Point-Counterpoint: Preventive Bracing For Ankle Sprains: Is it Legitimate?

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Yes. Doug Richie Jr., DPM, FACFAS says evidence-based medicine is overwhelmingly in favor of preventive bracing and notes that the literature discounts perceived negative
effects on athletic performance.

No. Lisa M. Schoene, DPM, ATC, FACFAS argues that clinicians should consider other modalities and be wary of a hasty return to play with bracing as a lack of follow-through with appropriate rehabilitation may lead to compromised tissue repair and recurrent sprains.

Yes.

This author says evidence-based medicine is overwhelmingly in favor of preventive bracing and notes that the literature discounts perceived negative
effects on athletic performance.

Preventive bracing for ankle sprains is legitimate and this position is clearly supported by the highest level evidence-based medicine. Preventive ankle bracing has consistently shown a protective benefit for the athlete with no sequelae for long-term use on a regular basis.

   So why is there any debate on this subject? Perhaps it is because parents, coaches, athletic trainers and physicians still cling to myths and misconceptions about preventive bracing of the ankle. Therefore, the facts of this debate deserve review and discussion.

   An ankle sprain is the most common injury in sport, comprising approximately 25 percent of all injuries reported for any part of the body.^1-3 In terms of sport, basketball has the highest incidence of ankle sprain, followed by volleyball and soccer.^1,2,4-7 These three sports have received the most intense focus of studies on preventive ankle bracing.

   The two classic studies showing positive effects of preventive bracing of the ankle were published in the 1990s and clearly show protective benefits in two different sports. Sitler and Horodyski performed a prospective study of over 1,600 basketball players at the United States Military Academy over a two-year period.⁷ Players who wore an Aircast type ankle stirrup (DJO) averaged 1.6 sprains per 1,000 games played while unbraced players suffered 5.2 sprains for the same amount of games. There was no difference in benefit whether the athletes had suffered a previous sprain.

   In a randomized prospective study of over 500 senior club soccer players, Surve and colleagues reported that the Aircast type stirrup ankle brace prevented sprains only in athletes who had suffered a previous sprain.⁸

   Later, Pedowitz and co-workers conducted an important seven-year study of female volleyball players at the University of Pennsylvania.⁹ This study showed a significant decrease in the incidence of ankle sprain in comparison to data published from the NCAA for female volleyball players during the same time period.

   Therefore, three prospective studies of three sports (basketball, soccer and volleyball) show significant benefit of preventive ankle bracing. Is any more data needed?

   If so, one only needs to evaluate today’s gold standard of evidence-based medicine: the systematic review of this subject published by the Cochrane Database Review.¹⁰ Here, the evidence becomes even more overwhelming supporting the notion that preventive bracing of the ankle is effective and safe. Overall, the review included 14 randomized trials with data for 8,279 participants. The main finding was a significant reduction in the number of ankle sprains in people who had external ankle support. This reduction was greater for those with a previous history of ankle sprain but still possible for those without a prior sprain. There was no apparent difference in the severity of ankle sprains or any change to the incidence of other leg injuries.

   Other systematic reviews of the large body of published research on preventive ankle bracing have shown similar results and conclusions. Kaplan recently published a review of 19 randomized, controlled trials consisting of a total of 12,233 participants.¹¹ The studies showed a significant reduction in the number of ankle sprains in individuals in an external ankle support group. This reduction was greater for those with a previous history of ankle sprains. Braces appeared to be more effective than tape in preventing ankle sprains.

Are There Any Negative Effects With Preventive Ankle Bracing?

The primary objections from parents, coaches and some physicians about the possible downside of ankle bracing include: cost, possible weakening of the ankle musculature, reduced proprioception and, most importantly, negative effects on athletic performance. However, a close review of credible evidence published in peer-reviewed literature reveals that none of these concerns are viable.

   Olmstead and colleagues studied the cost of bracing and taping to prevent a sprain during an entire season of both basketball and soccer.¹² This analysis showed that ankle bracing was cost effective and ankle taping was three times more expensive than bracing during an entire season.

   A common allegation about the negative effects of ankle bracing is that the continuous use of a brace would gradually weaken the ankle musculature. Yet several studies indicate that no effects or even the opposite effects occur. Cordova and co-workers showed that both semi-rigid and lace-up ankle braces caused no effects on activation of the peroneal musculature immediately or after eight weeks of use.¹³ In another study, Cordova and colleagues found that lace-up ankle braces actually facilitated the peroneal stretch reflex amplitude and that this increase persisted for eight weeks of use.¹⁴

   In terms of proprioception and muscle activation, Nishikawa and Grabiner showed that application of an ankle brace excited a number of ankle proprioceptive afferents possibly arising from a number of candidate mechanoreceptors.¹⁵

   Gross and colleagues performed a systematic review of both the protective benefits of preventive ankle bracing as well as any potential negative effects.¹⁶ The authors concluded that ankle braces do not appear to affect athletic performance adversely and provide significant effects to reduce the incidence of ankle sprains in athletic populations.

   In the best published study on this subject, Cordova and colleagues performed a meta-analysis of 17 randomized controlled trials that used a crossover design to measure effects of bracing on performance measures.¹⁷ The studies included a comparison of tape, semi-rigid braces and lace-up braces. Of these studies, approximately 30 percent used injured patients. In terms of sprint speed, the largest effect occurred with a lace up brace, which yielded 1 percent impairment. For agility speed, the net effects of all three supports were negative but only by 0.5 percent. For vertical jump, a 1 percent decrease in performance occurred in all three conditions.

   The authors concluded that these negative effects are trivial for most individuals but may have greater significance for elite athletes.¹⁸ They also recommended that the benefit of external ankle support in preventing injury outweighs the small negative effects on sports performance.

In Conclusion

Therefore, there are no negative effects of preventive ankle bracing as reported by credible researchers who have published their results in numerous peer-reviewed articles. Furthermore, there is overwhelming evidence published in the literature that bracing will prevent ankle sprains in a broad range of athletes in numerous sports. This begs a question: why would podiatric physicians not recommend preventive ankle bracing for all people actively participating in competitive soccer, volleyball and basketball?

[5]

   Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is in private practice in Seal Beach, Ca.

References
1. Bahr R, Karlsen R, Lian O, Ovrebo R. Incidence and mechanisms of acute ankle inversion injuries in volleyball. Am J Sports Med. 1999; 22(5):595–600.
2. Ekstrand J, Tropp H. The incidence of ankle sprains in soccer. Foot Ankle Int. 1990; 11(1):41-4.
3. Garrick JG, Requa RK. Role of external support in the prevention of ankle sprains. Med Sci Sport. 1973; 5(3):200-3.
4. Gomez E, DeLee JC, Farney WC. Incidence of injury in Texas girls’ high school basketball. Am J Sports Med. 1996; 24(5):684–687.
5. Glick JM, Gordon RB, Nishimoto D. The prevention and treatment of ankle injuries. Am J Sports Med. 1976; 4(4):136-140.
6. Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med. 1985; 13(4):259-262.
7. Sitler MR, Horodyski M. Effectiveness of prophylactic ankle stabilizers of prevention of ankle injuries. Sports Med. 1995; 20(1):53-57.
8. Surve I, Schwellnus MP, Noakes T, Lombard C. A fivefold reduction in the incidence of recurrent ankle sprains in soccer players using the sport-stirrup orthosis. Am J Sports Med. 1994; 22(5):604-605.
9. Pedowitz DI, Sudheer R, Parekh SG, Huffman G, Sennett BJ. Prophylactic bracing decreases ankle injuries in collegiate female volleyball players. Am J Sports Med. 2008; 36(2):324– 327.
10. Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2001; (3):CD000018.
11. Kaplan Y. Prevention of ankle sprains in sport: a systematic literature review. Br J Sports Med. 2011; 45(4):355.
12. Olmstead LC, Vela LI, Denegar CR, Hertel J: Prophylactic ankle taping and bracing: A numbness needed-to-treat and cost-benefit analysis. J Athl Train. 2004; 39(1): 95-100.
13. Cordova ML, Cardona CV, Ingersoll CD, Sandrey MA. Long-term ankle brace use does not affect peroneus longus muscle latency during sudden inversion in normal subjects. J Athl Train. 2000; 35(4):407-11.
14. Cordova ML, Ingersoll CD. Peroneus longus stretch reflex amplitude increases after ankle brace application. Br J Sports Med. 2003; 37(3):258-62.
15. Nishikawa T, Grabiner MD. Peroneal motoneuron excitability increases immediately following application of a semirigid ankle brace. J Orthop Sports Phys Ther. 1999; 29(3):168-73; discussion 174-6.
16. Gross MT, Liu HY. The role of ankle bracing for prevention of ankle sprain injuries. J Orthop Sports Phys Ther. 2003 Oct;33(10):572-7.
17. Cordova ML, Scott BD, Ingersoll CD, Leblanc MJ. Effects of ankle support on lower-extremity functional performance: a meta-analysis. Med Sci Sports Exerc. 2005; 37(4):635-641.

No.

This author argues that clinicians should consider other modalities and be wary of a hasty return to play with bracing as a lack of follow-through with appropriate rehabilitation may lead to compromised tissue repair and recurrent sprains.

Ankle sprains make up 85 percent of all ankle injuries and approximately 25 percent of all lower extremity athletic injuries.^1,2 These injuries pose a high financial cost to institutions, schools, private athletic clubs and teams due to playing time missed and medical intervention.

   The most common risk factor of an ankle sprain is a previous ankle sprain. Ankle sprains can be easily underdiagnosed or misdiagnosed so one should consider other diagnoses such as fractures, midfoot sprains, syndesmosis injury, peroneal injury, osteochondral injury or even nerve damage. Most often ankle sprains are undertreated by medical professionals or not treated at all due to underreporting. Accordingly, one should ascertain a proper history and perform physical and radiological exams to ensure an accurate assessment.

   Swift diagnosis, early intervention and aggressive and thorough rehabilitation are the key elements to preventing future sprains, and maintaining good stability of the joints involved. The athlete can return to play quickly with less chance of recurrence when there is a proper understanding of the injury, appropriate patient education and traditional and non-traditional holistic treatments. With these proper protocols, there is less necessity for bracing.

Pertinent Insights On Treating Sprains Without Bracing

Swelling and ecchymosis commonly occur with most ankle sprains so immediate and properly applied compression is imperative. Utilizing a horseshoe type felt or similar pad with a compression bandage that wraps around the malleolus and up the distal leg will force swelling and ecchymosis upward. This promotes venous return and reduces the likelihood of hemorrhages in and around the joint. These hemorrhages can lead to adhesions and decreased range of motion.

   Compression will reduce pain by affecting the surrounding proprioceptors via the “gait theory of pain.”³ One can utilize Kinesio Tape in a fan-like pattern, which also helps with the venous return and reducing pain at the receptor levels. Always utilize the compression wraps with a supportive shoe or walking boot.

   With grade I, II or III sprains, patients should avoid utilizing a posterior splint while they are non-weightbearing. They should also avoid wearing unsupportive shoe gear like flip flops or similar sandals. It is best to use a firm athletic shoe that ties up.

   For more serious sprains, one can use a walking orthopedic boot with the foot in a 90-degree position for optimal alignment of the ankle ligaments that place patients into their functional “closed pack” position. Patients can use crutches as needed but partial or full weightbearing is preferred. This aids in venous return, which creates microscopic massaging and pumping of the fluids in and around the joints. Protected 90-degree weightbearing is very important in the early stages of injury.

   Podiatrists should reconsider the use of nonsteroidal antiinflammatory drugs (NSAIDs). Recent studies have shown that utilizing COX-1 and COX-2 inhibitors reduces the recruitment of cellular activity by the immune system by inhibiting the inflammatory cascade.^4,5

   Consider alternative therapies that reduce swelling and improve cellular recruitment for repair, but do not interfere with immune activation. Physical therapy modalities such as electric stimulation and laser therapies are external, and will not interfere with internal immune functioning. Other external holistic treatments such as acupuncture, massage and magnets can quickly and effectively reduce swelling, ecchymosis and pain.6

   A combination of these traditional and non-traditional therapies can speed recovery of the tissue, thus preventing a possibly accelerated, histological, “chronic” tissue state. This will allow earlier range of motion and progression toward functional rehabilitation. Aggressive and functional therapy is vital for an uncompromised return to play. Range of motion exercises and patient directed early isometrics should begin immediately. One can also accomplish this by forced early partial or full weightbearing.

What You Should Know About Exercise And Rehabilitation

Very aggressive joint mobilizations and/or excessive exercises early on can have detrimental effects on ligament healing. Accordingly, protected weightbearing is still important in regard to transitioning the patient into a supportive tie shoe.

   Isotonic and eventual isokinetic exercises should start at the appropriate time and should continue even after early/partial return to play. One should emphasize the “eccentric” portion of the extrinsic foot muscle exercises as the lower extremity cannot function properly if eccentric control is weak. Patients should perform intrinsic foot muscle exercises as well, especially to ensure good proprioception abilities.

   Whether the sprain is grade I, II or III, it is important to start and proceed through therapy with correct timing. When they feel better, many athletes may discontinue therapy at this point and jump back into sports in a hasty manner either on their own or when misdirected by medical personnel, often with the assistance of an external brace.

   It is at this point where the brace has more perceived credence than the continued rehabilitation. This unfortunately will halt tissue repair to a major degree and may compromise it as the athlete is falsely confident in the less than optimally rehabbed ankle.

   It is at this point that the real therapy starts. It is vital to perform functional activities that mimic the sport as well as enhanced balance and proprioception drills. Weeks of inactivity may have deleterious effects on the foot and ankle proprioceptors so balance exercises are key in the rehab program.⁷ Hip and core muscle recruitment are also important because of possible disuse atrophy, pre-injury weakness, motor patterning faults from limping and from use of the orthopedic boot.

   Complete lower extremity exercises give such an advantage to athletes when they matriculate back into playing. It is very common that athletes re-sprain the same ankle shortly afterwards, creating a vicious cycle of medical intervention dollars, downtime and further tissue damage.

   During more advanced rehabilitation and eventual return to play, proper athletic shoe gear and evaluation for custom functional foot orthotics are essential for all athletes to return at maximal abilities. Placing the foot in the absolute best alignment will help the kinematics of the ankle and surrounding joints to function at their peak. The talus plantarflexes with pronation, which puts the ankle mortise in a compromised situation because the talar dome is wider anteriorly and more narrow posteriorly. When the foot excessively pronates, the talus is plantarflexed to a greater degree. Therefore, the mortise has more frontal plane joint play, predisposing the athlete to an inversion moment.

   Utilizing custom functional orthotics not only prevents abnormal pronation but when the lower extremity is properly functioning, all muscles of the lower extremity, including gluteal muscle recruitment, are better. Accordingly, the athlete benefits from improved neurological tone and motor patterning.

A Closer Look At The Potential Of Injection Therapy

Another holistic modality that is helpful is injection therapy, which can be a great advantage to the injured ankle. Injectable FDA-approved homeopathic medicines such as Traumeel (Heel, Inc.) and Lymphomyosot (Heel, Inc.) can reduce swelling, ecchymosis and pain early in the acute stages and later for the sprain that is in a chronic state. Traumeel activates the growth factor TGF-beta to speed and activate cellular repair.⁸

   Traumeel as well as other traditional prolotherapy solutions can speed the healing of the damaged ligaments and can improve chronic or old sprained tissues as well. Typically after six to eight weeks, the athlete is often back to play and, to a certain degree, ligaments may be repaired. Histologically, the collagen can take upward of 16-plus weeks to repair fully and certainly up to a year to remodel fully.

   The consensus is athletes report that they do not feel truly confident in that ankle for many weeks post-injury. One should utilize injection therapy after confirming with radiographic or ultrasound evaluation that the tissue is attenuated or partially torn to some degree. Injection therapy will create the “needle effect,” which triggers the inflammatory cascade to incite collagen growth. Rather than surgical repair, needling the ligaments will stimulate the collagen production to continue to strengthen the tissue and allow it to become as strong as it was pre-injury. These treatments can occur throughout the rehabilitation period as well as during some athletic participation. This creates an advantage over surgery.

   While one cannot repair complete tears via needling or prolotherapy, sprains with compromised tissues will benefit greatly with the use of these modalities. Chronically injured tissues may continue to cause pain as they are not functionally strong for the rigors of most athletic performance.

In Conclusion

The aforementioned statements prove how complex an ankle sprain may be and obvious reasons why they recur so frequently. Athletes with a damaged anterior talofibular ligament can be productive and functionally strong after a proper, aggressive and continued strength training program. Due to these facts, it behooves all practitioners to attempt all types of traditional and non-traditional modalities, and not stop short of complete tissue repair with excellent function.

   There will be athletes who will undoubtedly need some formal bracing for continued athletic pursuits. However, in theory, if the athletes had gone through a complete formal and functionally based rehabilitation program, they most likely would not need a brace. The common ankle sprain is not typically a grade II or III with complete disruptions so for the majority of sprains commonly seen, complete repair and full function is attainable with the correct treatments. When we continue down the slippery road of ankle sprain after ankle sprain, the thought of the impact on future healthcare dollars to insurance companies and institutions is staggering.

   Formal education of athletes, parents and coaches is vital in understanding the responsibility of properly tending to athletic injury. Whether it is our high-level athletes, weekend warriors or the high level children’s sports programs that bring the ankle sprain into the office, awareness, understanding and aggressive rehabilitation of this very insidious injury are critical.

[6]

   Dr. Schoene is a triple board certified sports medicine podiatrist and a certified athletic trainer. She is a Fellow of the American Academy of Podiatric Sports Medicine and the American College of Foot and Ankle Surgeons.

References

1. Garrick JG. The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am J Sports Med. 1977; 5(6):241-242.
2. Hockenbury RT, Sammarco GJ. Evaluation and treatment of ankle sprains: Clinical recommendations for a positive outcome. Phys Sports Med. 2001; 29(2):569-81.
3. Melzack R, Wall P. Pain mechanisms: a new theory. Science. 1965; 150(699):971-9.
4. Birnesser H, Klein P, Weiser M. A modern homeopathic medication works as well as COX 2 Inhibitors. Der Allgeminarzt. 2003; 25(4):261-264.
5. Simon AM, O’Connor JP. Dose and time dependent effects of cyclooxygenase 2 inhibition on fracture healing. J Bone Joint Surg Am. 2007; 89(3):500-511.
6. Editorial Staff. Researchers to study acupuncture for ankle instability and shin splints. Acupuncture Today. 2000; 1(9).
7. Mattacola CG. Effects of 6 week strength and proprioception training program on measures of dynamic balance: a single case design. J Ath Train. 1997; 32(2):127-35.
8. Orizola AJ, Vargas F. The efficacy of Traumeel versus Diclofenac and placebo ointment in tendinous pain in elite athletes: a double blind randomized controlled study. Med Sci Sports Exerc. 2007; 39(5):S78.

Additional References

9. Losito J. Foot and ankle injuries in basketball. Podiatry Management. 2004; 23(2):78-83.
10. Heine H, Schmolz M. Induction of the immunological bystander reaction by plant extracts. Biomedical Therapy. 1998; 16(3):224-226.
11. Loeser RF. Molecular mechanisms of cartilage destruction; mechanics, inflammatory mediators, and aging collide. Arthritis Rheum. 2006; 54(5):1357-60.
12. Wagner H, Jurcic K, Doenicke A. Influence of homeopathic drug preparations on the phagocytosis capability of granulocytes, In-vitro tests and controlled single blind studies. Biological Therapy. 1993; 11(2):43-49.
13. Rodd D, Schneider S, Sheehy T, Enzler D. Three ankle braces take performance test. Biomechanics. 1999.
14. Hauser R. Prolo your pain away. Beulah Land Press, Oak Park, IL., 2007.
15. Sinatra S, Healthy J. Arthritis Interrupted. Jim Healthy Publications, 2010.
16. Gross M, Liu H. The role of ankle bracing for prevention of ankle sprain injuries. J Orthop Sports Phys Ther. 2003; 33(10):572-7.

   For further reading, see the blog “Taping Versus Bracing: Which Is More Effective In Preventing Ankle Sprains In Athletes?” at http://bit.ly/FI64o [7] .