Wednesday, April 21, 2010

Ankle Sprains: Tape, Bracing - doesn't matter finds research - but how'd we get so busted up in the first place?

ResearchBlogging.orgA recent paper has presented the results of a bunch of trials looking at interventions for ankle sprains. Main result? if someone's had an ankle injury - like a sprain - then tape or brace doesn't seem to show a difference: both seem to cut down reinjury. What's troublesome on a metalevel, is first how sort of accepted the notion of this level of injury seems to be, and second how nascent in the approach described here is the model that for folks who haven't been injured - as a preventitive - they maybe should be immobilised too. Aren't there other questions to ask - perhaps especially about the injury free staying injury free - rather than whether incapacitating natural function is a Good Idea? But perhaps more fundamentally, how did we get to this point where someone is so beaten up their joints are written off as so dysfunctional they must be immobilized to perform?

Here's the abstract:

Epidemiological studies have shown that 10–28% of all sports injuries are ankle sprains, leading to the longest absence from athletic activity compared to other types of injuries. This study was conducted to evaluate the effectiveness of external ankle supports in the prevention of inversion ankle sprains and identify which type of ankle support was superior to the other. A search strategy was developed, using the keywords, ankle supports, ankle brace, ankle tapes, ankle sprains and athletes, to identify available literature in the databases (MEDLINE, PubMed, CINAHL, EMBASE, etc.), libraries and unpublished papers. Trials which consider adolescents and adults, elite and recreational players as participants were the study of choice. External ankle supports comprise ankle tape, brace or orthosis applied to the ankle to prevent ankle sprains. The main outcome measures were frequency of ankle sprains. Two reviewers assessed the quality of the studies included using the Joanna Briggs Institute (JBI Appraisal tool). Whenever possible, results were statistically pooled and interpreted. A total of seven trials were finally included in this study. The studies included were of moderate quality, with blinding as the hardest criteria to fulfill. The main significant finding was the reduction of ankle sprain by 69% (OR 0.31, 95% CI 0.18–0.51) with the use of ankle brace and reduction of ankle sprain by 71% (OR 0.29, 95% CI 0.14–0.57) with the use of ankle tape among previously injured athletes. No type of ankle support was found to be superior than the other.
 This is when it's nice to have the whole article, because you'd think it just stops there, right? For previously injured, folks who were taped didn't seem to get reinjured. How does one predict the future like that? Well that's the toughie: only one study had a control group - so did they just get reinjured that many more times than the athletes who braced? No, it's of the populations taped or braced, how many did NOT have a recurrence in a given period.

So what's going on here that this is even considered a useful strategy?

Apparently, there's a lot of functional instability, mechanical and proprioceptive factors are also considered in some of the studies to be impaired. Mechanical instability (lax joint) can be a cause of functional instability.  These effects build up from - you guessed it - repeated ankle injuries. Where reflexes get slower, joints can get hypermobile, funtional loss of static and dynamic support of the joint has gone way down. Effectively, the ankle for a potential variety of reasons, is so beaten up and abused, it can no long function as an ankle, so, a greater degree of immobility is preferable to too much.

Um. what happened that a person gets to this point of so MANY repeated injuries they're beyond the pale of recovering normal function? Ah right: this is sport, not health. 

Intriguingly, there's a claim that some bracing helps proprioception:
 "they restrict range of motion to a certain degree and enhance proprioception of the injured ankle making them more useful in the prevention of possible re-injury." 
Wow, that's wild. How does that work? And can that awareness be re-trained rather than delivered only through a device? Where's it coming from? But there's not a lot of interest in the article in looking at say other strategies like rehab, movement assessment. Why not? There's a model here that says once injured, you're toasted:
As mentioned earlier in the discussion, after a sprain, structural damage occurs to the ligamentous tissues, nervous and musculo- tendinous units in the ankle joint. Functional and mechanical instability arise. For these reasons, the risk of injury to a pre- viously injured ankle is increased. his is the point where external ankle supports play an important role.
And that may have informed the authors' decision simply to look at what type of bracing is better to reduce re-injury, rather than to wonder if
  • training that can find movement or other sensory-motor issues that may be related to WHY a person roles their ankles
  • investigation of the stupid shoes that may be killing proprioception necessary to reduce ankle sprains
  • anything else that may help the athlete perform with less likelihood of injury, better performance
What's kinda scary is a one line toss off in the conclusion:
This review provides good evidence for the use either ankle taping or ankle braces to prevent lateral ankle sprains among previously injured players. However, for those with- out previous ankle injuries this still needs to be proven. There is no evidence on which external ankle support is better than the other. Each has its own advantages and disadvantages.
You see it? These folks with this model of the weakness of the ankle - where "10-28%" of all athletic injuries occur - are already thinking MAYBE - we don't know yet - but maybe if we just brace the ankle up from the get go, we'll keep more ankles from being sprained.

There are alternatives approaches: perhaps we should ask, as indicated, what's causing these injuries in the first place? Is it a skills-on-the-field problem? turning skills? cognitive processing for field awareness skills? Is it lack of ankle flexion or hip/pelvis restrictions? Is it a sensory-motor disconnect with shoes or other gear killing proprioceptive awareness of foot placement?

Folks like Gray Cook working with NFL football teams have been looking at athletic mobility/stability. Eric Cobb has been looking more at sensory-motor approaches, and cognitive stress for field performance that's more effective and injury free.

Any solution assumes a model for which that solution is appropriate. The solutions proposed by these authors seems to presuppose a model where (a) the amount of reinjury that leads to such horrible dysfunction is taken as a given and seems to be ok such that (b) further bodily immobilization seems like a good idea to enable athletic movement seems problematic to me on a number of levels.

Strategies to understand why the injuries are so high in the first place - never mind acceptable - seems to be a more humane way to begin strategizing about enabling athltetes to play ball, no?

Related Posts

Dizon, J., & Reyes, J. (2010). A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players Journal of Science and Medicine in Sport, 13 (3), 309-317 DOI: 10.1016/j.jsams.2009.05.002


Bungalow Bill said...

Interesting post on a subject I'm (unfortunately) interested in. I've played soccer most of my life and had may sprains. Since my early 30's I have been unable to play or even kick a ball without the benefit of tape or a brace. I'm 52 now and it's not getting better.

What I find most interesting is that I am fine if I play bare-footed.

dr. m.c. said...

Wow thank you for the comment, David. That's really interesting about feeling better bare-footed. v. interesting.

If you'd like to chat at some point to take a look at what might feel better for your ankle, please send me a note.

Otherwise, it might be interesting to see if leaning towards more barefoot'ish footware all the time helps?


Bungalow Bill said...

Thanks for the link, I have been considering getting a pair of those vibram socks, er shoes, or whatever they are. I will be re-reading your article in more detail.

As for why I can play soccer bare foot without pain, I think it comes down to having less traction (so I don't roll it) combined with the fact barefoot play is pretty non-competitive, so I don't get kicked as much.


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