Ankle sprains are one of the most common musculoskeletal injuries associated with physical activity. An estimated 2.15 new injuries occur per 1,000 person-years in the United States,1 and 30% of those occur within organized sport.2 In the 2004–2005 secondary academic year alone, just over 7 million high school students participated in athletics, which increased to nearly 8 million by 2017.3 Of all recorded sport-related injuries during this time period, 50% of lower extremity injuries were ligament sprains and 40% of these sprains were to ligaments in the ankle.4 Similar statistics are reported in collegiate athletics, as lateral ligament complex ankle sprains have been the most commonly reported injury diagnosis.5 Although lateral ankle sprains are the most common injury in an athletic population,2,6,7 clinicians are also tasked with managing the less commonly diagnosed deltoid and tibiofibular ligament sprains.7
Ankle sprains are generally thought to be “mild” injuries, but they are associated with long-term consequences including diminished function,8 reduced physical activity,9 and deficits to health-related quality of life.10 Furthermore, these injuries have been associated with chronic conditions, such as chronic ankle instability11 and post-traumatic osteoarthritis.12 Due to the potential for poor outcomes13 and high risk of reinjury14 following an ankle sprain, there has been an increased focus on the proper management and treatment of these injuries. Recently, Simon et al15 evaluated athletic training services provided for ankle sprain injuries in the high school setting through the National Athletic Treatment, Injury and Outcomes Network (NATION) database, and reported that athletic trainers are generally following treatment guidelines set forth by the National Athletic Trainers' Association position statement.16 For example, athletic trainers frequently provided therapeutic exercise and neuromuscular reeducation for both time-loss and non–time-loss ankle sprain injuries.15 This strategy is in line with best practice for prevention of recurrent sprain,16 addressing deficits to strength, balance, and function.
Although recent findings have evaluated the services athletic trainers are providing for ankle sprains,15,17 several gaps in the literature still exist. First, injury documentation is often cited as a limitation within athletic health care research,18 and limits the ability to observe the athletic training services provided over the entire duration of care. Simon et al15 noted that their dataset may have been incomplete and, as a result, athletic trainers may not have reported all of the care provided for ankle sprain injuries. Incomplete documentation of athletic injuries is problematic and may lead to the underestimation or overestimation of findings. However, analyzing the services provided for complete patient cases from intake to discharge may provide a better estimation of treatment patterns at the point-of-care. Additionally, there has been limited evidence regarding the estimated direct costs associated with treatment and the care provided for these injuries. It has been proposed that athletic trainers reduce health care costs by limiting the number of referrals to other health care professionals15; however, the value of the athletic training services provided for these injuries has not been investigated. Both treatment strategy and estimated direct costs of care are important to the athletic training profession because they characterize and quantify the value of the care being provided to athletes. Therefore, the purpose of this study was to describe patient, treatment, and cost characteristics associated with complete ankle sprain patient cases managed by athletic trainers.
Design and Setting
This study was a retrospective analysis of de-identified patient electronic medical records (EMRs) collected within the Athletic Training Practice-Based Research Network (AT-PBRN). The AT-PBRN and its features, including its EMR system, infrastructure, clinician training, and data collection methods, have been described in previous studies.17,19 All patient records were created by the participating athletic trainer providing care within the secondary school or collegiate setting. For this study, there was a total of 43 clinical practice sites (secondary school = 39, college = 4) across 11 states (Arizona, Florida, Kansas, Massachusetts, Minnesota, Missouri, New Hampshire, New York, Utah, Virginia, and Wisconsin). Clinical practice sites were predominantly public high schools (83.7%), set in an urban area (41.9%), and employed one certified athletic trainer (48.8%).
A total of 113 athletic trainers practiced at these clinical practice sites during the study period. Most athletic trainers were female (60.2%) and held a master's degree (76.7%). On average, the athletic trainers were 30.0 ± 11.2 years old, certified for 3.9 ± 5.1 years, and employed at their current site for 0.7 ± 2.2 years, on a part-time (41.8%) or full-time (37.2%) basis. This study was deemed exempt by the university's institutional review board because it was a retrospective analysis of de-identified patient records.
All data were collected by a participating athletic trainer within the AT-PBRN using the web-based CORE-AT EMR system.19 Patient records from each of the AT-PBRN clinical practice sites between 2009 and 2017 were reviewed. Patient cases were first identified using the International Classification of Disease, version 9 (ICD-9) diagnostic codes in the injury demographics form of the EMR, following standard procedures used in previous studies.17,19 Cases were retained if the ICD-9 code matched one of the following: 845.0 (ankle sprain/strain), 845.1 (deltoid ligament sprain), or 845.3 (tibiofibular ligament sprain). In an effort to ensure quality data, only complete patient cases were included, defined as injuries that had (1) a documented first encounter or injury demographics form, (2) injury evaluation, (3) daily treatment forms with at least one encounter per week for the duration of care, and (4) discharge form (the last documented session with the patient). These data were used to analyze patient characteristics, treatment procedures, and associated cost for each ankle sprain injury.
Patient characteristic variables extracted from the demographics form included sex, sport, activity during injury (ie, practice or competition), mechanism of injury, and diagnosis. Procedures obtained from the daily treatment forms consisted of all of the current procedural terminology codes (CPT) that the athletic trainer implemented during each episode of care (ie, documented patient encounter) (Table 1). Each CPT code was associated with a direct cost of care, estimated by implementing the Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule for non-facility (ie, non-hospital) organizations (Table 1).20 Direct cost was calculated based on the fee associated with the CPT code and the number of 15-minute increments documented. The estimated direct cost of care for each treatment and the number of services rendered were used to calculate the average total direct cost per ankle sprain case and average direct cost per episode of care.
Athletic Training Services Provided for the Management of Lateral Ankle Sprains
The CORE-AT ( www.core-at.com)19 uses four forms for full documentation of an injury from first contact with the athletic trainer through discharge. After a patient has been entered into the system, the athletic trainer completes the injury demographics (eg, sex, sport, age, height, and mass), initial evaluation, daily treatments (ie, procedural summaries), and discharge (ie, functional and special tests used for decision making regarding discharge from care) forms throughout the duration of the injury. Patient data were formatted as structured variables within the EMR and recorded using either a drop-down menu or radio buttons. In-depth features and functionality of the CORE-AT have been thoroughly described in previous studies generated through the AT-PBRN.17,19
Summary statistics (frequency, percentage, and mean ± standard deviation) were calculated for all variables. Treatment characteristics included the type (CPT code), amount of care (number of services per case), and duration of care (number of days between intake and discharge). Direct cost characteristics included the number of services per case and procedural total cost per case and per episode of care. Additional calculations estimated the minimum, maximum, median, and interquartile range for the cost variables. All analyses were conducted using IBM SPSS Statistics software (version 24; IBM Corporation, Armonk, NY).
During the study period, 1,104 ankle sprains were documented, of which 130 patient cases were complete (males = 78 [60%]; secondary school setting = 101 [76.5%], age = 16.6 ± 1.9 years; height = 172.7 ± 9.9 cm; mass = 72.2 ± 15.5 kg). Of the complete cases, the most commonly documented diagnosis was sprain/strain (ICD-9 code: 845.0, n = 107, 82.3%), followed by tibiofibular ligament sprain (ICD-9 code: 845.1, n = 19, 14.6%) and deltoid ligament sprain (ICD-9 code 845.3, n = 4, 3.1%). Mechanism of injury included contact (n = 39, 39%), twisting (n = 37, 35.6 %), non-contact (n = 31, 23.8%), and falls (n = 23, 17.7%), and injuries were most likely to occur in football (n = 45, 34.6%), basketball (n = 22, 16.9%), soccer (n = 20, 15.4%), and volleyball (n = 11, 8.5%) (Table 2). Within each sport, in-season practices (n = 51, 39.2%) and in-season games (n = 51, 39.2%) were equally the most reported activities during injury (Table 3). Patients resumed full function 6.92 ± 14.39 days following injury.
Frequency of Ankle Sprain Cases According to Sport
Activity During Ankle Sprain Injury
A total of 2,292 procedures were documented for the treatment of patient cases, with 17.6 ± 12.6 services provided per case (range: 3 to 63 services). From first documented encounter to discharge, the duration of care lasted 21.5 ± 18.5 days (range: 1 to 88 days). The most commonly used procedures were hot/cold packs (n = 519, 22.6%), therapeutic exercise (n = 508, 22.2%), athletic trainer reevaluation (n = 382, 16.7%), and strapping (ie, taping and bracing; n = 210, 9.2%). The least used procedures were infrared (n = 1, < 0.1%), contrast bath (n = 6, 0.3%), and neuromuscular reeducation (n = 6, 0.3%) (Table 4). The average number of episodes of care per patient case was 7.55 ± 5.0 (range: 2 to 29), and patients received 2.3 ± 1.3 treatments per episode of care.
Athletic Training Services Provided During Patient Encounters
Patients received a total of 18.6 ± 13.7 services per case, rendering a total procedural direct cost of $533.72 ± $508.88 (median = $359.17, range = $75.44 to $2,856.21, interquartile range = $145.90 to $572.45; Figure 1). Patients received 2.34 ± 1.3 services per episode of care, resulting in a procedural direct cost of $70.73 ± $45.6 per episode of care (median = $65.08, range = $0.00 to $280.32, interquartile range = $33.79 to $96.37).
Total direct costs of care for ankle sprain cases. Bee swarm box plot of all results. The box indicates the 25th and 7th quartiles and the central line is the median. The ends of the whiskers are the 2.5% and 97.5% values. Each dot represents the total cost of care for one entire ankle sprain case.
To the best of our knowledge, this is the first study to describe patient, treatment, and cost characteristics specific to complete ankle sprain patient cases evaluated and managed by athletic trainers. The patient characteristics in this study were in line with previous point-of-care evidence17,19,21 because injuries occurred primarily within in-season practices and competitions during football, basketball, and soccer. Not only is the ankle the most commonly injured body part in sports, but it has also been reported that it is the most frequently treated by athletic trainers,21 highlighting the role that athletic trainers play in the athletic health care system. Although Simon et al15 reported the number of episodes of care and athletic training services per injury, they did not report the duration of care for these ankle sprain injuries. In the current study, ankle sprain injuries were treated for an average of 3 weeks and, to our knowledge, this is the first study to report such data. Previous investigations have provided insight into practice characterization, explained treatment strategies, and described time from injury until return to sport22; however, limited information is available regarding the services provided by athletic trainers for ankle sprains over the duration of care and the value of these services.
In the current study, athletic trainers provided an average of 18 services over 3 weeks for each ankle sprain case. The most frequently documented services included hot/cold pack (22.6%), therapeutic exercise (22.2%), reevaluation (16.7%), and strapping (9.2%). Of these procedures, therapeutic exercise is supported with the best evidence,16,23 because it has been shown to consistently improve self-reported function and prevent recurrent injury following acute ankle sprains, particularly when prescribed in high doses (ie, > 900 minutes of therapeutic exercise).24 A recent consensus statement25 recommended that clinicians use a rehabilitation-oriented assessment to develop appropriate management strategies and effectively target mechanical and sensorimotor impairments during rehabilitation. Furthermore, combining functional rehabilitation with an external support (eg, bracing, taping) has also been identified as an effective strategy to improve function and reduce recurrent sprains.23 Although evidence suggests that cryotherapy provides a temporary improvement in secondary outcomes (eg, pain),26 there is disparity over whether it improves primary outcomes (eg, self-reported function and clinical outcomes).16 As a result, it is important to consider the context of how the clinician incorporates this modality when treating ankle sprain injuries. Ice, or some other form of cryotherapy, is often immediately applied to provide an analgesic effect, control excess swelling, and reduce the risk of secondary hypoxic tissue damage.26 Due to the popularity of cryotherapy in athletic health care following an acute injury, evidence is limited as to whether cryotherapy on its own will improve primary outcomes; however, treatment success has been noted when ice is combined with therapeutic exercise.23
Simon et al15 reported that athletic trainers provided an average of 22 services per ankle sprain injury, listing therapeutic activities or exercises (47.4%), neuromuscular reeducation (16.6%), strapping (14.2%), and modalities (11.5%) as the most common services provided. In comparison, athletic trainers in the current study had a low use of neuromuscular reeducation (n = 6, 0.3%). It is possible that athletic trainers within the AT-PBRN may have been documenting this procedure under a different category, such as functional rehabilitation, or as a therapeutic activity. However, even if athletic trainers documented neuromuscular reeducation using the CPT code for therapeutic activities, there is a low prevalence of this treatment category being reported (n = 137, 6%). Although patients in the current study received an average of 3 weeks of care, the type of care provided may not have allowed for functional rehabilitation, strength, and sensorimotor deficits to be truly addressed and corrected. In addition, athletic trainers in the current study returned athletes to full sport participation approximately 1 week following injury. This finding is in line with previous evidence highlighting that there is a 95% probability that patients who suffer a first-time ankle sprain will return to full participation within 10 days.27 Nevertheless, a large proportion of patients who suffer an acute lateral ankle sprain experience prolonged mechanical and sensorimotor deficits following injury.11 This disparity between a seemingly not ideal rehabilitation progression and early return to sport is likely contributing to the high rate of injury recurrence and poor long-term outcomes following ankle sprain injuries.25,28 Moreover, previous investigations have identified that evidence-based rehabilitation reduces the risk of recurrent injury.29 Thus, it is imperative that clinicians assess mechanical and sensorimotor deficits on initial evaluation and throughout the rehabilitation process to appropriately manage these injuries and mitigate negative long-term consequences.25
The use of non-steroidal anti-inflammatory drugs, a treatment strategy supported by quality evidence,16 was not documented within this study or the study by Simon et al.15 Even over-the-counter medications require parental consent to be administered to minors, and the ability to obtain consent may hinder athletic trainers from providing non-steroidal anti-inflammatory drugs for the management of ankle sprains. However, parents or guardians may have been providing patients with these medications outside of the purview of the athletic trainer. Additionally, manual therapy was one of the least used services in both studies (approximately 3% of all treatments), although joint mobilizations are known to increase dorsiflexion range of motion and correct positional faults.30 Although additional research is warranted to determine the appropriate frequency and duration of this treatment, it is interesting that athletic trainers are generally not employing this type of intervention with athletes who have suffered an ankle sprain.
Methodologically, several differences exist between the current study and the study conducted by Simon et al.15 For instance, the AT-PBRN uses the CORE-AT EMR for all participating athletic trainers,19 whereas the NATION data collection tools are embedded into commercially available EMRs.31 The data are then sent to the Datalys Center for Sports Injury Research and Prevention, Inc., and combined across the numerous EMRs.15,31 Thus, variation may exist between how AT-PBRN participating athletic trainers and NATION participating athletic trainers are instructed to document injury treatment, and within the type of data analyzed (ie, structured vs unstructured variables).
Recently, there have been calls to highlight the value of athletic trainers in athletic health care. In a series of Value Models,32,33 the National Athletic Trainers' Association proposed that the value of the services provided must be established to eventually determine the value of those services, and ultimately demonstrate why athletic trainers are vital health care providers. Despite these calls, there is limited information regarding the estimated direct costs associated with services provided for ankle sprain injuries specifically by athletic trainers. In the United States alone, an ankle sprain averages $1,211.15 per emergency department visit,34 which typically consists of unnecessary imaging to rule out fracture and little to no follow-up treatment. In fact, approximately 80% to 90% of patients who report to the emergency department for an ankle sprain undergo imaging, but fewer than 15% of patients actually have a fracture.34 Feger et al35 estimate the financial burden associated with the diagnosis and management of lateral ankle sprain injuries to be $152 million in the United States, with most of the cost related to physician evaluations and only 7.9% resulting from physical therapy.
According to our study, the median cost per case was $359.17, comprising only services provided by athletic trainers and not unnecessary imaging or potentially un-warranted referrals. Eleven of these cases were identified as outliers, for which the direct cost of care was substantially higher than the rest of the cases. On further investigation, it was determined that nine of the outliers were injuries that occurred and were treated in the collegiate setting. It is likely that the athletic trainers treating these patients had a greater number of resources than those treating patients in the secondary school setting, contributing to the increased cost. Further, according to the Centers for Medicare and Medicaid Services,20 the CPT code for hot/cold pack does not render a cost associated with the treatment. Similarly, athletic trainers are often reevaluating and reassessing the status of an injury throughout the treatment process to monitor progress, but evaluation and reevaluation CPT codes can only be billed every 14 days. Both of these circumstances contribute to a potential underestimation of the direct cost of care for the actual services rendered.
In the current study, only 11.77% of the ankle sprain injuries documented during the study period met the criteria to be considered a complete patient case. We opted to only evaluate complete patient cases in an effort to combat some of the issues regarding documentation habits within the athletic training profession18; however, complete and consistent documentation of all patient care provided by athletic trainers would deliver stable data for point-of-care research. Future investigations should focus on a cost savings analysis within athletic training practice. To truly measure cost savings to the health care system as a result of services provided by an athletic trainer, we must first determine the worth of the services rendered, assess the quality of these services through the incorporation of patient outcomes, and incorporate stakeholders to ultimately estimate the value the care provided. In addition, although this study provides an estimate of the direct costs of care for the management of ankle sprains, indirect costs (eg, time loss or follow-up care) add to the societal burden following these injuries.11 Future investigations should also seek to determine the indirect costs of these injuries and how they are influenced by management strategies.
Implications for Clinical Practice
Although athletic trainers are generally following recommendations for the management of ankle sprain injuries, they appear to be underutilizing treatments that are effective in reducing recurrence and long-term complications, such as therapeutic activities, neuromuscular reeducation, and manual therapies. The estimated direct costs of care rendered from athletic training services for these injuries provide insight into the valuable role of athletic trainers in the management of ankle sprains.
- Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92:2279–2284. doi:10.2106/JBJS.I.01537 [CrossRef]
- Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42:311–319.
- National Federation of High School Associations. 2016–2017 High School Athletics Participation Survey. 2017; www.nfhs.org/ParticipationStatistics/PDF/2016-17_Participation_Survey_Results.pdf. Accessed July 1, 2018.
- Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emerg Med. 2007;14:641–645. doi:10.1197/j.aem.2007.03.1354 [CrossRef]
- Roos KG, Kerr ZY, Mauntel TC, Djoko A, Dompier TP, Wikstrom EA. The epidemiology of lateral ligament complex ankle sprains in National Collegiate Athletic Association sports. Am J Sports Med. 2017;45:201–209. doi:10.1177/0363546516660980 [CrossRef]
- Nelson AJ, Collins CL, Yard EE, Fields SK, Comstock RD. Ankle injuries among United States high school sports athletes, 2005–2006. J Athl Train. 2007;42:381–387.
- Swenson DM, Collins CL, Fields SK, Comstock RD. Epidemiology of U.S. high school sports-related ligamentous ankle injuries, 2005/06–2010/11. Clin J Sport Med. 2013;23:190–196. doi:10.1097/JSM.0b013e31827d21fe [CrossRef]
- Arnold BL, De La Motte S, Linens S, Ross SE. Ankle instability is associated with balance impairments: a meta-analysis. Med Sci Sports Exerc. 2009;41:1048–1062. doi:10.1249/MSS.0b013e318192d044 [CrossRef]
- Hubbard-Turner T, Turner MJ. Physical activity levels in college students with chronic ankle instability. J Athl Train. 2015;50:742–747. doi:10.4085/1062-6050-50.3.05 [CrossRef]
- Houston MN, Van Lunen BL, Hoch MC. Health-related quality of life in individuals with chronic ankle instability. J Athl Train. 2014;49:758–763. doi:10.4085/1062-6050-49.3.54 [CrossRef]
- Gribble PA, Bleakley CM, Caulfield BM, et al. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med. 2016;50:1496–1505. doi:10.1136/bjsports-2016-096189 [CrossRef]
- Golditz T, Steib S, Pfeifer K, et al. Functional ankle instability as a risk factor for osteoarthritis: using T2-mapping to analyze early cartilage degeneration in the ankle joint of young athletes. Osteoarthritis Cartilage. 2014;22:1377–1385. doi:10.1016/j.joca.2014.04.029 [CrossRef]
- Anandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle injuries. Br J Sports Med. 2005;39:e14. doi:10.1136/bjsm.2004.011676 [CrossRef]
- McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med. 2001;35:103–108. doi:10.1136/bjsm.35.2.103 [CrossRef]
- Simon JE, Wikstrom EA, Grooms DR, Docherty CL, Dompier TP, Kerr ZY. Athletic training service characteristics for patients with ankle sprains sustained during high school athletics. J Athl Train. 2019;54:676–683. doi:10.4085/1062-6050-449-16 [CrossRef]
- Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013;48:528–545. doi:10.4085/1062-6050-48.4.02 [CrossRef]
- Lam KC, Snyder Valier AR, Valovich McLeod TC. Injury and treatment characteristics of sport-specific injuries sustained in interscholastic athletics: a report from the Athletic Training Practice-Based Research Network. Sports Health. 2015;7:67–74. doi:10.1177/1941738114555842 [CrossRef]
- Bacon CEW, Eppelheimer BL, Kasamatsu TM, Lam KC, Nottingham SL. Athletic trainers' perceptions of and barriers to patient care documentation: a report from the Athletic Training Practice-Based Research Network. J Athl Train. 2017;52:667–675. doi:10.4085/1062-6050-52.3.15 [CrossRef]
- Valovich McLeod TC, Lam KC, Bay RC, Sauers EL, Snyder Valier AR. Practice-based research networks, part II: a descriptive analysis of the Athletic Training Practice-Based Research Network in the secondary school setting. J Athl Train. 2012;47:557–566. doi:10.4085/1062-6050-47.5.05 [CrossRef]
- U.S. Centers for Medicare & Medicaid Services. Physician Fee Schedule Search. 2019; https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. Accessed February 13, 2019.
- Lam KC, Valier AR, Anderson BE, McLeod TC. Athletic training services during daily patient encounters: a report from the Athletic Training Practice-Based Research Network. J Athl Train. 2016;51:435–441. doi:10.4085/1062-6050-51.8.03 [CrossRef]
- McCann R, Kosik K, Terada M, Gribble P. Residual impairments and activity limitations at return to play from a lateral ankle sprain. Int J Athl Ther Train. 2018;23:83–88. doi:10.1123/ijatt.2017-0058 [CrossRef]
- Doherty C, Bleakley C, Delahunt E, Holden S. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. Br J Sports Med. 2017;51:113–125. doi:10.1136/bjsports-2016-096178 [CrossRef]
- Bossard DS, Remus A, Doherty C, Gribble PA, Delahunt E. Developing consensus on clinical assessment of acute lateral ankle sprain injuries: protocol for an international and multidisciplinary modified Delphi process. Br J Sports Med. 2018;52:1539. doi:10.1136/bjsports-2017-099007 [CrossRef]
- Delahunt E, Bleakley CM, Bossard DS, et al. Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. Br J Sports Med. 2018;52:1304–1310. doi:10.1136/bjsports-2017-098885 [CrossRef]
- Knight KL. Cryotherapy in Sport Injury Management. Champaign, IL: Human Kinetics; 1995.
- Medina McKeon JM, Bush HM, Reed A, Whitington A, Uhl TL, McKeon PO. Return-to-play probabilities following new versus recurrent ankle sprains in high school athletes. J Sci Med Sport. 2014;17:23–28. doi:10.1016/j.jsams.2013.04.006 [CrossRef]
- Gribble PA, Bleakley C, Caulfield B, et al. 2016 consensus statement of the International Ankle Consortium: prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med. 2016;50:1493–1495. doi:10.1136/bjsports-2016-096188 [CrossRef]
- Bleakley C, Taylor J, Dischiavi S, Doherty C, Delahunt E. Rehabilitation exercises reduce re-injury post-ankle sprain, but the content and parameters of an optimal exercise program have yet to be established: a systematic review and meta-analysis [published online ahead of print October 26, 2018]. Arch Phys Med Rehabil. doi:10.1016/j.apmr.2018.10.005 [CrossRef]
- Hoch MC, Andreatta RD, Mullineaux DR, et al. Two-week joint mobilization intervention improves self-reported function, range of motion, and dynamic balance in those with chronic ankle instability. J Orthop Res. 2012;30:1798–1804. doi:10.1002/jor.22150 [CrossRef]
- Dompier TP, Marshall SW, Kerr ZY, Hayden R. The National Athletic Treatment, Injury and Outcomes Network (NATION): methods of the surveillance program, 2011–2012 through 2013–2014. J Athl Train. 2015;50:862–869. doi:10.4085/1062-6050-50.5.04 [CrossRef]
- National Athletic Trainers' Association. Secondary School Value Model. 2015. https://www.nata.org/sites/default/files/secondary_school_value_model.pdf. Accessed June 3, 2018.
- National Athletic Trainers' Association. College-University Value Model. 2013. https://www.nata.org/sites/default/files/college-value-model.pdf. Accessed June 3, 2018.
- Shah S, Thomas AC, Noone JM, Blanchette CM, Wikstrom EA. Incidence and cost of ankle sprains in United States emergency departments. Sports Health. 2016;8:547–552. doi:10.1177/1941738116659639 [CrossRef]
- Feger M, Glaviano N, Donovan L, et al. Current trends in the management of lateral ankle sprain in the United States. Clin J Sport Med. 2017;27:145–152. doi:10.1097/JSM.0000000000000321 [CrossRef]
Athletic Training Services Provided for the Management of Lateral Ankle Sprains
|Treatment or Procedure||CPT Code||Mean Fee (2009–2017)||Fee Range (2009–2017)|
|Aquatic therapy||97113||$40.87||$34.26 to $43.78|
|Athletic trainer evaluation||97005||$76.85||$69.97 to $86.49|
|Athletic trainer reevaluation||97006||$45.39||$37.51 to $58.74|
|Contrast bath||97034||$17.24||$14.79 to $18.33|
|Electrical stimulation||97014||$18.42||$16.23 to $19.40|
|Gait training||97116||$27.41||$24.53 to $28.75|
|Hot or cold pack||97010||$0.00||$0.00 to $0.00|
|Infrared||97026||$5.77||$5.05 to $6.12|
|Iontophoresis||97033||$28.51||$22.25 to $33.06|
|Manual therapy techniques||97140||$28.95||$25.97 to $30.51|
|Massage||97124||$25.33||$22.36 to $26.95|
|Neuromuscular reeducation||97112||$32.36||$28.85 to $34.45|
|Physical performance test or measurement||97750||$32.20||$28.85 to $33.67|
|Strapping: ankle||29540||$33.53||$26.23 to $39.09|
|Strapping: knee||29230||$43.19||$28.75 to $53.76|
|Therapeutic activities||97110||$33.66||$29.57 to $35.53|
|Therapeutic exercises||97530||$31.11||$28.13 to $33.02|
|Ultrasound||97035||$12.45||$11.54 to $12.94|
|Vasopneumatic devices||97016||$18.29||$15.15 to $19.74|
|Whirlpool||97022||$21.94||$17.31 to $24.05|
Frequency of Ankle Sprain Cases According to Sport
|Field hockey||3 (2.3)|
Activity During Ankle Sprain Injury
|Pre-season conditioning||4 (3.1)|
|Pre-season scrimmage||5 (3.8)|
|In-season practice||51 (39.2)|
|In-season game||51 (39.2)|
|Post-season practice||1 (0.8)|
|Post-season game||0 (0.0)|
|Off-season conditioning||1 (0.8)|
|Off-season practice||5 (3.8)|
|Not sports related||12 (9.2)|
Athletic Training Services Provided During Patient Encounters
|Treatment or Procedure||No. (%)|
|Hot or cold pack||519 (22.6)|
|Therapeutic exercise||508 (22.2)|
|Athletic trainer reevaluation||382 (16.7)|
|Strapping: ankle and/or foot||210 (9.2)|
|Athletic trainer evaluation||141 (6.2)|
|Therapeutic activities||137 (6.0)|
|Electrical stimulation||117 (5.1)|
|Manual therapy techniques||35 (1.5)|
|Vasopneumatic devices||14 (0.6)|
|Physical performance test or measurement||9 (0.4)|
|Contrast bath||6 (0.3)|
|Neuromuscular reeducation||6 (0.3)|
|Aquatic therapy||3 (0.1)|
|Strapping: knee||2 (0.1)|