control group, 50 cases in each. FU＇s subcutaneous needling on tenderness were employed in the treatment group, whereas voltaren was administered to the cases in the control group. The changes in symptoms and signs were then observed in the two groups. Results： The total effective rates in the treatment group and control group were 94.0% and 70.0% respectively, showing a statistical difference （P〈0.01）. Conclusion： FU＇s subcutaneous needling is better than voltaren for acute lumbar sprain.

单侧慢性踝关节不稳对双侧姿势稳定性、本体感觉、足底触觉和肌肉力量的影响

背景:单侧慢性踝关节不稳会对患侧肢体产生不良影响,有线索表明非患侧可能同样受到累及,但目前尚缺乏直接证据。目的:探讨单侧慢性踝关节不稳对于双侧姿势稳定性、本体感觉、足底触觉和肌肉力量的影响。方法:招募122例受试者,其中单侧慢性踝关节不稳者67例,非慢性踝关节不稳者55例。测试了单侧慢性踝关节不稳者双侧以及非慢性踝关节不稳者的姿势稳定性、本体感觉、足底触觉和肌肉力量。使用单因素方差分析或克鲁斯卡尔-沃利斯检验对比组间差异。结果与结论:①相较于非慢性踝关节不稳者,单侧慢性踝关节不稳者双侧前后方向的稳定时间均更长(P=0.001-0.012),患侧内外方向的稳定时间更长(P=0.012-0.025);双侧踝关节跖屈、背伸、内翻和外翻的本体感觉阈值均更高(P=0.000-0.035);双侧足底大脚趾、第1跖骨头、第5跖骨头、外侧足弓、足跟的足底触觉灵敏度均更低(P=0.000-0.008);双侧踝关节内翻和外翻的肌肉力量均更弱(P=0.000-0.019)。②单侧慢性踝关节不稳者存在双侧姿势稳定性、本体感觉、足底触觉和肌肉力量缺陷。因此,在治疗慢性踝关节不稳时应全面考虑双侧肢体的康复需求。

Observations on the Short-term and Long Term Effects of Point Houxi(SI 3) Electroacupuncture on Acute Lumbar Sprain

Objective： To investigate the clinical efficacy of point Houxi（SI 3） electroacupuncture for treating acute lumbar sprain. Methods： Three hundred patients with acute lumbar sprain were randomly grouped with a random number table. The electroacupuncture group was treated by electro-acupuncture at point Houxi （SI 3） and the medication group, with meloxicam. Results： A comparison of the short-term effects showed that the efficacy rate was 97.3% in the electroacupuncture group and 89.3% in the medication group. The average rank of the short-term effect score was lower in the electroacupuncture group than in the medication group （P〈0.01）; there was a significant difference between the two groups. A comparison of the long-term effect showed that the efficacy rate was 99.3% in the electroacupuncture group and 93.2% in the medication group. The average rank of the long-term effect score was lower in the electroacupuncture group than in the medication group （P〈0.01）; there was a significant difference between the two groups, Conclusion： Both point Houxi （S1 3） electroacupuncture and meloxicam have a marked effect on acute lumbar sprain, but the short-term and long-term effects are better in the electroacupuncture group than in the medication group.