Return-to-play probabilities following new versus recurrent ankle sprains in high school athletes

doi:10.1016/j.jsams.2013.04.006

Journal of Science and Medicine in Sport

Volume 17, Issue 1, January 2014, Pages 23-28

https://doi.org/10.1016/j.jsams.2013.04.006 Get rights and content

Abstract

Objectives

Although ankle sprains have the highest recurrence rate of any musculoskeletal injury, objective estimates of when an athlete is likely to return-to-play (RTP) are unknown. The purpose was to compare time to return-to-play probability timelines for new and recurrent ankle sprains in interscholastic athletes.

Design

Observational.

Methods

Ankle sprain data were collected at seven high schools during the 2007–2008 and 2008–2009 academic years. Ankle sprains were categorized by time lost from participation (same day return, next-day return, 3-day return, 7-day return, 10-day return, >22-day return, no return [censored data]). Time-to-event analyses were used to determine the influence of ankle injury history on return-to-play after an ankle sprain.

Results

204 ankle sprains occurred during 479,668 athlete-exposures, 163 were new (4 censored) and 35 recurrent (1 censored). There was no significant difference (p = 0.89) between the time-to-event curves for new and recurrent ankle sprains. The median (inter-quartile rage) time to return-to-play for new sprains (inter-quartile range) = 3 days (same day to 7 day return); recurrent sprains = next day return (next day to 7 day return). Noteworthy probabilities [95% CIs] include: same day return (new = 25.2[18.7, 31.9], recurrent = 17.1[6.6, 30.3]); next-day return (new = 43.6[35.3, 52.7], recurrent = 51.4[32.5, 67.5]); and 7-day return (new = 85.9[73.8, 94.4], recurrent = 94.3[47.8, 99.5]).

Conclusions

Previous injury history did not affect time until return-to-play probabilities for ankle sprains. Time until return-to-play analyses that describe the likelihood of return-to-play are useful to clinicians by providing prognostic guidelines and can be used for educating athletes, coaches, and parents about the likely timeframe of being withheld from play.

Introduction

Ankle sprains are the most prevalent sports related injury sustained in high school athletics, representing a significant health problem.1, 2 Among recurrent injuries, the ankle is also the most common site³ and many individuals will go on to develop residual problems, such as pain and recurrent bouts of instability. The recurrent nature of these injuries increase the likelihood of decreased physical activity,⁴ post-traumatic ankle osteoarthritis,⁵ and resultant increased healthcare costs. It has been estimated that at least 1 out of 3 individuals who suffer an ankle sprain will go on to have recurrent issues.⁶ This indicates that current care and decisions for return to activity may be inadequate for ankle sprains. Furthermore, it is currently unknown whether there is a difference in return to activity timelines for first-time and recurrent ankle sprains.

While ankle sprains are the most common injuries associated with sports, there are few prognostic indicators and a lack of objective evidence supporting an estimate of when an athlete will return to participation. Typical tissue healing timeframes for ligaments range into 6–12 weeks⁷ for scar tissue to mature to full tensile strength, yet reported timeframes for return-to-play (RTP) indicate that more than 50% of all ankle sprains that occur in high school sports return in less than 1 week.¹ These time frames suggest that athletes are routinely returned to participation prior to complete tissue healing. Moreover, tissue damage may not be a strong prognostic indicator (at least not in isolation) in these cases; objective and evidence-based predictors of when an athlete is likely to RTP following an ankle sprain are needed. While the pattern of how injury history affects time to RTP is unpredictable⁸ it is unknown if subsequent ankle sprain influences RTP time frames. There is evidence to suggest that recurrent injuries tend to be more severe than the initial and in fact, there may be a cumulative effect on the health of the structure affected.⁹ In order to reduce the risk of recurrent injury, minimizing the effects of the initial injury should be paramount among the goals of rehabilitation.⁹ When considering the high recurrence rates of these injuries, it may be that individuals who suffer ankle sprains may return to activity earlier than physiologically possible without greatly increasing the risk of recurrent injury.¹⁰

A method of generating evidence-based, objective estimates of when an athlete is likely to return-to-play is through the use of time-to-event probability analyses. Time-to-event probabilities can be used to estimate how likely an athlete is to RTP following a given injury, and are commonly used to determine survival probabilities for those with life-threatening conditions¹¹ or risk factors.¹² As with the prognosis of other medical conditions, time-to-event analyses do not take the place of RTP decisions made by the sports medicine clinician for each individual patient, as symptoms and treatment vary for each case. Instead, they provide a framework to augment current RTP decision-making by incorporating objective evidence from epidemiological trends associated with the injury,¹³ thereby improving overall prognosis. With prognosis, the rehabilitation process must begin with accurate and precise information to educate the injured athlete about their injury.¹⁴ With improved prognosis and better understanding by the athlete regarding the injury, adherence to the rehabilitation process improves.¹⁵

Statistical estimates of the probability of RTP following sports-related ankle sprains have not been previously published. To date, there have been no analyses of the timeframe estimates of RTP for new or recurrent ankle sprains. Recurrent ankle sprains are particularly difficult to analyze in this manner since most injury surveillance systems have de-identified records which does not allow for linking multiple injuries to a particular athlete, an important feature for these types of analyses. The probability of RTP for given timeframes is of direct clinical and prognostic importance by providing an evidence-based, objective tool for educating coaches, athletes, and parents on the likely course of RTP following an ankle sprain. Therefore, the primary purpose of this study was to generate statistical estimates of RTP probabilities following sport-related ankle sprain and to compare new and recurrent ankle sprains among high school athletes. Based on previous research on the increasingly severe nature of recurrent injuries¹⁰ we hypothesized that recurrent ankle sprains would have longer RTP estimates that new ankle sprains.

Section snippets

Methods

This study employed an observational design. Ankle sprain injury data (academic years 2007–08, 2008–09) were collected for this study from seven high schools of Central [blinded] by the athletic trainer (AT) employed at each high school (7 ATs in total) and entered into an injury surveillance system. Subjects were injured high school athletes who participated in at least 1 of the 2 academic years at any sporting level (varsity, junior varsity, or freshmen). Sports included in this study were

Results

During the 2007–2009 academic years, approximately 3000 athletes per year participated. There was a combined total of 1532 reported sports-related injuries during 479,668 AEs. Of those injuries, 806 were sustained to the lower extremity. There were 228 ankle injuries reported with 204 were identified as lateral ankle sprains, representing 13.5% of all reported injuries, 25.6% of lower extremity injuries, and 90.8% of all ankle injuries. Of the 204 lateral ankle sprains, 170 were not referred by

Discussion

The primary purpose of this study was to generate and compare statistical estimates of RTP time frames following sport-related new and recurrent ankle sprains. The primary result was that there was no difference in RTP timeline between new and recurrent ankle sprains, and that the median RTP for an ankle sprain for a high school athlete is approximately 1–3 days regardless of injury history. When considering the high recurrence rate associated with these injuries, this finding may contextualize

Conclusions

There was no difference time until RTP timelines between new and recurrent ankle sprains, with an approximate 70% chance of return 3 days after the injury. Time to RTP analyses describe the likelihood of return-to-play within certain timeframes, providing objective, research evidence that aligns with the evidence-based practice model which integrates clinical experience and patient values with the best available research evidence.³⁰ The generated RTP estimates are immediately useful to

Practical implications

•
There was no difference in the probability of return-to-play for new vs. recurrent ankle sprains.
•
Time-to-event analyses evaluate the likelihood of return-to-play after an injury during certain timeframes.
•
These analyses are immediately useful to clinicians by providing prognostic guidelines based on epidemiological trends and can be used for educating athletes, coaches, and parents about the likely course of an ankle sprain.
•
The clinician must keep in mind that these are probabilities and there

Acknowledgements

We would like to thank the certified athletic trainers at UK Healthcare Sports Medicine in Lexington, Kentucky for their assistance with this research study.

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Original researchReturn-to-play probabilities following new versus recurrent ankle sprains in high school athletes

Abstract

Objectives

Design

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Practical implications

Acknowledgements

Ankle injuries among United States high school sports athletes, 2005–2006

J Athl Train

Epidemiology of lower extremity injuries among U.S. high school athletes

Acad Emerg Med

Patterns of recurrent injuries among US high school athletes, 2005–2008

Am J Sports Med

A twofold reduction in the incidence of acute ankle sprains in volleyball after the introduction of an injury prevention program: a prospective cohort study

Scand J Med Sci Sports

Ligamentous posttraumatic ankle osteoarthritis

Am J Sports Med

Persistent disability associated with ankle sprains: a prospective examination of an athletic population

Foot Ankle Int

Ankle ligament healing after an acute ankle sprain: an evidence-based

Approach J Athl Train

Patterns of recurrent injuries among US high school athletes, 2005–2008

Am J Sports Med

Subsequent injury patterns in girls’ high school sports

J Athl Train

Consequences of ankle Inversion trauma: a novel recognition and treatment paradigm

Exploring differences in survival from cancer among indigenous and non-indigenous Australians: implications for health service delivery and research

Asian Pac J Cancer Prevent

The impact of tobacco smoking and alcohol drinking on survival of patients with non-Hodgkin lymphoma

Int J Cancer

Incidence, severity, aetiology and prevention of sports injuries. A review of concepts

Sports Med

Enhancing athletic injury rehabilitation adherence

J Athl Train

An exploration of athletes’ views on their adherence to physiotherapy rehabilitation after sport injury

J Sport Rehabil

Original research
Return-to-play probabilities following new versus recurrent ankle sprains in high school athletes