Double bandaging of sprained ankles

The healthcare establishment generally ignores mundane important issues, preferring to consider popular (sexy) topics. Who wants to assess the cost effectiveness of different management strategies for sprained ankles when you could be introducing a new technology (toys for the boys)? Most of the contacts patients have with the NHS relate to non-life threatening conditions, and their management does not require state of the art technology. However, if the NHS is to operate in the most effective and efficient manner all aspects of health care must be appropriately evaluated. This short paper uses the management of sprained ankles as an example.

The problem

Ankle injuries are common (estimated at 600 000 attendances at accident and emergency departments per year in the United Kingdom), and 30% of patients may have continuing symptoms.¹ Traditional teaching states that the treatment is RICE (rest, ice, compression, elevation). Many accident and emergency departments use a cylindrical elasticised bandage for the compression, many centres using double layer bandaging. An adult would be expected to need at least 50 cm of tubular bandage, which becomes 300 km of bandage per year for ankle sprains in the United Kingdom, or double that if two layers are applied. This equates to a bandage reaching from London to Berwick upon Tweed if it were used double (without stretching it) and a cost for the bandages alone of £654 000.² These estimates exclude people who treat themselves or are treated by their general practitioner. We aimed to examine the evidence for the use of tubular bandages.

The evidence

We conducted a Medline search (1963-98) to identify all trials of treatment for ankle sprains, using combinations of the keywords sprain, ankle, compression, Tubigrip, and trial. We reviewed the abstracts of the 148 articles obtained to determine their relevance. Only 12 trials studied compression for the treatment of ankle sprains. The results are summarised in the table.

The results of these studies suggest that early movement gives the best result. The method of least restricting the ankle may be to apply no bandage and give advice on exercises. Patients received neither bandaging nor plaster of Paris cast in only one trial.¹⁴ In this study of 241 patients the best outcome, as measured by return to work and clinical scoring, was found in the group given no support and minimal bandaging. Another group, given early physiotherapy, had almost equivalent outcomes but also had better rates of patient satisfaction. The groups allocated to double Tubigrip and plaster of Paris cast faired worst. Unfortunately this study had some methodological problems—namely, a poor rate of follow up and the possibility that the non-intervention groups had less severe injuries.

Conclusions

Common sense leads us to question the value of using cylindrical bandages for treating sprained ankles when an ankle has a 90° curve. Inevitably, the bandage will tend to produce an anterior compressive band, with elastication being insufficient to prevent inversion and eversion of the ankle.

We suggest that the current literature does not support the widespread use of elasticised cylindrical bandages to treat sprained ankles. Furthermore, well conducted randomised controlled trials are needed to elucidate the best treatment for this common condition.

All aspects of health care need to be critically reviewed. Existing practice is often not evidence based, and the greatest strides in improving patient satisfaction and cost effectiveness may be made by examining the management of minor injuries. The sacred cow of double bandaging of ankles should be slaughtered until proof is available.

Table.

Outcome of trials investigating different compression treatments for ankle sprains

Reference No	Interventions compared	Preferred intervention
3	Nottingham ankle support v Tubigrip v eversion strapping	New support
4	Compression bandage + early movement v elastic bandage + limited weight bearing	Early movement
5	Ace bandage v compression bandage	No difference
6	Plaster of Paris v tubular bandage	Tubular bandage
7	Aircast splint v plaster of Paris	Aircast
8	Plaster cast v air stirrup v elastic wrap	Elastic wrap was equivalent to air cast; both better than cast
9	Elastic wrap v plaster splint	Elastic wrap
10	Air stirrup v compression	Air stirrup
11	Layer bandage v adhesive tape	No difference
12	Operation v plaster of Paris v strapping	Operation
13	Operation v early movement with support	Early movement
14	Minimal bandage v Tubigrip v plaster of Paris v early physiotherapy	Early physiotherapy