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Managing Soft Tissue
Ankle Injuries
A summary of recent research
Composite
Contents
Introduction .........................................................................................2
Summary of research conclusions ................................................................................... 2
The research .........................................................................................4
Part 1: Evidence for management – a literature review ................................................... 4
Part 2: Claims analysis ................................................................................................... 5
Ankles and ankle injuries ....................................................................7
The ankle joint ................................................................................................................ 7
Ankle injuries ................................................................................................................. 7
Diagnosis and classification ............................................................................................ 8
Associated injuries ......................................................................................................... 8
Management ................................................................................................................... 9
Treatment providers ..........................................................................10
Part 1: The evidence for treatment and management – literature review ...............11
Therapeutic heat and cold, compression and elevation ................................................. 11
Immobilisation .............................................................................................................. 12
Functional treatment ..................................................................................................... 13
Electrotherapy .............................................................................................................. 14
Manual therapy ............................................................................................................. 17
Rehabilitation of ankle sprain ....................................................................................... 18
Acupuncture ................................................................................................................. 18
Recommendations for treatment and management ........................................................ 19
Part 2: Analysing ACC claims ..........................................................................20
Choosing outcomes, claims and ‘predictors’ for the study ............................................. 21
Results: characteristics of claimants and claims ........................................................... 22
Results: number of visits .............................................................................................. 24
Results: duration of claim ............................................................................................. 26
Results: any time off work ............................................................................................. 27
Results: days off work ................................................................................................... 28
Results: costs (less ERC) .............................................................................................. 28
Patterns that emerged ................................................................................................... 31
Recommendations for claims handling ......................................................................... 33
Glossary..............................................................................................34
References ..........................................................................................37
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Introduction
Ankle injuries are a common and recurrent problem around the world. International figures
report that ankle sprains represent 15-20% of all sporting injuries, and about 10% of all
presentations to accident and emergency departments. Between 20% and 40% of ankle sprains
go on to develop residual symptoms with varying degrees of disability.
Ankle sprains represent a significant cost to ACC, accounting for more than 82,000 new claims
in the 2000/01 year at a cost of over $19 million. In the same year 17,200 ongoing claims cost
an estimated $12.8 million. Collectively, new and ongoing ankle claims represent the fourth
largest cost to ACC after injuries to the lower back, neck and shoulder.
Concerned about these figures, in 2001 ACC commissioned an independent study of the
management of ankle sprains that involved assessing current practice (and developing
recommendations on treatment and management), identifying trends in claimant and provider
behaviour and clarifying costs to the scheme. It was undertaken by the Effective Practice
Institute, Division of Community Health, University of Auckland.
This document summarises the final report and contains general information designed for
treatment providers and other interested parties. The full report, which contains more detailed
statistical information, is available from the Effective Practice Institute and www.acc.co.nz.
Summary of research conclusions
Evidence on treating and managing ankle sprains
•
The evidence supports using functional treatment with early mobilisation for all grades of
ankle sprain, including proprioceptive (balance and co-ordination) training in
rehabilitating ankle sprains.
•
There is good evidence to discourage:
–
using cast immobilisation for any grade of ankle sprain
–
using laser therapy.
•
There is some evidence to support elevation.
•
The evidence is inconclusive on using:
–
ice for ankle sprains
–
electrotherapy
–
manual therapy.
•
There was insufficient evidence to evaluate the use of acupuncture.
•
Contrast baths may do more harm than good by increasing swelling.
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Claims analysis
Key findings from analysing ACC claims data include:
•
Maori receive less care than non-Maori
•
people defined as ‘professionals’ receive more care than other occupational groups
•
claimants in provincial cities have more treatment visits and are more likely to take time
off work than those in main city areas or smaller communities
•
claimants who visit a GP first use fewer resources (ie, fewer visits, less likely to have time
off, and cost less) than others. Those who see a physiotherapist first have more visits than
others, but are much less likely to take time off work
•
claimants with a history of four or more claims (for any cause) within the past five years
have more visits and cost more per claim than others
•
the extent to which these differences reflect differences in the severity of the initial injury
could not be determined.
Recommendations for research and development
•
There is a need for well designed and conducted randomised controlled trials with
adequate power, clinically relevant outcomes and of sufficient duration to assess the
effectiveness of the following interventions (of which some could be combined in a single
trial):
–
manual therapy (joint mobilisation and manipulation)
–
rehabilitation programmes, including strength, proprioceptive and flexibility
training
–
acupuncture
–
immediate treatment with continuing follow-up versus, for example, a five-day
delay before follow-up
–
visit frequency, such as several visits per week versus a single visit followed by
self-management with advice.
•
An incidence-based controlled study could identify risk factors for ankle sprains and, if
associated with a prospective cohort study, could describe factors that lead to residual
symptoms and recurrent sprain. Predictive models could then be used to develop
preventive and rehabilitation strategies.
•
There should be an investigation of current clinical practice to identify gaps, to be
followed up with treatment guidelines.
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The research
In 2001, ACC commissioned the Effective Practice Institute of the University of Auckland to
review the management of acute soft tissue injuries of the ankle joint. The study involved:
•
identifying and evaluating New Zealand and international evidence on interventions
commonly used by general practice, physiotherapy, chiropractic, osteopathy and
acupuncture in managing acute soft tissue injuries in adult populations (pharmacological
and surgical management was excluded)
•
analysing ACC ankle claims data over a three-month period and examining relationships
between claimants’ demographic characteristics, patterns of care and specified outcomes
(such as days off work, duration of claims and cost of claims).
The Institute was asked to address the relationship between the treatment of soft tissue injuries
of the ankle and early return to work for the use of GP, physiotherapy, acupuncture, chiropractic
and osteopathy. It also sought evidence on the effectiveness of interventions used in managing
soft tissue injuries of the ankle.
Part 1: Evidence for management – a literature review
A comprehensive literature review identified and critically appraised over 40 randomised
controlled trials involving individuals between 15 and 60 years old with acute or sub-acute soft
tissue injuries. It considered seven broad types of interventions:
•
therapeutic heat or cold, with compression and elevation
•
rigid and semi-rigid immobilisation
•
functional treatment
•
electrotherapy
•
manual therapy
•
rehabilitation
•
acupuncture.
The review specifically excluded surgical interventions, interventions relating to using any type
of medication and/or injections, and interventions to prevent ankle sprain. It could not address
the evidence on delay to first treatment or treatment intensity (frequency of visits) owing to a
lack of evidence addressing these topics in the literature.
The trials selected had to use at least one of 10 outcome measures:
•
pain, swelling, loss of range of movement
•
ability to bear weight
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•
incidence of recurrent sprains
•
subjective evaluations of results
•
satisfaction with result
•
return to work
•
return to previous levels of activity, including sport
•
incidence of functional or mechanical instability
•
costs
•
adverse events.
The literature review covered general databases, Internet searches, Cochrane-related sources*,
reference lists, conference proceedings and correspondence with relevant organisations.
Limitations of the review
The review included only published studies in the English language, with limited handsearching of relevant journals.
* The Cochrane Collaboration is an international organisation that aims to help people make
well informed decisions about healthcare by preparing, maintaining and promoting the
accessibility of systematic reviews of the effects of healthcare interventions. For more
information, visit www.cochrane.org.
Part 2: Claims analysis
ACC provided the Institute with data for all people who had made one or more claims following
a soft tissue injury to the ankle between 1 July 2000 and 30 September 2000.
To identify claimant characteristics, patterns of service and related outcomes in a clearly
defined population, the Institute extracted a subset of 13,421 claims (53.3% of the total) that
met pre-defined criteria. This subset comprised claimants over 15 years of age with a soft tissue
injury to the ankle and no other co-morbidities or complications. Overseas residents, and
claimants whose injuries occurred overseas were excluded from further analysis.
The selected patient outcomes included:
•
number of visits for treatment
•
duration of the claim (days)
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•
whether claimants who were earners took time off work
•
the days claimants who were off work were paid earnings-related compensation (ERC)
•
the costs of claims (excluding ERC).
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Ankles and ankle injuries
Soft tissue injuries of the ankle encompass a broad range of soft tissue injuries, from sprains of
the ankle ligaments to injuries to muscles and tendons. Most ankle sprains resolve with
functional treatment, however an estimated 20% to 40% go on to develop residual symptoms
with varying degrees of disability.7 11-13
These residual symptoms can present as pain, swelling and stiffness as well as instability,
limiting participation in sport, recreation and some daily activities. The recurrence of ankle
sprain has been estimated at around 80%7 10 14 and is one of the risk factors for developing
chronic disability.6 The epidemiology clearly demonstrates this is a common and recurrent
problem.
The ankle joint
Note the glossary on page 34 explains some of the terminology in this report.
The ankle joint acts with other joints of the foot and lower limb to provide both support and
propulsion for the human body.18 It sustains the greatest loading force per surface area of any
joint, and is therefore susceptible to injury and potentially long-term difficulties in mobility.2
This makes it critical to diagnose and manage ankle injuries accurately and appropriately to
restore optimal function and prevent long-term disability.
Three joints are important in diagnosing and managing ankle sprains:
•
the talocrural joint
•
the inferior tibofibular syndesmosis
•
the subtalar joint.
Four groups of ligaments contribute to the ankle joint’s stability, guide movement and provide
proprioceptive information necessary for normal joint function:6
•
the lateral ligament
•
the medial ligament
•
the syndesmotic ligaments
•
the subtalar ligaments.
Ankle injuries
Most ankle sprains are weight-bearing injuries.19
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A typical injury involves plantarflexion and inversion of the foot, which causes damage to the
ligaments in a predictable sequence. The anterior talo-fibular ligament (ATFL) is torn first,
followed by the calcaneo-fibular ligament (CFL), and lastly the posterior talo-fibular ligament
(PTFL).4-6,11 Damage to the PTFL is usually associated with severe injury and may involve ankle
dislocation, avulsion fracture of the lateral or medial malleolus, and compression fractures of the
talus.6
Other mechanisms of injury may damage other structures. Eversion injuries affect the medial
ligament, and forced external rotation of the foot may damage ligaments of the syndesmosis.9
The mechanism of injury is therefore important in alerting clinicians to possible pathologies
involved in an ankle injury.
Diagnosis and classification
The Ottawa Ankle Rules are used to identify the need for radiography to exclude fractures.20-22
Once fractures are excluded, the next task is to identify the extent of soft tissue damage.
Traditionally, ankle sprains have been described in terms of the severity of damage to the lateral
ligaments of the joint, which are involved in 85% of soft tissue ankle injuries.6 23 This
classification defines three grades of pathology:3 6 23
1.
Grade 11: Stretch of the ligament without macroscopic tearing; little swelling or
tenderness; slight or no functional loss; no instability.
2.
Grade II
II: Partial macroscopic tearing of the ligament; moderate pain, swelling and
tenderness over the involved structures; some loss of motion; some instability (mild or
moderate).
3.
Grade III
III: Complete rupture of one or more ligaments; severe swelling, haemorrhage,
tenderness; considerable loss of motion, and moderate or severe instability.
Classification is usually done using a history of the injury and a clinical examination. The
anterior drawer test and the talar tilt test are manual stress tests that evaluate the competence of
the ATFL and CFL respectively,6 23 but their reliability in assessing acute ankle injury within
the first 24 hours has been questioned.24 Meanwhile, radiographic imaging has a controversial
role in diagnosing acute ankle sprains, other than to exclude fractures. Computerised
tomography (CT) and magnetic resonance imaging (MRI) are also considered of ‘limited utility’
in evaluating acute ankles.27
Associated injuries
These classification methods may mean that injuries to other structures around the ankle joint
are missed in the initial diagnosis. These injuries include:
•
avulsion fractures (tibia, fibula or base of the fifth metatarsal)23
•
fractures of calcaneal process30
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•
osteochondral fractures31
•
syndesmosis ligament involvement, with or without diastasis of the inferior tibio-fibular
joint32
•
medial ligament tear31
•
subtalar ligament tear33
•
peroneal tendon subluxation or dislocation19 34
•
Achilles tendon rupture19
•
tibialis posterior tendon rupture (relatively rare)35
•
peroneal and tibial nerve neurapraxia owing to traction injuries.36
It is important to consider the likelihood of these injuries, particularly in the more severe ankle
sprains, in both prognosis and management.29
Management
It is generally accepted that Grades I and II ankle sprains are best managed with rest, ice,
compression and elevation (the ‘RICE’, or ‘Rest, Ice, Compression, Elevation’ protocol) followed
by early mobilisation.6 11 23 37 Protected weight bearing (crutches) or non-steroidal antiinflammatories and various types of soft bracing and/or taping may also be used in the early
phase of management.4 6 19 37 38
There has been much debate on whether Grade III ankle sprains should be managed surgically
(primary repair), conservatively (cast immobilisation), or by early weight-bearing and
mobilisation (functional treatment).39-42 Functional treatment appears to be the treatment of
choice for all grades of soft tissue ankle injuries.4 6 8 9 11 12 19 23 43-46 This involves using rigid or
semi-rigid bracing, taping and elastic bandage to facilitate early weight-bearing and
mobilisation.47 Other interventions are frequently used to facilitate the healing process and to
regain mobility, strength and co-ordination.
RICE is the standard management for all acute soft tissue injuries in the first five to seven days
of injury to reduce inflammation.48 49 Various forms of electrotherapy (ultrasound, short-wave,
interferential, TENS and laser) as well as acupuncture are also used to relieve pain and reduce
swelling. Manual therapy includes using mobilisation and manipulation to recover range of
movement in the involved joints. Proprioceptive re-training (using wobble and tilt boards) helps
restore co-ordination and balance, and muscles are strengthened by appropriate exercise
regimes.
Treatment for ankle sprains aims to reduce the time lost from work, provide a return to normal
daily activities and sport, and prevent ankle instability and recurrent sprain.30 37 Recovery from
Grades I and II sprains may take up to four to six weeks, while recovery from more severe
sprains may take three to six months or longer.6 9 11 23 30
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Treatment providers
ACC claimants can access any one of 14 treatment provider types for their first visit.
GPs and physiotherapists provide most services for ankle injuries, while orthopaedics and
radiology are the specialist services most involved. Orthopaedic surgeons comprise the main
specialist group involved in managing ankle injuries, but see less than 1% of claimants.
Complementary and alternative medicine (CAM) disciplines (chiropractic, osteopathy and
acupuncture) can also provide services for ACC claimants; however current figures suggest they
play a minor role in managing ankle injuries.
A sprained ankle is considered within ACC’s scope of practice for practice nurses, osteopaths,
physiotherapists and registered medical practitioners. It is not considered within the scope of
practice for chiropractors and acupuncturists. Only a registered medical practitioner can assess
work incapacity and authorise time off work under the claim.50
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Part 1: The evidence for treatment and management
– literature review
It should be noted that studies were generally disappointing, with much current clinical practice
not supported by good evidence.
Therapeutic heat and cold, compression and elevation
Common treatment methods
Key conclusions
• Cooling (in the acute phase)
• The evidence for using ice and compression for acute
ankle sprains is inconclusive
• Heat (to promote recovery): hot packs, hot water,
radiation, conversion
• The use of heat, cold and contrast baths may increase
swelling
• RICE
• There is some support for the effectiveness of
elevation for reducing swelling in ankle sprains
Therapeutic heat and cold are commonly used as adjuncts to physiotherapy treatment of soft
tissue injuries. Cryotherapy (cooling) is used primarily in the acute phase, while thermotherapy
(warming) is used in the latter stages of recovery to promote tissue healing by increasing
circulation through vasodilation of blood vessels, increased cellular metabolism, increased
nerve conduction and muscle spindle activity.56
Heat can be applied directly to the tissues with hot packs or by immersing the part in hot water.
Heat can also be achieved at deeper tissue levels by radiation (infrared) and conversion (shortwave, microwave and ultrasound)56 – the electrotherapy section on page 14 covers this in more
detail.
The ‘RICE’ protocol for acute soft tissue injuries is widely used49 to minimise the acute
inflammatory response to injury. This phase lasts up to seven days depending on the severity of
the injury.48
There is still some controversy on the use of ice, as the scientific basis for its use is still
unknown.49 Ice can be applied using chipped ice, iced towels, gel packs, chemical cold packs
and cold baths. The duration of treatment varies, but is often between 20 and 30 minutes,
usually applying a wrap between the ice and the skin to prevent frostbite. Applications can be
repeated two hourly.49 The effects of ice are transmitted to the tissues by conduction and
convection.56 Complications include frostbite and nerve palsy (usually where nerves are
superficial).
Compression is frequently used in conjunction with ice and elevation of the swollen limb. It can
help resolve swelling which, if prolonged, can cause secondary hypoxia in the tissues.57 The
types of compression used include pneumatic compression, u-shaped pads for focal
compression, inflatable cuffs, compression bandages and compression splints.
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Conclusions
Seven studies were investigated, using a range of interventions that included ice, heat,
compression or elevation.
Based on these studies, the research team concluded that:
•
the evidence for using ice and compression for acute ankle sprains is inconclusive
•
the use of heat, cold and contrast baths may increase swelling
•
there is some support for the effectiveness of elevation for reducing swelling in ankle
sprains.
Immobilisation
Common treatment methods
Key conclusions
• Plaster cast
• There is no evidence to support the use of
immobilisation in ankle sprains
• Removable devices
• Early mobilisation improves early outcomes, such as
return to work, with some evidence for similar
outcomes long-term
Immobilising acute ankle injuries has been a contentious issue over many years, but there is
now widespread agreement (as a result of numerous trials) that there is little benefit in operative
treatment in the acute stage of ankle injury management.
Immobilisation has traditionally been by plaster cast, but modern materials and technology have
enabled the use of removable devices, which can both limit mobility and still allow early active
range of movement in the ankle joint. These have shown that early active mobilisation is the
treatment of choice, even with a severe ligament rupture.
Conclusions
The research team studied 16 trials in comparing immobilisation (plaster of Paris) and some
form of bracing or early mobilisation. The period of immobilisation ranged from one week to six
weeks, and the results showed a general tendency towards early mobilisation.
The studies were generally of poor quality so it is difficult to draw strong conclusions. However:
•
there is no evidence to support the use of immobilisation in ankle sprains
•
early mobilisation improves early outcomes, such as return to work, with some evidence
for similar outcomes long term.
Further improved studies are needed to validate or refute the results.
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Functional treatment
Common treatment methods
Key conclusions
• Adhesive tape
• There is no evidence that any type of taping or brace
is more effective than any other. Personal preference,
comfort (and therefore compliance) and cost are
probably main considerations
• Elastic bandage or elasticised ankle supports
• Lace-up ankle braces using soft material such as
canvas or nylon
• Further trials are needed to evaluate the use of taping
and bracing for stable and unstable ankle sprains
• Semi-rigid types of bracing such as aircast splints
• Adverse reactions, costs and comfort should be
included as outcome measures
‘Functional treatment’ means using various types of support to allow early mobilisation while
still protecting the joint.
Functional treatment is the recognised preferred treatment for all grades of ankle sprain, and is
classified by type of material used, and degree of rigidity.19 Functional treatment includes
using:
•
adhesive tape
•
elastic bandage or elasticised ankle supports
•
lace-up ankle braces using soft material such as canvas or nylon
•
semi-rigid types of bracing such as aircast splints, which use a more rigid thermoplastic
material as part of the brace.47
These aim to re-approximate ligament ends and protect the ankle by controlling inversion. At a
later stage in rehabilitation, bracing is used to prevent re-injury. However, a support is only
useful as long as it is available and used appropriately – other goals need to address issues of
cost, ease of application, comfort, and that it does not interfere with performance.19 The choice
of taping technique or type of brace depends on ‘personal preference, superstition or
anecdote’.80
Conclusions
The review covered seven studies that investigated the use of various types of taping and bracing
as part of managing acute soft tissue ankle injuries. The soft tissue bracing included
compression pads,81 aircast stirrup,82 scotchrap,83 malleotrain,84 Nottingham ankle brace,86 gel
cast85 and various types of strapping.87 One trial compared different methods of taping with no
taping.87 Comparisons included the use of taping, bandage or Tubigrip.
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Outcome measures varied – four trials included days off work as an outcome measure, and three
of these resulted in a significant reduction in sick leave time.81 82 85 Other outcomes included
pain, swelling, range of movement, ability to weight bear and comfort. Two trials made specific
reference to cost, primarily owing to earlier return to work.82 85
The team concluded that:
•
there is no evidence that any type of taping or brace is more effective than any other.
Personal preference, comfort (and therefore compliance) and cost are probably main
considerations
•
further trials are needed to evaluate the use of taping and bracing for stable and unstable
ankle sprains
•
adverse reactions, costs and comfort should be included as outcome measures.
Electrotherapy
Common treatment methods
Key conclusions
• Ultrasound
• The evidence does not support the use of ultrasound,
with many studies and several reviews suggesting
no evidence of benefit
• Short-wave
• Transcutaneous nerve stimulation (TENS)
• Interferential
• The evidence on short-wave and pulsed diathermy
indicates little benefit, and the better studies show
no benefit
• Laser therapy should be discontinued as it has been
shown to delay recovery and is cost inefficient
• No studies were found for TENS and interferential
therapy
Electrotherapy is one of the fundamental elements of physiotherapy practice.88 The agents used
in physiotherapy include infrared, ultraviolet, ultrasound, short-wave, microwave, laser,
interferential, transcutaneous nerve stimulation (TENS), and neuromuscular and muscular
electrical stimulation modalities.
Studies in the United Kingdom90 Australia91 and Alberta92 indicate widespread use of
ultrasound, interferential and TENS. Pulsed short-wave and Flowtron were commonly used in
the UK study, but short-wave was only occasionally used in the Australian study. Hot packs
were used more commonly in the Australian study and not mentioned in the UK study. In
Alberta, Canada, hot packs, followed by ultrasound, ice, TENS, and interferential were the most
frequently used.92
This review covered studies evaluating the use of ultrasound, short-wave, laser, TENS and
interferential (see page 11 on the use of hot and cold packs).
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Ultrasound
Ultrasound has been widely used by physiotherapists since the 1950s to promote circulation,
reduce oedema, relieve pain, accelerate tissue repair and modify scar formation.95 However, its
biological effects are as yet poorly understood.95 96
Ultrasound is generally used in conjunction with manual therapy and exercise and involves the
application of high-frequency sound waves (up to 1MHz) to tissue by means of a sound head,
which is moved over the affected area using an inert water-based gel as a contact medium.
Ultrasound may be continuous or pulsed, and is usually applied for three to five minutes. Sound
waves are mainly absorbed by tissue with a high protein content (muscles, joints, and bony
tissue)96.
Conclusions
There is a ‘paucity of knowledge of how ultrasound influences the molecular and cellular
mechanisms involved in inflammation and repair’109 as well as ‘inconclusive’ results from a
series of reviews on the effects of ultrasound on musculoskeletal injuries.
The review concluded that there may be beneficial effects of ultrasound at the physiological
level, but it appears to have little benefit in functional outcomes, such as a return to usual daily
activity, sport and work.
Short-wave
Short-wave electromagnetic radiations range in frequency from 10 MHz to 100MHz, with those
at the shorter end of the spectrum used for therapeutic purposes (usually at 27.12MHz). The
patient becomes part of the circuit via either a coil or capacitive electrodes, which produce both
electrical (E fields) and magnetic fields (H fields) in the tissues. The tissues thus act as a
dielectric and heating occurs through vibration of molecules.89
Shortwave may be continuous (SWD) or pulsed (PSWD), the latter providing bursts of energy
lasting about 65 microseconds. In physiotherapy, pulsed high-frequency electromagnetic
radiation (HFE) has been used for a variety of conditions including recent injuries, postoperative pain, traumatised hands, recent burns, plastic surgery, bells palsy, post-laminectomy
pain, sinusitis, chronic arthritis and other degenerative conditions.110
Conclusions
The research covered six randomised controlled trials investigating the effects of either PSWD
or SWD on acute or sub-acute ankle sprains in people over the age of 15. Outcome measures
included pain, swelling, range of movement, ability to bear weight, functional activities, and
return to work, sport and usual activities.
From a clinical point of view, PSWD is neither time nor cost efficient. Given that it is no longer
routinely taught, further investigation into its effectiveness is not warranted.
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Laser
Low-level laser therapy (LLLT) has been used in clinical practice for the past 20 years. In
physiotherapy it is mainly used for reducing pain in musculoskeletal disorders, and is different
from laser used in surgery.
Laser is thought to stimulate or inhibit biochemical and physiological activities at the cellular
level. Cells in cultures communicate with each other by electromagnetic energy, and this
influences metabolic and catabolic activity. Laser is thought to influence this communication
when it is disrupted with tissue damage.119 However, a lack of a convincing biological basis
raises questions about treatment indications.120
Conclusions
It has been suggested that laser has a therapeutic effect for post-traumatic joint disorders,
myofascial pain and rheumatoid arthritis. However, there were major design flaws in most
studies and further work is needed to determine the efficacy of laser therapy.119
A high-quality randomised controlled trial found that treatment with both high-dose and lowdose laser therapy resulted in delayed recovery compared with a placebo laser. The use of laser
therapy for acute ankle sprain should be discouraged.
TENS
TENS machines are now not only used in physiotherapy clinics but are available to the public
through a variety of outlets, promising relief from all types of pain. They are small, portable
machines, usually with two pairs of electrodes attached by flexible leads.
The response to TENS is variable and unpredictable, requiring trial and error to find the
optimum settings and placement of electrodes.
TENS has mostly been used for treating chronic rather than acute pain, the latter being
effectively treated with simple analgesics. A well designed randomised double-blind controlled
trial investigated the use of TENS compared with oral analgesic and found that TENS was more
effective than placebo TENS and equally as effective as oral analgesic for pain relief. This has
implications in clinical practice for patients where oral analgesics are contra-indicated, or where
they experience adverse side effects.125
TENS has been shown to be effective for acute pain during labour, post-operative pain and acute
oro-facial pain.
Conclusion
As no studies were found investigating the use of TENS for acute ankle sprains, there is
insufficient evidence for any recommendation.
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Interferential
Interferential current therapy (IFC) uses a medium-frequency current with the amplitude
modulated so that the effects of low-frequency stimulation can be produced while increasing the
level of comfort during the application.
Interferential machines allow the practitioner to select settings for the various parameters (such
as frequency and intensity). This, along with electrode type (flexible or suction electrodes) and
placement enable a significant range of settings for therapeutic effect.126
Conclusions
Many of the claims made in the literature about the therapeutic value of interferential therapy
are based on anecdotal evidence. Further studies are required to investigate the use of IFC for
pain relief using both a placebo group and a TENS group.127
As no studies were found investigating the use of interferential in treating acute ankle sprains,
there is insufficient evidence for any recommendation.
Manual therapy
Common treatment methods
Key conclusions
• Joint mobilisation
• Further research is needed on the efficacy of manual
therapy in improving functional outcomes for ankle
sprains
• Joint manipulation
• Soft tissue techniques (eg, massage and deep
transverse frictions)
Joint mobilisation and manipulation are passive techniques applied to joints to improve function
(mobilisation is a passive oscillatory type of movement, and manipulation more of a sudden
thrust128). Both are used to restore normal accessory movements in restricted joints.129 Gentle
joint oscillations that modulate nervous tissue are also used for pain relief in an acute joint.130
Manual therapy also includes using soft tissue techniques (such as massage and deep transverse
frictions131) in addition to other modalities in treating ankle sprains. However, there is a lack or
research on the clinical benefits of these techniques based on randomised controlled trials.
Conclusions
Two papers investigated the use of manual therapy techniques in treating acute ankle sprains.
One investigated using an antero-posterior (AP) glide of the talus to restore dorsiflexion in the
acutely sprained ankle130, and the other a gapping adjustment in sub-acute and chronic ankle
sprains to improve function.134
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The clinical relevance of using a mobilising technique in an acute ankle sprain to restore range
of movement has to be questioned. There were also no significant differences in return to normal
walking, running and return to work and sport.
Further research is needed on the efficacy of manual therapy in improving functional outcomes
for ankle sprains.
Rehabilitation of ankle sprain
Common treatment methods
Key conclusions
• Exercise that addresses proprioceptive re-training
• Supervised rehabilitation and the use of
proprioceptive training should be recommended as
part of ankle sprain management
• Co-ordination training (usually wobble boards and
tilt boards)
• Agility training on parameters of balance (such as
joint position sense and postural sway)
Much of the literature claimed that adequate rehabilitation is important in preventing functional
instability and recurrent sprains, which are a common sequelae of ankle sprains. Exercise that
addresses proprioceptive re-training is considered particularly important because
mechanoreceptors found in joint capsules, ligaments, muscles and skin are damaged during
injury and interfere with the normal neuromuscular feedback mechanisms required for balance
and co-ordination.7 74
Conclusion
The three trials in this review investigated the effects of various types of exercise or
rehabilitation programmes on functional outcomes, such as incidence of functional instability
and recurrent sprain.
These trials suggest that supervised rehabilitation and the use of co-ordination training reduce
the recurrent injury rate and functional instability. This is important in terms of secondary
prevention, given that the incidence of re-injury is high. Supervised rehabilitation and the use of
co-ordination training should be recommended as part of ankle sprain management.
Acupuncture
Key conclusions
• Evidence for the use of neuroprobe in managing acute ankle injuries is inconclusive
A number of health practitioners use acupuncture in reducing swelling and relieving pain in
ankle sprains.
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Over the past 30 years a vast body of scientific knowledge has accumulated and few would now
deny there is a physiological basis to acupuncture. Acupuncture analgesia has been studied
extensively, and there is strong evidence for the endorphin hypothesis. There is also moderately
strong evidence for the involvement of midbrain monamines (serotonin and norepinephrine), and
studies are continuing for possible involvement of the pituitary-hypothalamic system.147
Conclusion
The research did not reveal any randomised controlled trials for the use of acupuncture in acute
sprained ankles. One study investigated the role of the neuroprobe in treating Grade II ankle
sprains, but did not involve needling (it used an electrical probe that delivered mild electrical
stimulation to selected acupuncture points on both ankles and the ear).
Therefore evidence for the use of neuroprobe in managing acute ankle injuries is inconclusive.
Recommendations for treatment and management
In conclusion, there is good evidence to encourage:
• functional treatment with early mobilisation for all ankle sprains
• rehabilitation programmes that include balance and co-ordination exercises.
There is good evidence to discourage:
• cast immobilisation
• laser therapy.
There is some evidence to encourage elevation.
The evidence is either weak or absent for:
• all other forms of electrotherapy, including short-wave, ultrasound, TENS, interferential and neuroprobe therapy
• acupuncture
• manual therapy
• any type of bracing or taping being more effective than any other.
The evidence for cold with ankle sprains was inconclusive, but there is no evidence to refute using cold as a
standard treatment for acute soft tissue injuries. However, opinions vary on the duration, frequency and mode of
application. For the most part, cold is not harmful, however there are risks and the variation of advice reflects the
lack of evidence.
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Part 2: Analysing ACC claims
This part of the study sought evidence on whether any identifiable groups of claimants or
patterns of service provision by health practitioners (including general practitioners,
physiotherapists, acupuncturists, osteopaths, chiropodists and podiatrists) relate to key outcome
measures.
The study used ACC claims data for all people who made one or more claims following a soft
tissue injury of the ankle (whether for medical costs only or for entitlements) between 1 July and
30 September 2000.
This data included:
•
demographic information about the claimant eg, age at date of injury, gender, ethnicity
and earner status
•
the context and characteristics of the injury eg, date, location, activity before injury, side
of body affected and diagnosis
•
administrative details of the claim eg, date claim was lodged, fund code and earner status
•
treatment services provided following the injury eg, provider type, first treatment date,
costs of services, and referrals made to other providers
•
payments made under the claim eg, earnings-related compensation (ERC), support
services and transport reimbursement.
Important note:
The ACC claims data analysis was limited owing to four key aspects:
1. Restricted outcomes data: The data ACC collects is more for daily operations and reporting than for research
purposes, so contains no outcomes information that is claimant-oriented (eg, quality of life or return to normal
function). Analyses were limited to the data available on the database.
2. Missing data: While key information (such as age, gender and funding source) was reasonably complete, other
data were often missing. Much of the information sought on claim forms, when left unanswered by the claimant
and not regarded as crucial for claims-handling purposes, is never completed and therefore not available for
analysis. Examples include ethnicity and activity before injury.
3. Weaknesses in coding: Standardised coding systems are essential for consistent data classification. However,
some coding systems are of variable transparency and relevance, and the purpose of coding may not be apparent,
or may be limited to the coder’s own perspectives and needs. For example, the claimant’s occupation code
influences the decision on whether they need to take time of work as a result of the injury – however, claims
managers’ ability to determine occupation code with any accuracy is limited by the little information (if any)
provided at claims registration. As a consequence, categorisation by occupation is fairly crude.
4. Absence of a severity scale: The analysis could not account for severity as (at the time of the study) ACC did
not have a severity scale to apply to ankle injuries, such as their effects on function, mobility or pain, and little
information on recurrence.
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Choosing outcomes, claims and ‘predictors’ for the study
Outcomes
In consultation with ACC staff, the research team chose five outcomes for the study:
•
number of visits for treatment
•
duration (in days) of claim
•
whether or not time off work was claimed, and if so
•
for how many days was ERC paid, and
•
costs of the claim after excluding ERC.
Claims
The analysis was restricted to New Zealand residents aged 15 years or over who had suffered
uncomplicated soft tissue injuries of the ankle in New Zealand during the three-months July to
September 2000.
It excluded claims:
•
from all children aged under 15 years at date of injury
•
from overseas residents or if the injury occurred overseas
•
with a mention of fracture, evidence of other injuries, an involvement of any other part of
the body, or rupture of the Achilles tendon
•
with no outcome information.
As a result of these exclusions, the analysis probably over-represents young men and men with
nil or one claim in the previous five years and people from Auckland, smaller North Island
centres, and Christchurch. It also under-represents students, men with many previous claims
and retired people. Any results’ interpretation should consider these factors.
The selection process left 13,421 claims (53.5% of the total) meeting the selection criteria.
‘Predictors’
Many variables (or ‘predictors’) are gathered during the claims-handling process. These can help
in understanding patterns in treatment choice, benefits derived from services provided, and
costs and resources used to handle injuries.
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The research team chose nine potential predictors for the study:
•
age group
•
gender
•
ethnicity
•
occupation
•
history of previous ACC claims in the previous five years
•
whether this was a recurrent injury
•
delay to first treatment
•
first provider type
•
location.
Where it was appropriate, whether a claimant had seen a particular provider was also included.
When analysing time off work as an outcome, only claims made by earners aged under 65 years
were considered.
Results: characteristics of claimants and claims
The key findings from the analysis follow. However, it is important to note that:
•
by including claims from injuries occurring in July, August and September 2000, the
analysis may over-represent injuries relating to the three major sporting codes (netball,
rugby and soccer) that were all in season at that time (and account for over 60% of sportrelated injuries)
•
if major sporting events were held during that period (eg, national championships or
school competitions), particular locations may be more highly represented than
otherwise)
•
people with acute ankle injuries who were treated first by bulk-funding providers (such
as public hospitals and ambulance services) are included in the analysis only if they
subsequently received services. It is difficult to estimate how these claimants, had they
been included, would have altered the mix of claimants represented here, but it could be
argued that they were, on average and at least initially, more severely injured.
Key findings
•
The proportion of claims dropped, mostly because of missing data in outcomes, increases
with age (other than in those aged under 15 years).
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•
In the age range 15-34 years, more men make claims for ankle injuries than women, but
after that women lodge more claims.
•
Students were the single largest group of the total selected claims (14.8%).
•
Almost half (48.4%) of the claimants were not in paid work at the time of claim.
•
Only 24% of claimants had made no ACC claim in the previous five years, 46.7% had
made between one and three claims in that period, and 29.1% had made four or more
claims. 12.5% had a claim for an ankle injury in the previous two years.
•
For 11.9% of claimants the injury happened while at work.
•
Overall, about 8% of injuries are known to have been incurred during sport, but these
figures seem to be underestimates owing to missing data. When only those claims that are
entitlement claims (escalated) are considered, the proportion rises to 29%, possibly
reflecting greater attention to data quality and completeness in entitlement claims (ie,
claims that include costs other than medical treatment).
•
A greater proportion of women had nil or few claims in the previous five years, while men
had a greater proportion with multiple claims (three or more).
•
Over half (52%) were seen on the day of injury or the next. A further 25% were seen after
that but before day seven, and the remaining 23% were seen a week or more after the
injury. There are presumably many people whose ankle injuries resolve without medical
treatment.
•
In most (70%) of the selected claims, the GP was the first treatment provider. 19% of
injuries were seen first by physiotherapists, and 3% by hospitals or ambulances. The
remainder were seen by a mix of providers, or the details were not provided.
•
Most claimants were youth or young adults, with 39% aged between 15 and 24 years, and
a further 24% aged 25-34 years. Only 10% were aged over 55 years.
•
Men and women were approximately equally represented, but proportionately more men
at younger ages, and more women after age 45 years.
•
Women have fewer claims and cost less than men until the age groups over 45 years.
Both men and women in the age group 25-34 years incur greater costs than other age
groups. Men in the 35-44 age group cost disproportionately more than in other age or
gender groups.
•
The total cost for all 13,421 claims was $12.8 million. Allowing for claims with missing
cost data (having zero cost) leaves a mean of $967 per claim. The mean cost for women
was $176 and for men $200. 25% of claims incurred less than $34; 50% incurred less
than $167 (the median) and 10% over $350. When claims with missing cost data are
excluded (rather than given a zero value), a higher mean of $1,276 and a median of $319
per claim is obtained.
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Results: number of visits
The total number of treatment visits was calculated from all visits charged for under each claim,
regardless of provider or the time from the date of injury, by summing the total for each service
type (GP, physiotherapist, acupuncturist etc).
The total does not include treatment visits for which the claimant paid themselves or through a
private insurance scheme, or which were paid for under a contractual arrangement with ACC eg,
through the public hospital emergency department system. This means the total underrepresents the true counts, particularly in more serious cases that are treated first in hospital.
Key findings
A total of almost 68,000 visits were recorded on the 13,421 selected claims.
•
Of all the visits recorded, 59% were for physiotherapists and 23% for GPs, reflecting a
mean of 6.2 and 1.4 visits respectively for those provider types.
•
24.6% of claimants recorded only one visit to any provider, 30.1% had just two or three
visits, and 10.6% had 12 or more visits.
•
While 74.8% saw a GP as the first provider, others saw a GP after seeing firstly another
provider, to bring the total who saw a GP to 80.9%.
•
Just 15.1% saw a physiotherapist first, but 48.0% saw one at some time. There are
indications (from numbers of treatment visits, time off work etc) that those seeing a
physiotherapist first are less severe cases, but with no available measure of severity it is
not possible to be certain.
•
36% of people were recorded as being seen by a private radiologist, but this
underestimates the true percentage since it is not known how many additional cases seen
first in public hospitals had X-rays during their first visit.
•
Less than 1% saw an acupuncturist, an osteopath or a chiropractor. Those who did made
more visits per claim – the mean number of visits for an acupuncturist was 8.2, for an
osteopath 6.5 and for a chiropractor 5.2.
•
The mean number of visits across all providers for women (5.2) was higher than that for
men (4.9). Those identified as Maori had fewer visits (3.9), as did Pacific people (4.3) and
the youngest age group, 15-24 years (4.7).
•
Saturday injuries show more visits than other days, with a mean of 5.4 visits.
•
Higher socio-economic groups had more treatment visits than agricultural or fisheries
workers and those in elementary occupations. Professionals, legislators, administrators,
managers and technicians all had a mean of 5.5 visits or more, compared with below 4.5
for agriculture, fisheries and elementary workers.
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•
Those with no previous claims had an average of 4.4 visits per claim, rising to 6.2 visits
where more than seven claims had been made.
•
Those who attended a GP first had a mean of 4.7 visits, with 6.3 visits for those attending
a physiotherapist first, and 6.9 for hospitalised patients.
•
There was considerable geographic variation in the number of visits, ranging from a mean
high of 5.6 in provincial cities, down to 4.6 in the smaller South Island centres and 4.5 in
smaller North Island centres.
•
Increasing age was associated with a generally higher number of visits per claimant
compared with those aged 15-24 years, more so after age 55 years.
•
Delays to first treatment, whether just a few days or longer, are associated with about
13% fewer visits.
•
When an ankle injury was a recurrence of an ankle injury occurring within the previous
two years, it was associated with a 12% higher number of visits. Those who had more
than four claims to ACC within the previous five years had 28% more visits.
•
People whose injury occurred while at work had 23% fewer visits than others. Those who
visited their GP first (rather than a physiotherapist, hospital or other provider) had 33%
fewer visits.
•
Claimants who saw a physiotherapist at any time (not just the first visit) for the injury had
on average more than four times the number of visits to health providers compared with
those not seen by a physiotherapist. Similarly, those seen at all by an acupuncturist or
chiropractor had almost three times the number of visits.
Comment
The fact that Maori and Pacific people have fewer visits than others suggests several
possibilities:
•
a reluctance to attend a service provider to whom they are culturally unaccustomed
•
possible differences in musculoskeletal structures
•
a social perspective that expects less from service providers
•
a higher severity threshold applied by providers when deciding when a particular patient
should cease treatment.
Other more practical or financial considerations include greater difficulties of access (travel
etc), reluctance to take time off work, and the surcharge made by some service providers.
However, if these were important, one would expect occupation to feature more strongly in the
results.
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Note:
There is a risk of over-interpreting these results, as there is no way to adjust for severity of sprain. Severity is
likely to be highly correlated both with the type(s) of treatment provider(s) seen and the number of visits, so it
is impossible to distinguish whether a higher (or lower) number of visits is because of the severity of the injury,
or because of the advice and treatment offered by that provider, or some other factor.
Results: duration of claim
The duration of claims for these purposes was calculated as the difference, in days, between the
date of injury and the date last seen for treatment.
Key findings
•
Overall, the mean duration was 17.4 days, with a median of 13 days.
•
There is a clear association with increasing age, rising from a mean of 15.8 days among
those aged 15-24 years to a mean of 21.8 for those aged 65-74 years.
•
Trades workers, plant and machinery operators and assemblers, and those in elementary
occupations had, on average, claims of generally shorter duration. Conversely,
agricultural and fishery workers, managers, legislators and professionals had claims of
longer duration.
•
The longer the delay to first visit, the longer the duration of claim, particularly for those
not seeking treatment until after day seven (for whom the mean duration is 36 days
compared with 12 days for those getting help on the day of injury or the next day, and 15
days if treated first on days two to six).
•
Claims from Auckland and Hamilton were of shorter duration (17.0 and 14.4 days
respectively) and those from Wellington, Christchurch and Dunedin were longer (18.8,
18.4, and 18.5 days respectively).
Comment
•
The geographic variations in duration are unlikely to result from differences in severity.
While population characteristics may account for some variation, there are probably
differences in treatment patterns and claims handling patterns but it is not possible to
identify these data reliably given differences in patters of missing data on claims.
•
Although there is a strong association of delay to treatment and duration of claim, delay
to treatment was earlier seen to be not associated with number of visits (see page 25).
•
Duration of claim is difficult to predict because of its association with time from injury to
first visit. Delay to treatment and severity are irretrievably linked, and cannot be
separated in analyses of duration.
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Results: any time off work
The ACC database details the periods of each ERC payment and the medical certificates that
authorise time off work. If either of these indicates a person has had time off work, they are
recorded here; otherwise it is assumed they did not have time off work.
Note time taken off work during the first week after an injury is not recorded by ACC, as it is not
covered under the Act and therefore not eligible for compensation. These analyses cannot report
whether a claimant took time off work during the first week.
Key findings
•
Of the 9,174 earners aged 15-64 years, 8,802 (95.9%) had taken no time off work under
the claim, and 372 (4.1%) had taken time off which was paid for under the claim.
•
Those who attended hospital as the first provider comprised the greatest percentage
taking time off work, with 14% taking time off.
•
Maori were more likely than most to take time off work, with 71 of 952 (7.5%) taking time
off.
•
Of the 1,534 whose first visit was to a physiotherapist, only six (0.4%) took time off.
•
Some occupation groups have higher rates because of the nature of their work: service
and sales (10.2%), agriculture and fishery (8.1%), and trades workers (12.2%).
•
Neither gender nor age was associated with whether time was taken off work.
•
If the first provider seen was a GP, there was a reduction in the risk of taking time off
work of 75%. If the first provider was a physiotherapist, the risk was reduced by 97% to
an almost zero probability.
•
Those in provincial cities have an 85% higher risk of taking time off work.
Comment
The absence of information on injury severity limits this analysis.
Of the potential predictors examined, being Maori and occupation are most easily seen as being
related:
•
occupation is a characteristic clearly associated with whether or not time off work is
taken, given the range of physical demands made by different occupations
•
the reasons for the high time-off rates for Maori are unclear.
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The low rates for those who see a physiotherapist first may be:
•
because claimants know physiotherapists are not permitted by ACC to approve time off
work, so attend a GP directly
•
or (more probably) because of the prevailing practice among physiotherapists to,
wherever possible, mobilise the joint and encourage activity. However, it may be that
those who saw a physiotherapist first were less severely injured.
Results: days off work
The number of days taken off work takes into account the number of days specified in the
payment records, the dates given, and the medical certificates in the database. Days are counted
by calendar ie, regardless of days of week usually worked or weekends etc.
Time taken during the first week is not recorded, again because ACC’s legislation does not
provide for compensating claimants who take time out only during the first week after injury. In
reality, the length of time actually taken off work by these 372 claimants will be about seven
days longer than reported here. Other claimants may have taken a few days off, but would not be
reported here.
Key findings
•
Only 372 people (4.5% of earners, 2.8% of all selected) had taken time off work.
•
Earners aged under 65 years took a total of 8,460 days off work (with a mean of 22.7
days).
•
30% took seven days or less, and 30% more than 22 days. These days exclude days taken
during the first week following the injury.
•
Claimants who waited more than six days before seeking treatment had 61% (about 11
days) longer time off work, and those in smaller North Island centres had an increase of
31% (about 4 days).
Results: costs (less ERC)
Total cost less ERC was chosen as the outcome variable as ERC costs are determined largely by
occupation.
If no costs had yet been recorded against the claim, the cost has been taken as missing (rather
than zero). This resulted in 70 claims being dropped from analyses.
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Total costs (including ERC) recorded against claims, by type of cost
claimants
%
total
costs $
% cost
median
$
mean
$
13366
100.0
2,505,469
100.0
83
187.50
6448
48.2
857,486
34.2
114
133.00
375
2.8
473,266
18.9
649
1262.00
10853
81.2
443,178
17.7
26
40.80
4883
36.5
296,308
11.8
42
60.70
80
0.6
92,112
3.7
42
1151.40
Ambulance
177
1.3
83,377
3.3
476
471.10
Elective services
440
3.3
79,188
3.2
129
180.00
Support services
150
1.1
51,873
2.1
209
345.80
Conveyance
89
0.7
22,172
0.9
148
249.10
Acupuncture
55
0.4
19,474
0.8
271
354.10
197
1.5
9,764
0.4
38
49.60
1711
12.8
9,396
0.4
3
5.50
Osteopathy
38
0.3
6,266
0.3
143
164.90
Chiropractic
20
0.1
1,976
0.1
105
98.80
Total
Physiotherapy
ERC
GP
Radiology
Hospital
Podiatry
Nurse
Key findings
•
The mean cost less ERC for the remaining 13,366 claims was $187.50 (median $83).
10% had $320 or more.
•
$857,000 or 34.2% of all costs on these ankle injury claims was for physiotherapy
treatment, incurred by 48.2% of claimants.
•
ERC was the next greatest type of expense ($473,000, 18.9%) but was excluded from the
analyses of total cost.
•
GP treatments are the third greatest cost ($443,000 or 17.7% of the total costs), incurred
on 81.2% of claims. Nurses are believed to be a related cost, appearing in 12.8% of
claims but for only a small proportion (0.4%) of costs.
•
Radiology is the only other substantial cost source, incurred in 36.5% of claims and
accounting for 11.8% of costs.
•
No other services exceeded 4% of total costs, and costs of all four ‘alternative’ provider
types combined were under 1%.
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•
The highest mean non-ERC costs are incurred by claimants who attend hospital as the
first provider ($422), professionals ($185), legislators, administrators and managers
($174), retired people ($212), and those who saw a provider first in Wellington ($174).
Lowest mean non-ERC costs are incurred in Maori ($117) and Pacific people ($118), and
following work injuries ($120).
•
There is a clear relationship between age and total cost of a claim, rising from 14% more
(approximately $27) among those aged 25-34 years than those aged 15-24 years, to 40%
($76) more in those aged 65-74 years.
•
Maori and Pacific people’s claims were settled for about 20% ($38) less than similar
others after adjustment for other predictors. Those in professional occupations were paid
about 19% ($36) more.
•
Recurrent ankle injuries had 14% higher costs, a similar increase to those with more
than four claims in the previous five years.
•
Claims first seen the day after the injury or later cost ACC about 18% less overall than
those seen on the day of injury.
•
Those seen first by a GP were associated with 21% lower costs, and if seen first by
hospital or ambulance, with 2 times the costs.
•
GP attendance increases costs on average just 15% compared with over three-fold for
physiotherapy and almost five-fold for acupuncture. Radiology, which was related to an
increase of just 75% in mean number of visits per claim, is associated with 2 times the
cost because of the higher per-visit cost.
Comment
Medical treatment is the largest component of non-ERC costs following ankle injuries, and
indeed of overall cost. Work injuries are associated with the greatest reduction, costing only
about 81% of comparable claims that are not work related. Reduced costs associated with Maori
and Pacific people seem to reflect fewer visits. The effects on lower costs of being seen first by a
GP and delay in treatment are also linked to fewer visits.
Conversely, non-ERC costs increase with age, recurrent injuries, those with many previous
claims or in professional occupations, and these appear to be linked with more visits.
However, being seen first in a hospital does not appear to be linked with number of visits, at
least not with visits paid for under the claim. Probably, these claims are more serious on
average, and require assistance from other service providers, or perhaps aspects of entitlement
other than ERC eg, home support or transport costs.
Additional costs for the different treatment provider types relate both to the mean number of
visits to the provider type and the typical cost of the provider. So while the number of visits per
claimant to a radiologist is low, because of the greater mean cost, it contributes relatively more
to total non-ERC costs. The low use of complementary care providers means they have little
impact on overall costs.
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Patterns that emerged
Several patterns emerge among the outcomes and predictors. However, they need to be
interpreted with caution given the relatively high rates of missing data in some key variables,
the uncertainty of some diagnoses, the absence of an indicator of severity at first treatment, and
the potential sources of bias and error.
Age and gender
Those in older age groups had more visits and higher costs per claim, even after adjusting for
occupation. However, increasing age is not related to the risk of having time off work, although
those aged 35-44 appeared to have longer off work. These differences have fairly little effect on
the cost of claims, as most claims for soft tissue injuries of the ankle are in younger people.
Ethnicity
Maori have fewer visits, and they and Pacific people have lower costs per claim. Potential
explanations include:
•
being provided with less service
•
the claimants not seeking services
•
having more difficulty accessing services.
Maori claimants appear more likely to take time off work for their injury, but duration of time
taken off, and the related costs, were less compared with non-Maori claimants, even after
considering occupation and place of claim.
Occupation
Claimants classified as ‘professionals’ (which excludes legislators, managers and technical
occupations) obtain more services and their claims cost more, even when ERC is excluded.
Potential explanations include professionals:
•
receiving preferential treatment and being over-serviced
•
having a better understanding of their entitlements and therefore expecting more.
First treatment
There is a clear relationship between first provider and outcomes, visible in:
•
numbers of visits
•
whether time off work was taken
•
costs of claim.
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The increased risk among those who present first at hospital or by ambulance is most likely to
be related to perceived severity at onset.
Those seeing a GP first are likely to have fewer visits than those seeing a physiotherapist or
other provider. Those who see either a GP or physiotherapist are much less likely to take time
off work than others. Delay to first treatment is associated with both number of treatment visits
and total costs less ERC, but not with time off work. This is likely to be at least partially related
to severity.
Geographic groups
Claimants in provincial cities were more likely to take time off work, and claimants in smaller
North Island centres had more days off but cheaper non-ERC costs.
Specific service providers
Both the number of visits and the costs increase as the number of treatment provider types
involved in a claim increases.
The data show that being seen first by a GP or physiotherapist is associated with a reduced risk
of taking time off work. That is likely to relate to severity. However, seeing a GP at all is
associated with a slight increase in number of visits. Seeing a physiotherapist is associated with
four-fold increases in the number of visits, but also with a reduction in the proportion taking
time off work by a very substantial 97%. These findings could reflect the possibility that
claimants with milder injuries are more likely to select physiotherapists or GPs as first
providers.
Other service providers are linked with a high number of visits and higher costs. However, they
contribute in only a small way to the total non-ERC costs because so few claimants use their
services. There is insufficient evidence from these data to suggest that complementary providers
either improve or worsen outcomes.
Service provision
The claims analysis had highlighted inequities in services provided under ACC claims. In
particular, Maori claim for less care, and professionals claim for more care, than other groups.
Those in provincial cities show higher numbers of treatment visits and more take time off work.
Those who visit a GP first use fewer resources, and those who see a physiotherapist first are less
likely to take time off work, though the extent to which this is a result of lesser severity is
unclear. These areas may warrant further attention.
Claimants with a history of four or more claims (of any type of injury) within the past five years
have more visits and cost more per claim than those who do not have such a history.
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Recommendations for claims handling
In conclusion, the review recommended:
•
encouraging and evaluating the use of both the full READ code and the severity indicator
•
reducing the amount of missing information in the ACC database – particularly on
ethnicity, occupation and first provider type
•
identifying and querying data that are clearly incorrect, for example claimants being seen
for treatment on a claim before the date of their injury
•
considering more complete registration and costings of ACC claimants treated in
hospitals and ambulances
•
improving the quality of the data capture process by gathering information from audits on
data accuracy and completeness.
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Glossary
Accessory
movements
Joint movements which are not under voluntary control. These are
described as gliding, rolling and spinning of one joint surface in relation to
the other during normal movement.
Anterior drawer
sign
The anterior drawer test is performed with the patient sitting with the knee
flexed to relax the calf muscle. The heel is grasped and pulled forward.
With a positive sign, a sulcus is observed anteriorly and medially over the
ankle joint, indicating a tear of the ATFL. The amount of laxity when
compared with the normal foot is graded as mild, moderate or marked. With
stress radiography, a positive test is when there is an absolute anterior
displacement of 10mm or a side-to-side difference greater than 3mm.
AP
Antero-posterior.
ATFL
Anterior talo-fibular ligament.
Avulsion fracture
Avulsion fractures occur at the attachment of ligaments or large tendons to
bones, when a fragment of bone becomes detached with injury.
CAM
Complementary and alternative medicine.
CFL
Calcaneo-fibular ligament.
Conversion
Means by which one energy form (ultrasound and shortwave) is converted to
another energy form (heat) in the tissues.
CT
Computerised tomography.
Dorsiflexion
The movement at the subtalar joint which pulls the foot up.
Electrophysical
agents
Modalities which use forms of electric stimulation for therapeutic purposes.
Interferential, TENS, ultrasound and shortwave are all examples of
electrophysical agents.
Entitlement claims A claim that incurs costs other than medical fees, for example earningsrelated compensation or home help.
ERC
Earnings-related compensation.
Eversion
Movement at the subtalar joint which turns the foot out.
Functional
treatment
The use of various types of support to allow early mobilisation while still
protecting the joint.
HFE
High-frequency electromagnetic therapy.
IFC
Interferential current therapy.
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Interferential
therapy
The transcutaneous application of alternating medium-frequency electrical
currents for ‘therapeutic’ effect.
Inversion
Movement at the subtalar joint which turns the foot in.
Lateral ligament
A ligament comprising three bands which stabilise the lateral aspect of the
ankle joint: the anterior talo-fibular ligament, the calcaneo-fibular
ligament, and the posterior talo-fibular ligament.
LLLT
Low-level laser therapy.
Manual therapy
Passive mobilisation and manipulative techniques applied to joints to
restore mobility and improve function.
Medial ligament
A strong triangular ligament attaching the tibia to the navicular, calcaneous
and talus.
Mobilisation
Passive oscillatory movement applied at a joint to increase accessory
movement or to modulate pain.
MRI
Magnetic resonance imaging.
Myofascial pain
Pain in the muscular and fascial components of soft tissues.
Neurapraxia
Damage to a nerve from compression or overstretching. There is no
disruption to the nerve. Symptoms include pain, tingling and numbness in
the distribution of the nerve. These usually resolve spontaneously.
Osteochondral
fracture
A fracture of the dome of the talus, often occurring with a compressive
component to the inversion injury, as in landing from a jump. These are
commonly overlooked.
Plantarflexion
The movement at the ankle joint which points the foot down.
Proprioception
Proprioception is the general term used to describe nerve impulses
originating from joints, muscles, tendons and associated deep tissues,
which are then processed in the central nervous system to provide
information about joint position, motion, vibration and pressure.
PSWD
Pulsed shortwave diathermy.
PTFL
Posterior talo-fibular ligament.
Radiation
Means by which electromagnetic energy (infra red) is absorbed into the
more superficial tissue layers.
RICE
Rest, ice, compression, elevation.
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Sensitivity
The proportion of patients with the disease who have a positive test.
Specificity
The proportion of patients without the disease who have a negative test.
Subtalar joint
The articulation between the talus and the calcaneous.
Subtalar ligaments The interosseous and cervical ligaments have been described as the
cruciate ligaments of the subtalar joint. They provide stability between the
calcaneous and the talus.
SWD
Shortwave diathermy.
Syndesmotic
ligaments
A group of four ligaments which provide support to the inferior tibio-fibular
articulation. These include the anterior, posterior and transverse
ligaments. The interosseous ligament can extend upwards from 2-6cm and
the elasticity of this ligament allows movement between the tibia and fibula
on walking and activity.
Talar tilt test
The talar tilt, or inversion tilt, test is performed by grasping the calcaneous
and talus and inverting the foot on the tibia. A positive test is when there is
a mild, moderate or marked increased range of inversion compared with the
normal foot. With stress radiography, the general rule is that there is laxity
of >10° compared with the normal foot.
Talo-calcaneal
ligament
The ligament attached between the talus and the calcaneous on the lateral
aspect of the subtalar joint, providing support for the subtalar joint.
Talo-crural joint
The articulation between mortise formed by the tibia and fibula and the
talus, commonly called the ankle joint.
TENS
Trans-cutaneous nerve stimulation.
Tibio-fibular
syndesmosis
The articulation between the inferior aspect of the tibia and fibula.
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