reported that near-continuous HVPC applied within 24 hours of acute lateral ankle sprains did not affect RTP in intercollegiate and professional athletes. Practical constraints delayed the initiation of electrical stimulation on average by almost 8 hours, well after edema formation was underway as a result of acute inﬂammation; this is a plausible rationale for the different outcomes between laboratory and clinical studies. Thermotherapy. Traditionally, thermotherapy has not been recommended for acute management of ankle sprains given the widely held empirical belief that heat increases swelling and blood ﬂow and exacerbates the injury . In 1 of the few studies of thermotherapy, Cote et al 35 examined the effect of cold, warm, and contrast therapy (alternating cold and hot) on subacute ankle edema. No effect was reported, and all interventions increased limb volume, but the most significant increases were with warm and contrast therapies. As a result, thermotherapy is not recommended due to the lack of quality research needed to make a clinical recommendation either for or against the practice. Thermal ultrasound therapy is used by clinicians for a variety of soft tissue injuries to reduce pain and increase ROM, yet the literature does not support the use of ultrasound in managing ankle sprains due to the lack of high-quality clinical trials. 36 Nonsteroidal Anti-Inﬂammatory Drugs. Strong evidence 27,29 indicates that nonsteroidal anti-inﬂammatory drugs (NSAIDs) used during the acute and subacute phases of injury decrease pain and improve short-term function after acute ankle sprains . Slater et al 29 compared piroxicam with placebo in 364 military recruits who sustained lateral ankle sprains. The NSAID group had less pain, returned to training more quickly, and had better exercise endurance than those who received placebo treatment. However, the piroxicam group had greater instability, less ROM, and more swelling 14 days after injury. The authors speculated that the analgesic effect of piroxicam might have allowed the participants to return to activity before the healing process was complete; this issue has been raised by others, 27 who advise caution in using oral NSAIDs. Some 107 have suggested that NSAIDs may result in reduced strength of the healed tendons and ligaments and may, therefore, make those structures more vulnerable to future injury. In addition, gastrointestinal irritation is common with NSAIDs. Adverse effects and other medical concerns must be factored into the decision by the athletic trainer and physician to include NSAIDs in the treatment plan for a lateral ankle sprain. In addition to oral NSAIDs, topical NSAIDs have been effective in reducing pain and improving function in patients with ankle sprains and other soft tissue injuries. 28 Topical NSAIDs in the form of creams, gels, and sprays are applied or massaged (or both) over the injury site and can be reapplied several times during the day, depending on the type of medication. The major advantages to topical
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