Management of Minor Ankle Sprains

Ankle sprains are the most common sport-related injury, with an estimated 28,000 occurring daily in the U.S. Fortunately, most of these injuries are Grade I or mild sprains of the ligaments on the lateral aspect (outside) of the ankle. Grade I sprains are characterized as a stretching of the ligament with mild pain and minimal loss of function. Recently, the National Athletic Trainers' Association released a Position Statement that thoroughly discussed the conservative management and prevention of mild to severe ankle sprains in athletes.

Much of the information in this statement pertained to the more serious Grade II or III injuries. These injuries involve partial or complete tears of the ligaments that support the ankle with considerable pain and loss of function. These can take months to heal and sometimes even require surgery. The Position Paper provided information to doctors related to these more serious sprains, such as when to perform magnetic resonance imaging (MRI) following an ankle injury and when immobilization is the best initial treatment. In addition to information regarding higher grade sprains, the Position Paper offered a number of important "take home" messages that applied to anyone who inadvertently "rolls" their ankle, sustaining a minor sprain.

• RICE therapy (rest, ice, compression, and elevation) continues to be the most accepted and effective management of acute ankle sprains. Rest means keeping the ankle comfortable by avoiding activities that cause discomfort for at least 24 hours after the injury. Ice is typically applied for 20 to 30 minute periods following the acute injury and can be repeated at hourly intervals for the first couple of days. Compression is usually administered via an ACE wrap or soft ankle brace. Elevation (usually in combination with ice and compression) is especially beneficial in preventing swelling immediately after the injury.
  
• The Ottawa ankle rules, a means of determining the likelihood of an ankle fracture following an ankle sprain, were deemed to be reliable. These rules, developed to help doctors decide when to perform x-rays, involve a determination of the location of bone tenderness and the patient's ability to bear weight following the sprain. From the perspective of a lay person assessing their own injury, being able to bear weight and walk more or less normally after an ankle injury practically eliminates the possibility of a significant fracture.
  
• Non-steroidal anti-inflammatory drugs (NSAIDs) were found to reduce pain and swelling and improve short-term function after ankle sprains. The NSAID, piroxicam, was mentioned in the position paper, but the widely available non-prescription NSAIDs, ibuprofen or naproxen, taken at recommended dosages, should be equally effective.
  
• Functional rehabilitation was found to be more effective than immobilization in managing minor ankle sprains. In other words, the use of a boot, avoiding bearing weight while on crutches, or the use of some other device to keep the ankle from moving is not the best way to manage a minor ankle sprain. Functional rehabilitation includes the use of range-of-motion, flexibility, and strengthening exercises with progressive weight bearing as tolerated. The following link outlines a comprehensive functional rehabilitation program.

Another important point from the Position Paper is that the most common cause of a repeat ankle sprain is an incompletely rehabilitated ankle following an initial sprain. Even though most minor ankle sprains will heal without long-term consequences, the importance of functional rehabilitation cannot be overemphasized. In the case of more serious sprains, medical evaluation and the guidance of a physical therapist or athletic trainer is the best course of action in order to assure complete recovery and avoidance or re-injury.

There was far more information included in the Position Paper than was covered in today's Health Tip, including return-to-play recommendations, taping and bracing considerations, and management of chronic ankle sprains. To learn more about the management of ankle sprains, you can read the entire Position Paper published in the Journal of Athletic Training.

Health Tip: A "Formula" for Losing Weight

We occasionally receive messages from eDoc clients expressing frustration with not being able to lose weight, despite eating a low-calorie diet and getting regular exercise. Once issues such as hypothyroidism are ruled out, the cruel reality is that weight loss occurs only when the number of calories that we burn exceeds the number that we consume. We burn calories through our basal metabolism, activities of daily living, and exercise. Basal metabolism or basal metabolic rate (BMR) refers to the number of calories that we consume in order to maintain our current weight and to support certain "basal" functions, such as brain activity, breathing, and pumping blood throughout the body. The BMR varies from individual to individual because of differences in body weight, height, gender, and age. By knowing our basal metabolic rate, we can come closer to being able to estimate the maximum number of calories that we can eat and still lose weight.

One way of estimating the daily caloric intake is by applying the Harris-Benedict Principle. This equation takes into consideration those factors (age, height, weight, etc.) that affect basal metabolism, as well as factoring in the person's activity level. This equation will be fairly accurate in all but the very muscular (under-estimates calorie needs) and the very fat (over-estimates calorie needs). Here's how the equation works:

1. As mentioned, the BMR varies depending on whether you are a man or a woman:

• For men, the BMR equals 66 + (6.23 times your weight in pounds) + (12.7 times your height in inches) - (6.8 times age in years).
  
  
• For women, the BMR equals 655 + (4.35 times your weight in pounds) + (4.7 times your height in inches) - (4.7 times your age in years).
  
  
• As an example, if you are a 48 year old woman whose weight is 168 pounds and height is 5 ft. 6 inches, the calculations would go as follows:
  
  
• BMR = 655 + (4.35 X 168) + (4.7 X 66) - (4.7 X 48)
  
  
• BMR = 655 + 730.8 + 310.2 - 225.6
  
  
• BMR = 1470.4 calories per day. This is the number of calories that you could eat if you were completely sedentary and that would support your current weight and basal metabolism. In other words, you would neither gain nor lose weight.
  

 2. Since almost everyone is active to some degree, the next step is to factor in your estimated activity level. This is done by multiplying your BMR by an activity factor (these are the same for men and women). They are as follows:

• Sedentary = BMR x 1.2 (Office Job - Not very active)
  
  
• Lightly Active = BMR x 1.375 (1-3 days/wk light exercise)
  
  
• Moderately Active = BMR x 1.55 (moderate exercise 3-5 days/wk)
  
  
• Very Active = BMR x 1.725 (intense exercise 5-7 days/wk)
  
  
• Athletic = BMR x 1.9 (Hard exercise daily. Active job. Training for sports contest/competition)
  
  
• So, keeping with the previous example, in a moderately active woman whose BMR is 1470 calories, she would burn approximately 2279 (1470 X 1.55) calories in a day.
  

Now comes the weight loss part. In order to lose weight, this individual would have to consume fewer than 2279 calories per day or would have to increase her exercise level so that she was burning more than 2279 calories per day. In order to lose a pound of weight a week, our subject would need to create a calorie deficit of 500 calories per day or approximately 3500 calories per week. She could do this by burning an extra 250 calories and cutting back by 250 calories from her diet or any other combination that will result in 500 fewer calories. Obviously, one day's worth of dieting or a particularly vigorous exercise session will not make much difference. Weight loss typically requires that you create a caloric deficit for a longer period of time to be successful.

The Harris-Benedict principle is not exact, but does provide a more accurate estimate of daily caloric expenditure than many other methods. It is best applied with the use of diet and exercise diary to keep track of the number of calories that are being consumed as well as the number of calories expended through exercising.

Travelers' Diarrhea, "peel it, boil it, or forget it"

Every year, an estimated 10 million international travelers are affected by traveler's diarrhea (TD), a gastrointestinal disorder that causes loose stools and abdominal cramping. For Americans, the risk for developing TD is particularly high in the developing countries of Latin America, Africa, the Middle East, and in Asia.

What causes TD? TD is caused by consuming food or water that is contaminated with an infectious agent. Approximately 80% of the time, the source is a type of E. coli bacteria (enterotoxigenic), that produces toxins within the bowel. Other bacteria (Campylobacter, Salmonella, Shigella) as well as a variety of viruses (Hepatitis A, Norwalk Virus, Rotavirus), and parasites (Giardia, Cryptosporidium) are less common causative agents.

Are certain people at risk for developing TD? Travelers to areas of the world with substandard water purification or sanitary practices are at particular risk for the development of TD. Young adults, people taking certain medications including stomach acid-blockers (Prevacid, Prilosec, others) or immune-suppressants (prednisone, methotrexate, others), and people with certain diseases, such as diabetes or inflammatory bowel disease are at particular risk.

What are the symptoms of TD? Most people with TD have the sudden onset of diarrhea, passing 4 to 5 loose stools per day. This may be accompanied by abdominal cramps, nausea, vomiting, generalized weakness or discomfort, or low-grade fever.

How is TD treated? Traveler's diarrhea usually resolves on its own within 48 hours and is rarely life threatening. Drinking clear liquids or oral rehydration solutions to prevent dehydration and loss of electrolytes is usually all that is required. A rehydrating solution can be prepared by mixing together:

• 1/2 teaspoon salt
• 1/2 teaspoon baking soda
• 4 tablespoons sugar
• 1 liter safe drinking water

Taking antimotility agents (Imodium, Lomotil) can relieve TD-associated diarrhea and cramps, but they may also prolong the duration of the illness. Antibiotics can shorten a course of diarrhea and discomfort, but taking them is generally unnecessary. However, when symptoms warrant, such as with the development of bloody diarrhea, high fever, or severe cramps, antibiotics belonging to the fluoroquinolone group ( Cipro, Norfloxacin) have been shown to be effective.

Can medications prevent TD? Certain antibiotics have been shown to be effective at preventing travelers' diarrhea, however, the CDC does not generally recommend that they be used. The reasons for this include the relatively benign nature of TD, the possibility of adverse effects from taking an antibiotic, and the risk of the development of antibiotic-resistant organisms. Bismuth subsalicylate preparations, such as Pepto Bismol, taken as 1 oz of liquid or two 262.5-mg tablets four times daily can reduce the risk of becoming infected with the common bacteria that cause TD. This medication is not recommended for children, pregnant women, or people who are allergic to aspirin.

How else can TD be prevented?The risk of developing TD can be greatly reduced with attention to the following measures:

• Tap water and dairy products, particularly those that are unpasteurized, are some of the most likely sources of contamination associated with the development of TD. When travelling in high risk countries it is safer to drink bottled water, pasteurized milk, hot tea or coffee, or canned or bottled drinks.
• Avoid eating raw fruits and vegetables unless washed (with purified water) and peeled by yourself. It is best to avoid eating salads and fruits or vegetables that cannot be peeled, such as grapes and berries.
• Avoid eating raw or undercooked meats or seafood.
• Avoid purchasing food or drinks from street vendors or from sources where the sanitation is suspect.
• Unsterilized water, either from tap, well or ground sources, must be purified by boiling, filtering, or treating with iodine or chlorine. The Centers for Disease Control (CDC), advises that water should be brought to a rolling boil for at least 1 minute. At altitudes greater than 6,500 feet (2000 meters), boiling time should increase to around 3-5 minutes. Several manufacturers, including Katadyn, Sawyer, and MSR, offer portable filtration systems that are effective in removing bacteria and parasites. When shopping for a filter, make sure that it has a pore size no larger than 0.1 microns. Recognize also that most "backpacking" filters will not remove viruses unless their microfilter has an extremely small pore size (0.01 microns) or has a disinfecting stage (usually incorporating iodine). Water disinfecting tablets containing iodine (Potable Aqua) or chlorine (MSR Aquatabs) are also effective when used as directed.

Other sources of contamination that people may not think about while travelling include getting water in the mouth while showering, rinsing with tap water after tooth brushing (use bottle or filtered water instead), and drinking beverages chilled with ice made from tap water. Medical attention should be sought for severe or persistent symptoms of TD to determine the exact cause and proper treatment.