Alternative and Complementary Therapies
“There’s a sucker born every minute.”
—Old American saying, commonly attributed to P. T. Barnum
“Minds are like parachutes: They function only when they are open.”
—Anonymous proverb
Both things are true. Evidence matters. But so does humility about what we don't yet know. For decades, ulcers were largely blamed on stress, spicy foods and excess stomach acid. Then researchers demonstrated that Helicobacter pylori bacteria caused many ulcers, revolutionizing treatment.
FROM THE TRENCHES
Spend any time in an ankle-fracture group and you'll discover that people are willing to experiment when healing is slow—or just when they want to speed it up. That includes me. Why not? Who doesn’t want to get off the couch and back to their life?
In my Facebook support group, red-light therapy comes up frequently. Several people said they used it regularly and believed it helped with pain or healing. One person with an open fracture said it seemed to ease his pain. Another had already bought a red-light panel for cosmetic purposes and turned it on his ankle during recovery. His surgeon was impressed with how well he healed—but he was also doing several other things at the same time, so he couldn’t say if red light specifically helped.
TENS gets similar reviews, particularly for pain. One person said it had been a big help with nerve pain. Another was combining TENS, acupuncture and twice-weekly physical therapy and believed it was helping.
Recovery stories are valuable because they tell you what real people experienced. They're lousy at proving what caused it.
People are rarely conducting one-person clinical trials. They're using the red light while taking supplements, doing physical therapy, gradually increasing weight-bearing, sleeping better, eating differently and healing with the passage of time.
Someone feels dramatically better after starting a treatment, and perhaps the treatment helped. Perhaps Tuesday was also the day the fracture was finally ready to feel better.
That doesn't make these therapies useless. It makes the stories what they are: reasons to investigate, not proof.
Reasonable Treatment or Expensive Wishful Thinking?
If you’re hoping to find something that might encourage the bone to heal, calm inflammation, help damaged soft tissue, reduce pain—or simply get you functioning better a little sooner, you have plenty to choose from.
Some are established medical treatments used for specific problems. Some have encouraging research behind them but aren't yet supported by enough good studies to know how much they help. Some may help with one part of recovery but not another. And some are backed by considerably more marketing than science.
Insurance coverage doesn't settle the question. Insurance companies make coverage decisions for many reasons, including evidence, regulatory approval, medical necessity and cost. A treatment can have value and not be covered.
So how do you tell the difference between a reasonable treatment to consider and expensive wishful thinking?
FOUR QUESTIONS
Before you spend money on something outside your usual treatment plan, ask yourself these four questions.
1. What am I trying to accomplish?
Are you trying to get a fracture to unite? Help a tendon recover? Reduce swelling? Control pain? Improve range of motion? Deal with a delayed union or nonunion?
A treatment can be useful for one of those things and completely useless for another. Asking whether something “helps ankle recovery” is too broad a question to mean much.
2. What does the evidence actually show?
Was the treatment studied in humans? Were there enough people in the study to tell us much? Was there a comparison group? Has the result been repeated? And, importantly, were researchers treating anything remotely similar to what you have?
3. What can it hurt?
If something might help, has a low risk of harm, doesn't interfere with your established treatment and is affordable to you, you may decide that imperfect evidence is good enough to give it a try.
Some treatments have direct risks. Others may be inappropriate with an incision, implanted hardware or a particular medical condition.
The less certain the benefit, the more important a low risk becomes.
4. What will it cost me—and is it worth that to me?
That's a personal calculation.
A $100 treatment with limited but encouraging evidence and very little risk may be an easy experiment for one person. Something that costs a great deal or has a bigger downside is a different proposition.
The question isn't simply, Does it work?
It's Does it make sense for me, for this problem, at this point in my recovery?
With those questions in mind, here are some of the treatments you may encounter.
Bone Growth Stimulators
Bone-growth stimulators use electrical, electromagnetic or ultrasonic energy to promote bone formation. Prescription devices are used as an adjunct to standard fracture treatment and in some cases for established nonunions or failed fusions. Effectiveness varies by device, fracture and clinical situation.
The important distinction is between a medical bone-growth stimulator prescribed for a particular indication and a consumer gadget that uses similar-sounding technology.
If your fracture is healing normally, there may be no reason to stimulate it. But if healing is delayed, you have a nonunion or your surgeon believes you are at increased risk of one, a bone stimulator can be a legitimate medical option.
Cost and insurance coverage vary, making this one worth discussing with your surgeon rather than shopping for on your own.
Red Light and Low-Level Laser Therapy
Photobiomodulation—now that’s a mouthful—uses specific wavelengths of light in an attempt to influence cellular activity. Red-light therapy and low-level laser therapy fall under this broad heading.
Biological research supports the concept, and human studies have reported possible benefits for pain and physical function after fractures.
There’s a practical problem: “red light therapy” can mean almost anything. Wavelength, power, dose, distance from the skin and treatment time matter. A medical or research device and a cheap panel purchased online aren't necessarily delivering comparable treatment.
If your goal is pain, inflammation or possibly soft-tissue recovery, photobiomodulation may be worth investigating. When properly used, it’s noninvasive and generally considered low risk.
Pulsed Electromagnetic Field Therapy — PEMF
PEMF exposes tissue to pulsed electromagnetic fields. This deserves some nuance because the same general type of energy that’s used in legitimate prescription bone-growth stimulators is also marketed in an enormous assortment of consumer mats, pads and portable devices.
PEMF has been studied extensively for bone healing. Some research and systematic reviews have found benefits, while results differ depending on the type of fracture, treatment protocol and outcome being measured. The evidence doesn't establish that every PEMF product will accelerate healing every fracture.
If you're considering it, find out exactly what device you're looking at and what evidence exists for that device—or at least for a comparable treatment protocol.
Shockwave Therapy
Extracorporeal shockwave therapy uses acoustic waves delivered through the skin. It has established orthopedic uses for some chronic tendon problems and has also attracted interest in fracture healing.
The evidence is more interesting for delayed unions and nonunions than for an uncomplicated fracture progressing normally. Systematic reviews have found encouraging results for difficult-to-heal fractures, while also pointing out small studies and differences in treatment protocols that make firm conclusions difficult.
For someone whose fracture is healing normally but who has persistent tendon pain, shockwave therapy may still be worth discussing. For someone six months down the road whose fracture stubbornly refuses to unite, the conversation is different—but potentially just as relevant.
Platelet-Rich Plasma — PRP
PRP starts with your own blood. It is drawn and processed to produce a platelet-rich preparation, which is then injected into the area being treated. Platelets release growth factors involved in healing.
PRP is widely used in sports medicine and orthopedics, but the evidence varies dramatically by condition. PRP may have a role in some tendon and soft-tissue problems, while evidence for routinely adding it to an otherwise normally healing ankle fracture is much less persuasive.
This treatment involves an injection. Pain, bleeding, infection and other complications are possible. However, serious problems are uncommon when it is appropriately performed.
If you’re considering PRP, ask what specific structure is being treated and what evidence exists for PRP for that particular problem. PRP is frequently paid for out of pocket.
Hyperbaric Oxygen Therapy
Hyperbaric oxygen therapy involves breathing 100 percent oxygen in a chamber pressurized above normal atmospheric pressure. It has recognized medical uses for certain difficult wounds, serious infections and compromised tissues, among other conditions.
HBOT isn't completely benign. Pressure changes can injure the ears or sinuses, temporary vision changes can occur, and oxygen itself can cause toxicity at sufficiently high exposures. Treatment also requires a substantial commitment of time and, when insurance doesn't cover it, potentially money.
MY TAKE ON IT
My interest in hyperbaric therapy was piqued when I watched a video from longevity expert Bryan Johnson about his experimentation and results with it. He has his own chamber, and was very positive about its effects on everything from his inflammation levels to his skin. I figured it would work wonders for my ankle as well.
However, hyperbaric oxygen therapy isn't generally prescribed or covered by insurance simply to speed up an otherwise normally healing fracture. Coverage is usually limited to specific medical conditions, including certain difficult-to-heal wounds and serious infections.
Hospitals in my area wouldn’t offer this treatment even when I offered to self-pay. I finally found a group in The Villages, Fla., that offers it, and their doctor approved me. But it was five days a week at two hours a session, and the facility was an hour away from my house—and I couldn’t drive. Further, the cost was about $8,000. It was impractical—and as my pockets aren’t quite as deep as Bryan’s—too expensive to consider.
I also examined treatments in a soft hyperbaric chamber, which are more widely available and affordable. Alas, the evidence that these low-pressure chambers offer meaningful benefits is scant.
Regenerative Medicine and “Stem Cell” Treatments
Regenerative medicine is an enormously important field of research. But not everything being sold under the label “regenerative medicine” is legitimate—or safe.
Commercial clinics advertise stem cells, exosomes, amniotic products, umbilical-cord products and other biologic treatments for orthopedic problems. The claims can be impressive. The evidence supporting many of those claims is not.
The FDA specifically warns consumers about unapproved regenerative medicine products. Stem-cell and related products marketed by clinics have not been approved to treat orthopedic conditions, and unapproved products have been associated with serious complications.
That doesn't mean regenerative medicine is bunk. Quite the opposite: it is an active and potentially important area of medical research.
If you're considering one of these treatments, look beyond the clinic's testimonials. Find out whether the product is FDA-approved for your condition, what credible research supports its use, and what risks you're taking.
ASK YOUR SURGEON
Is there evidence for this treatment for my particular problem?
What are the risks, including with my hardware, incision, medications or medical history?
Could it interfere with healing or rehabilitation?
If you don't recommend it, why? Is there evidence that it doesn't work, evidence that it could hurt me, or simply not enough evidence yet?
NOBODY TOLD ME...
My surgeon, by all accounts, is brilliant at putting ankles back together. But when I asked her about some alternative therapies, she wasn’t up to speed on them. While I wanted to make her part of my decision-making process, the treatments I was considering weren’t her area of expertise—or her interest.
What I ended up often asking my surgeon was, “Do you have a problem with me using it?” rather than trying to have an in-depth conversation about what the most recent studies said about PEMF.