Osteopathic Manipulative Treatment in the
Emergency Department for Patients With Acute Ankle Injuries

Anita W. Eisenhart, DOTheodore J. Gaeta, DO, MPHDavid P. Yens, PhD Study Objective: The purpose of this study was to evaluate
pression dressings, elevation of the affected ankle, analgesia the efficacy of osteopathic manipulative treatment (OMT)
(specifically, nonsteroidal anti-inflammatory drugs [NSAIDs]), as administered in the emergency department (ED) for
the treatment of patients with acute ankle injuries.
Despite this current practice, 25% to 40% of ankle sprains are associated with recurrent injury or prolonged disability.6-8 Methods: Patients aged 18 years and older with unilateral
Some authors have postulated that such common complica- ankle sprains were randomly assigned either to an OMT
tions are the result of inadequate treatment of the initial study group or a control group. Independent outcome
injury because insufficient consideration is given to the exact variables included edema, range of motion (ROM), and
nature of the pathologic process in each patient.5-8 pain. Both groups received the current standard of care
Osteopathic manipulative treatment (OMT) has been for ankle sprains and were instructed to return for a follow-
proven efficacious in the setting of acute sprains and strains.
up examination. Patients in the OMT study group also
In 1980, Blood9 reported using OMT to treat patients with received one session of OMT from an osteopathic physi-
ankle sprains. He describes a method of correcting the under- lying somatic dysfunctions, restoring functional anatomy,and decreasing edema. To date, no study has evaluated the Results: Patients in the OMT study group had a statistically
efficacy of OMT on acute ankle sprains. The primary objec- significant (F = 5.92, P = .02) improvement in edema and
tive of this study was to evaluate quantitatively the effect of pain and a trend toward increased ROM immediately fol-
OMT on ED patients with acute ankle injuries. The specific lowing intervention with OMT. Although at follow-up
aim of this study was to assess the immediate effects of a both study groups demonstrated significant improvement,
single session of OMT when performed in the ED, as well as patients in the OMT study group had a statistically sig-
determining what additional benefit patients may receive nificant improvement in ROM when compared with
when OMT is added to the current standard of care for acute patients in the control group.
Conclusions: Data clearly demonstrate that a single ses-
sion of OMT in the ED can have a significant effect in
Study Design
the management of acute ankle injuries.
This is a prospective, randomized, controlled, nonconsecu-tive clinical trial of adult patients presenting to an urban, uni- Ten percent of emergency department (ED) visits are versity-affiliated ED with acute ankle injury.
related to ankle injury, and approximately 75% of these injuries are sprains.1,2 The current standard of care for acute Patient Population
ankle sprains includes resting the ankle, cryotherapy, com- All patients 18 years of age or older who presented within 24hours of their injuries were considered for study enrollment.
Patients with an ED diagnosis of acute unilateral first- or Dr Eisenhart is the Residency Director in the Department of Emergency second-degree ankle sprain by ED history, physical examina- Medicine at St Barnabas Hospital in Bronx, NY. Dr Gaeta is the ResidencyDirector in the Department of Emergency Medicine at New York Methodist tion, and radiographic interpretation were considered for Hospital in Brooklyn, NY. Dr Yens is a statistician and the Director of the Edu- cational Development Resource Unit at the New York College of Osteopathic Patients were excluded if they were younger than 18 Medicine of the New York Institute of Technology in Old Westbury, NY.
This study was partially funded through a GlaxoSmithKline Resident years (as nondisplaced Salter-Harris I fractures may be missed on radiographic evaluation), had a positive ankle drawer test Address correspondence to Theodore Gaeta, DO, MPH, New York (indicating ankle instability and a third-degree sprain), had a Methodist Hospital, 506 Sixth St, Brooklyn, NY 11215-3609.
chronic ankle injury on the contralateral side, or if they were Eisenhart et al • Original Contribution JAOA • Vol 103 • No 9 • September 2003 • 417
inebriated or otherwise had an altered mental status whenpresenting to the ED. If the official radiographic interpretation Ⅵ The fibula and tibia should be palpated. There is was significant for a fracture missed by the ED physician, the often a slight torsion of the interosseous ligament with patient was removed from the follow-up analysis. The ED the proximal fibula noted to be more posterior. This presentation was maintained in our intention-to-treat anal- effect can be reduced using simple torsion and soft After providing informed consent for participation in the study, patients were randomly assigned as subjects in either the Ⅵ Using soft tissue and fascial techniques, the osteo- OMT study group or in the control group. Patients in both pathic physician can evaluate and then treat the patient groups were evaluated for edema, range of motion (ROM), and by examining the relationships of the bones from the pain. Edema was measured in centimeters as the maximal toes to the ankle. For example, given the common laxity circumference about the medial and lateral malleoli and was of the fibularis muscles, there is often a dropped compared with measurements taken of the uninjured ankle (ie, cuboideum (cuboid bone), which has to be reduced.
delta circumference). Using a goniometer placed at the lateralmalleolus with the approximate axis of motion at an imaginary Ⅵ A patient who has pain and tenderness along the line between the medial and lateral malleoli, investigators fibularis muscles and tendons can be treated by the (A.W.E. and T.J.G.) measured patients’ ROM as the degrees of osteopathic physician using muscle energy and strain motion from full, patient-active plantar flexion to dorsiflexion.
and counterstrain techniques. Additionally, strain and Investigators compared these results with the same measure- counterstrain techniques will often help if used directly ment in the uninjured ankle (ie, delta range). Patients were on the anterior talofibular ligament, especially in cases then asked to quantify their pain using a 1 to 10 visual analog Ⅵ Lymphatic drainage techniques should be used to OMT Study Group
One of the authors (A.W.E.) provided OMT to patients in theOMT study group. The specific osteopathic manipulative tech-niques administered to each patient varied based on the osteo- Sources: Pennington GM, Danley DL, Sumko MH, Bucknell A, Nelson JH.
pathic physician’s assessment of the patient’s physical exam- Pulsed, non-thermal, high-frequency electromagnetic energy (DIAPULSE) ination and included a combination of the soft-tissue techniques in the treatment of grade I and grade II ankle sprains. Mil Med.
listed in the Figure. The duration of each treatment session 1993;158:101-104.
Blood SD. Treatment of the sprained ankle. J Am Osteopath Assoc.
was 10 to 20 minutes. Immediately following the treatment ses- sion, the sprained ankle was reevaluated for edema, ROM,and pain.
Figure. Soft tissue techniques for the assessment and management
Discharge Treatment and Instructions
of acute ankle sprains. In keeping with osteopathic principles and prac- Patients in both groups received the current standard of care tice, the osteopathic manipulative technique or techniques used by for acute ankle sprains: RICE therapy (rest, ice, compression, the osteopathic physician to provide individualized treatment is elevate) and analgesics. Patients were advised to rest and ice based on the physician’s palpatory findings and is unique to each the ankle for 20-minute intervals. Patients’ injured ankles were patient. However, a common pattern of injury has been described for then placed in a Jones compression dressing (ie, alternating the care and management of acute ankle sprains, so a uniform treat- layers of elastic bandages and compression bandages) and ment regimen could often be followed. Each patient in this study was they were instructed to elevate the ankle. Patients were given treated in one session only while lying in the supine position. prescriptions for ibuprofen unless they gave a history of pepticulcer disease or intolerance to aspirin or NSAIDs. Such patientswere instead offered acetaminophen. Patients were also Statistical Analysis
instructed on the safe and proper use of crutches. Each patient This study used repeated observations of each patient in the was further instructed to return in 5 to 7 days for a follow-up OMT study group and in the control group. Observations were made on both the injured ankle and on the uninjured ankle.
At follow-up, a research assistant repeated the afore- In this study, several analyses were used: (1) a 2-way mentioned measurements on the sprained and on the unin- repeated analysis of variance (ANOVA) was used with each jured ankle. Patients were offered continued follow-up in the measure; (2) repeated measures analysis of covariance to determine whether use of the uninjured ankle as a covariatewould improve the analysis; and (3) repeated measuresANOVA and the Student t test on the OMT study group to 418 • JAOA • Vol 103 • No 9 • September 2003
Eisenhart et al • Original Contribution ORIGINAL CONTRIBUTION
assess the immediate effectiveness ofthe additional intervention (ie, the Characteristics of Study Subjects and Baseline Outcome Variables, N = 55*
Treatment, No. (%)
Control, No. (%)
ages using the normal, uninjuredankle as the denominator. This pro- cedure has been used in analogousstudies.10,11 The covariance analyses group and 27 in the control group.
The mean age was 31 years, and Table 1 summarizes the demographic characteristics of the patient popu-lation for this study and outlines the injured-contralateral (degrees) Ϫ31.24 Ϯ 12.4 between the delta ankle circumfer-ence (as a measure to evaluate * All values are expressed as mean Ϯ SD for continuous variables.
† Percentages reported were rounded for each demographic characteristic. Therefore the sum of these ‡ Patients were asked to quantify their pain using a 1 to 10 visual analog pain scale.
OMT provided in an ED are pre-sented in Tables 1 through 3. Toassess the effectiveness of OMT inthis setting, Student t tests were con- Osteopathic Manipulative Treatment: Outcome Measures Before and After
One Session in Emergency Department, N = 28*
after OMT was provided (Table 2)and subsequently at 1-week follow- Variable
Before Treatment
After Treatment
injured-contralateral (degrees) Ϫ31.24 Ϯ 12.4 (11 degrees), this finding was notstatistically significant. Similar resultswere found in the analyses of the * All values are expressed as mean Ϯ SD for continuous variables.
† Patients were asked to quantify their pain using a 1 to 10 visual analog pain scale.
percentages, except that a significantinteraction was found for ROM(F = 5.92, P = .02). Analyses run withthe uninjured ankle as a covariatedid not change these findings.
Eisenhart et al • Original Contribution JAOA • Vol 103 • No 9 • September 2003 • 419
One-Week Follow Up:
Outcome Measures for Patients Who Received Osteopathic Manipulative Treatment
and Control Subjects, N = 40*
that can delay healing and decreaseROM.6 Simko et al16 state that therecovery rate for ankle function fol- Treatment
(n = 20)†
(n = 20)†
phatic system for optimal healingto occur.17 trend toward increased ROM—immediately following one OMT * All values are expressed as mean Ϯ SD for continuous variables.
† Fifteen patients (27%) were lost to follow-up. The 8 patients in the treatment group and the 7 patients in the control group did not differ with regard to baseline characteristics.
‡ Patients were asked to quantify their pain using a 1 to 10 visual analog pain scale.
had a statistically significantimprovement in ROM when com-pared with the control group. Our Seventy-three percent of the patients enrolled returned for results imply that there is both an immediate advantage and follow-up evaluation. The 15 patients lost to follow-up did a delayed benefit to adding OMT in the acute care setting of not differ with regard to baseline characteristics. All patients ankle injuries. After a brief OMT session in the ED, patients will had a statistically significant improvement in all three out- have a significant reduction in swelling and, consequently a come measures at follow-up. Comparison of the two study reduction in their level of pain. Patients who receive OMT as groups at follow-up revealed a statistically significant improve- an adjunct to traditional pain management will have greater ment in ROM in the group that received OMT in addition to the current standard of care for acute ankle sprains.
This study has some limitations. It was based on a “con- venience sample,” and the same osteopathic physician (A.W.E.) treated all patients. Although we were able to show the efficacy An ankle sprain is a traumatic, ligamentous injury at the level of OMT in the ED, the external validity of a study must come of the ankle mortise. Three levels of ankle sprain severity are into question when only one physician performs the investi- commonly described.1,2,12-15 Multiple studies have confirmed that the majority of ankle sprains occur from a foot inversion In addition, other studies involving OMT have used sham mechanism, with as many as 85% of inversion injuries causing treatments. Our study design did not include such a placebo isolated anterior talofibular ligament tears.1,2,6,14,15 The second control. In the design phase of the trial, we decided that the most commonly affected structure is the calcaneofibular liga- OMT session would be tested against what is currently prac- ment at the fibular origin—most often an accompanying injury ticed in the ED. Future studies should include larger cross- to an anterior talofibular ligament sprain.2 The traumatic vector sections of osteopathic physicians at all levels of training (ie, of force occurs with ankle inversion, internal rotation, and interns, residents, and attending physicians), and sham therapy plantar flexion of the foot relative to the leg.9 This force exceeds should be considered the most appropriate control.
the ROM of the lateral ligaments and results in injury to them.
Finally, we report preliminary data regarding the imme- For clinicians treating patients with such injuries, two diate and short-term impact of OMT in ED patients with acute general treatment goals exist: the restoration of functional ankle injury. Future research should include the investigation anatomy and a decrease in edema. When these goals are of the role of OMT as provided in the ED in long-term outcome accomplished, an increased ROM and patient comfort will measures, including prevention of recurrent injury and long- follow. Additionally, restoring functional anatomy will allow for easier drainage of excess fluids, or edema. It is important The efficacy of OMT has been demonstrated in multiple to reduce the accumulation of fluids surrounding the injury settings. This study illustrates an approach to a common pre- because fluid around the joint increases pain. Obviously, the sentation in emergency medicine using osteopathic principles 420 • JAOA • Vol 103 • No 9 • September 2003
Eisenhart et al • Original Contribution ORIGINAL CONTRIBUTION
and practice. Our data clearly demonstrate that a single session 9. Blood SD. Treatment of the sprained ankle. J Am Osteopath Assoc.
of OMT in the ED can have a significant effect on the man-agement of acute ankle injuries.
10. Pennington GM, Danley DL, Sumko MH, Bucknell A, Nelson JH. Pulsed,
non-thermal, high-frequency electromagnetic energy (DIAPULSE) in the treat-
ment of grade I and grade II ankle sprains. Mil Med. 1993;158:101-104.
11. Diebschlag W, Nocker W, Bullingham R. A double-blind study of the
1. Wedmore IS, Charette J. Emergency department evaluation and treat-
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4. Wilkerson GB, Horn-Kingery HM. Treatment of the inversion ankle sprain:
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comparison of different modes of compression and cryotherapy. J Orthop Sports Phys Ther. 1993;17:240-246.
15. Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence
5. Higgins G. Towards evidence based emergency medicine: best BETs from
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16. Simko M, Deslarzes C, Andrieu R. Hydrostatic pressure therapy in the treat-
ment of edema [in French]. Rev Med Suisse Romande. 1987;107:935-939.
6. Mascaro TB, Swanson LE. Rehabilitation of the foot and ankle [review].
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7. de Bie RA, de Vet HC, van den Wildenberg FA, Lenssen T, Knipschild PG.
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Eisenhart et al • Original Contribution JAOA • Vol 103 • No 9 • September 2003 • 421

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