Ankle Sprains: Medical Management Options
Abstract & Commentary
By Matt Shores, MD, St. Joe's Hospital and Medical Center, Family Medicine Residency, Phoenix, AZ, is Associate Editor for Urgent Care Alert.
Dr. Shores reports no financial relationships relevant to this field of study.
Synopsis: Acetaminophen at 1300 mg tid is no less effective than Ibuprofen 400 mg tid in treating acute ankle sprains.
Source: Dalton JD Jr, Schweinle JE. Randomized controlled noninferiority trial to compare extended release acetaminophen and ibuprofen for the treatment of ankle sprains." Ann Emer Med. 2006;48:615-623.
In emergency departments, urgent care centers, and family medicine offices across the country, ibuprofen is a mainstay in the treatment of acute ankle sprains. After all, ibuprofen is cheap, fairly well tolerated, available over the counter, and a proven success in treating pain and inflammation. However, it is not the only option. In a November 2006 article published by the Annals of Emergency Medicine, Dalton and colleagues set out to prove that the use of acetaminophen was not inferior to the use of ibuprofen in the treatment of acute ankle sprains.
In this study, a randomized, double-blind, parallel-group study, patients with acute ankle sprains were evaluated in a wide variety of settings, including urgent cares, and were randomized to either receive acetaminophen 1300 mg tid or ibuprofen 400 mg tid for the treatment of their ankle injury. Only patients with grade I or grade II ankle sprains were included in the study. Ankle sprains were graded using the Leach classification:
- Grade I ankle sprain presents as stable, with a partial tear of ATF, intact CFL, negative anterior drawer test, and negative talar tilt test;
- Grade II ankle sprain presents as stable, with a complete tear of ATF, with or without a partial tear of CFL, a positive anterior drawer test, and a negative talar tilt test;
- Grade III ankle sprain presents as unstable, with a complete tear of both ATF and CFL, a positive anterior drawer test, and a positive talar tilt test.
Two hundred and sixty patients were evaluated using a visual analog scale (VAS). Follow-up was scheduled for day 4 and day 9 status post treatment initiation. The primary end point in this study was pain, with walking on day 4 as a change from the baseline assessed by the patient using VAS. Secondary end points included pain with walking on day 9, as well as changes from baseline on day 4 and 9 in various categories, including ability to walk, ankle swelling, ankle bruising, range of motion in the ankle, overall satisfaction of treatment, percentage of patients with positive anterior drawer test, and total time back to normal activity.
The primary end point of pain of walking on day 4 resulted in a change from baseline of 35.78 (using VAS) in the acetaminophen group and 36.46 in the ibuprofen group. On day 9, the change from baseline on pain with walking was 54.37 in the acetaminophen group and 59.51 in the ibuprofen group. Each of the secondary end points produced similar results. The study ultimately concluded that acetaminophen taken at 1300 mg tid was not inferior in treating ankle sprains than ibuprofen 400 mg tid.
Ankle sprains are a large contributor to patient visits at healthcare centers across the nation. It is estimated that one million ankle sprains present each year.1 As detailed above, the evaluation of ankle sprains stratifies injuries into grade I, II, or III injuries.
The mainstay of treatment for ankle sprains, particularly grades I and II, is RICE therapy: rest, ice, compression, and elevation. Ivins details the PRICE theory, adding protection to the RICE foundation.2 In addition, whether physician driven or patient driven, the use of medications in treating ankle sprains is often times a foregone conclusion.
The purpose of this study is to determine whether acetaminophen is inferior to ibuprofen in the treatment of acute grade I or grade II ankle sprains. In order for this comparison to have relevance, it must be known that ibuprofen at 1200 mg/day is superior to placebo in treating ankle sprains; this was done by Moran in 1991.3 In the end, Dalton et al accomplish what they set out to do; they demonstrate that 1300 mg of acetaminophen tid is comparable to 400 mg of ibuprofen tid in expediting the recovery from ankle sprains. By no means does this relegate ibuprofen to the proverbial bench; it simply adds acetaminophen as an effective alternative to NSAIDs in treating ankle sprains when NSAIDs may be contraindicated in certain patients. In addition, acetaminophen and ibuprofen are not the only options when it comes to effectively treating ankle sprains.
In a literature search, ibuprofen and various anti-inflammatory medications have been studied in the treatment of ankle sprains. In Moran's 1991 study, diclofenac potassium was shown to be superior to ibuprofen in the treatment of ankle sprains and, in turn, ibuprofen was superior to placebo.3 Multiple studies have taken a look at cox-2 inhibitors such as celecoxib. In a 2001 study by Ekman and colleagues, it was shown that celecoxib at 200 mg bid allowed for a return to function in 5 days, as opposed to ibuprofen at 800 mg tid, which allowed for return to function in 6 days; both were to superior to placebo, returning function in 8 days.4 Petrella and colleagues, in 2004, analyzed the efficacy of celecoxib (200 mg bid) vs naproxen (500 mg bid) in the treatment of ankle sprains; they demonstrated that celecoxib was not inferior to naproxen, and celecoxib produced less dyspepsia as an adverse effect than naproxen.5 In regards to recent fears surrounding cox-2 inhibitors, in January of 2007, in the American Journal of Cardiology, White and colleagues performed the largest meta-analysis on the risk of cardiovascular side effects related to celecoxib, and failed to demonstrate increased risk for cardiovascular events vs placebo.6
In conclusion, multiple studies have proven the efficacy of anti-inflammatory medications in the treatment of ankle sprains. In many urgent care facilities, emergency departments, and primary care offices, the mainstay of treatment is ibuprofen 1200-2400 mg/day or naproxen 500 mg bid. Both medications have proven to be effective vs placebo and, in the right patient populations, are very well tolerated.3,5 As an alternative to these medications, physicians should feel comfortable exploring other options. As demonstrated in this featured study, acetaminophen is a safe (OTC) alternative to NSAIDs and is just about equal in efficacy to ibuprofen in treating ankle sprains.1 In addition, cox-2 inhibitors, such as celecoxib, may be superior to medications like ibuprofen and naprosyn.4,5 Ultimately, every physician must make a choice based on their own comfort level as they assess each patient's individual risk and needs. Of course, it's nice to know there are multiple effective options.
- Dalton JD Jr, Schweinle JE. Randomized controlled noninferiority trial to compare extended release acetaminophen and ibuprofen for the treatment of ankle sprains. Ann Emerg Med. 2006;48:615-623.
- Ivins D. Acute ankle sprains: An update. Am Fam Physician. 2006;74:1714-1720.
- Moran M. Double-blind comparison of diclofenac potassium, ibuprofen, and placebo in the treatment of ankle sprains. J Int Med Research. 1991;19:121-130.
- Ekman EF, et al. Efficacy of celecoxib versus ibuprofen in the treatment of acute pain: A multicenter, double-blind, randomized controlled trial in acute ankle sprain. Am J Orthop. 2002;31:445-451.
- Petrella R, et al. Efficacy of celecoxib, a COX-2 specific inhibitor, and naproxen in the management of acute ankle sprain: Results of a double-blind, randomized controlled trial. Clin J Sport Med. 2004;14:225-231.
- White WB, et al. Risk of cardiovascular events in patients receiving celecoxib: A meta-analysis of randomized clinical trials. Am J Cardiol. 2007;99:91-98.