Janse van Rensburg, C

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Ankle ligament injuries are one of the most common injuries encountered in anygeneral practice.1-3 According to one estimation there is one inversion injury per10 000 people per day.4 The ligament injuries are mostly caused by an inver-sion stress.1,5 The anterior talofibular ligament (ATFL), being the first to getinjured, progresses posteriorly through the lateral capsule and the calcaneofibu-lar ligament (CFL).1,3,5 If not managed correctly, long-term sequelae, such aschronic instability and premature arthritis of the ankle joint, can result.4,6Treatment protocols range from cast immobilisation to functional rehabilitationto acute surgical repair.ANATOMICAL CONSIDERATIONSAnkle jointThis joint consists of the articular surfaces of the tibia, fibula and talus.7 Thereare three articulations, i.e. tibiotalar, fibulotalar and tibiofibular.8 The joint actsas a hinge, with movement primarily in the sagittal plane (dorsiflexion and plan-tarflexion), although limited frontal plane motion (inversion and eversion) is possi-ble.LigamentsThere are 3 groups of ligaments surrounding the ankle joint, the more commonlyaffected lateral complex consisting of the ATFL, CFL and posterior talofibular liga-ment (PTFL) (Fig.1).  The medial (deltoid) ligament is divided into a superficialand deep part and is less likely to be injured6,7 (Fig. 2).  The syndesmotic liga-ments connect the tibia and fibula and prevent rotational and axial forces fromseparating these bones.7CHRISTA JANSE VANRENSBURGMB ChB, MSc (Sports Medicine), MMedPhysical Medicine (Rheumatology)HeadSection of Sports Medicine University of PretoriaChrista Janse van Rensburg is based at theSection of Sports Medicine, University ofPretoria.  Her rheumatology practice is atEugene Marais Hospital, Pretoria.  She isan active member of the South AfricanSports Medicine Association, the SouthAfrican Osteoporosis Society, and theSouth African Rheumatology and ArthritisAssociation.   She accompanied the SouthAfrican team to the Commonwealth and AllAfrica Games as a Medical Officer in2002 and 2003 respectively.ANKLE INJURIES112 CME March  2004  Vol.22  No.3APPROACH TO AND MANAGEMENTOF ACUTE ANKLE LIGAMENTOUSINJURIESAnkle ligament injuries are one of the most common injuries encountered in anygeneral practice.Fig.1.Lateral ligment complex. (Adapted from Netter FH. Atlas of HumanAnatomy. 2nd ed. East Hanover, NJ: Hoechstetter, 1999: 491.)Right foot: lateral viewPosterior talofibular ligamentCalcaneofibular ligamentAnterior talofibular ligamentComponents of lateral(collateral) ligamentof ankle}Soft tissue structuresApproximately 5 nerves, 5 veins, 2major arteries and 13 tendons crossthe ankle joint.  Injuries to or chronicproblems with regard to any of thesestructures (e.g. tendon dislocation,nerve entrapment) can create painaround the ankle.6,7MECHANISM OF INJURYThe classic mechanism of ligamentinjury to the ankle is forced adduction,supination and internal rotation of thefoot.  The ATFL, being the weakest, isthe first to rupture.  The CFL is rup-tured in approximately 60% of casesand the PTFL in less than 5% ofcases.1,2 In a series of ankle arthro-scopies in 30 patients, fresh injury tothe cartilage was seen in two-thirds ofcases.2EVALUATION OF THEINJURED ANKLEOnly after performing a thorough his-tory and physical examination can theclinician make a differential diagnosis(Table I).1 One can then proceed withimaging in order to make a final diag-nosis and start a treatment plan.HistoryDetermine the following: • mechanism of injury• position of the ankle during injury• weight-bearing status after injury• prior injury to the ankle.Patients mostly recall the injury as a‘twisting’ of the ankle with an audible‘snap’ or ‘pop’.2,6InspectionIf possible, observe the patient whiles/he is standing and walking.  Onemust inspect for swelling, ecchymosis,cyanosis, pallor, or breaks in the skin(Fig. 3).  Remember the role of gravity— one can be misled into thinking thatuninjured soft tissues are injured.1,2,4,5PalpationNote temperature and tautness of skin,and pain with direct palpation, activemovement and passive stretching.Also check for palpable defects in ten-dons and ligaments, as well as tender-ness of bones proximal and distal tothe ankle joint (i.e. proximal fibula,base fifth metatarsal).  Muscle strengthand neurovascular status should alsobe evaluated.1,2,4-6Specific testsSqueeze test (Fig. 4)Use the squeeze test to assess the syn-desmotic ligaments.  The examinerplaces one hand 15 - 20 cm belowthe knee on the midshaft of the lowerleg.  The tibia and fibula are thensqueezed together.  The test is positiveif pain is localised in the antero-lateralregion of the ankle or the distalfibula.6Anterior drawer test (Fig. 5)This test assesses the ATFL after aninversion-type injury.  With the knee inflexion and the foot in a neutral posi-tion the one hand stabilises the lowerleg and pushes it posteriorly, while theother hand grasps the heel and dis-places it anteriorly.  Opinion varies onhow much displacement is abnormal,but anterior subluxation of the talus inthe mortise is clinically indicative of anATFL sprain.1,4-6Talar tilt test (Fig. 6)This test is used to assess the integrityof the CFL. The lower leg is stabilisedwith one hand while the other handANKLE INJURIESMarch 2004  Vol.22  No.3  CME 113Fig.2. Medial ligament complex. (Adapted from Netter FH. Atlas of HumanAnatomy. 2nd ed. East Hanover, NJ: Hoechstetter, 1999: 491.)Right foot: medial viewPosterior tibiotalar partTibiocalcaneal partAnterior tibiotalar partTibionavicular part Medial (deltoid)ligament of ankle {Table I. Differential diagnosisof acute ankle injuryATFL sprainCFL sprainSyndesmosis sprainAnterior process calcaneus fractureLateral process talus fractureFifth metatarsal base fractureSubtalar injuryPeroneal tendon injuryOsteochondral injury of the talusPeroneal nerve injurySural nerve injuryCalcaneocuboid injuryFig. 3. Swelling and ecchymosisafter ankle ligament injury.Fig. 4. Squeeze test.114 CME March  2004  Vol.22  No.3ANKLE INJURIESgrabs the heel, places it in neutralposition and then inverts and evertsthe foot.  The test is positive if compar-ison of the medial and lateral aspectsdemonstrates a difference of greaterthan 25%.4-6Van Dijk et al.9 found better specificity(84%) and sensitivity (96%) of thedrawer test and talar tilt test if exami-nation was delayed for 4 - 7 days,compared with examination within 48hours (specificity 33%, sensitivity71%).9SPECIAL INVESTIGATIONSModes of imaging that can be usedinclude X-rays, ultrasound and magnetic resonance imaging (MRI).The Ottawa Ankle Rules (OAR)4 havebeen developed and verified as a pre-dictor of patients with a sprainedankle who should have an X-ray exam-ination:• tenderness at the posterior edge ortip of the medial or lateral malleo-lus• inability to bear weight (4 steps)either immediately after the injuryor in the emergency room, or• pain at the base of the fifthmetatarsal.If radiographs are necessary, theseshould include anteroposterior (AP),lateral and mortise views.4,10 Stressradiographs are generally not indicatedfor acute ankle sprains because find-ings will not change the treatment pro-tocol.1,4 However, they are of value inthe assessment of chronic instability.The most commonly used criteria forabnormal laxity are those describedby Karlsson:11 anterior displacement of≥ 10 mm, or a side-to-side differenceof > 3 mm, and for the tilt test 10°greater than the uninjured ankle (Fig. 7).Ultrasound can easily show the mainankle ligaments and can also assist inthe assessment of most tendon disor-ders.  The one disadvantage of thisotherwise very helpful investigation isthat the interpretation is operatordependent.12MRI is very expensive, but can be ofgreat value in evaluating osteochon-dral lesions and tendon disorders.1,13It has limited value in evaluation of lig-amentous disorders as it cannot deter-mine ligamentous laxity.GRADING OF LATERALLIGAMENT SPRAINS4,5The degree of instability is graded inorder to design a treatment protocol.Grading, however, remains a largelysubjective interpretation.Grade I injuries involve no macroscopictearing, with little swelling or tender-ness and minimal functional loss.  Nomechanical joint instability is noted.A grade II injury is a partial macro-scopic tear with moderate pain andswelling and tenderness over theinvolved structures.  There is mild tomoderate joint instability.A grade III injury is a complete tearwith marked swelling and tenderness.There is loss of function and markedjoint instability.MANAGEMENTThe aims of treatment for all threegrades are to restore range of motion(ROM), to strengthen muscles and toregain proprioception.5 The functionaltreatment protocol is based on the bio-logical healing process.  Initial treat-ment is directed towards avoidingexcess swelling and injury.  Fromweeks 1 - 3 there is vascular ingrowth,new collagen formation and fibroblastproliferation.  In this phase thereneeds to be protection from inversionto prevent excess formation of theweaker type III collagen.Approximately 3 weeks after injury collagen starts to mature.  One nowneeds to put controlled stress on theligament to promote proper collagenformation.  With healing, the collagenmatrix matures and full return to activi-ties will be possible between 4 and 8weeks after injury.4,14Initial management3,5Grades I and IIInitial management for grades I and IIcomprises:• rest, ice, compression and eleva-tion (RICE)• short period of immobilisation andprotection• early range of movement exercisesfollowed by neuromuscular ankleFig. 5. Anterior drawer test.Fig. 6. Talar tilt test.Fig. 7. Positive talar tilt on stressradiograph.training (including plantarflexion,dorsiflexion, inversion and ever-sion)• proprioceptive training — usuallycommenced after 3 - 4 weeks (e.g.balancing on one leg, tilt board).Return to sport is only permitted whenfunctional exercises (jumping, twisting)can be performed without pain.Protective taping or bracing should beused for 6 - 12 months after injury.4,14Grade IIIA number of prospective, randomisedtrials since the mid-1980s have notshown any significant differences inoutcome after operative v. non-opera-tive treatment for acute rupture of thelateral ligament complex.1-5,15Some authors, like Clanton and Porter3and Zwipp et al.,2 have some prefer-ences on indications for surgery:• rupture of the medial and lateralligaments• talar tilt of more than 30°• osteochondral fracture of the talus• massive haematoma requiringimmediate decompression• widening of the ankle mortise.Altogether these indications charac-terise 1 - 5% of cases.In professional athletes there is a trendtowards surgical repair (Fig. 8),although there is no clear evidence ofbetter outcome. However, there is con-sensus that any form of treatmentshould be supplemented with earlymobilisation in an ankle orthosis.THE DIFFICULT ANKLESequelae after ankle ligament injuriesare very common.  In 10 - 30% ofpatients chronic symptoms may devel-op.  These symptoms include pain,persistent synovitis, ankle stiffness,swelling, muscle weakness and givingway.The key to successful management isaccurate diagnosis.  Therefore otherproblems that can mimic lateral ankleligament injuries must be considered1,3,16(Table II).If all of the above are excluded andonly chronic instability remains as thediagnosis, a well-controlled physiother-apy programme with peronealstrengthening and proprioceptive train-ing (with or without bracing and/ortaping) can be helpful.1,5 In patientsrefractory to this treatment surgery isoffered.  The subtalar ligaments mustalso be taken into consideration.Return to sport activity is allowed 3months postoperatively.  An anklebrace may be needed for a further 6 - 8 months after surgery.  The resultsof delayed surgery are very good.1,5,14I would like to thank Brenda Wederfor typing the manuscript and Maureen Brassel for her help with theliterature survey.Rerences available on request.ANKLE INJURIESMarch  2004  Vol.22  No.3 CME 115Acute sprains of the lateral liga-ment complex of the ankle are com-mon injuries. Functional treatment has beenshown to be the treatment ofchoice.The results of functional treatmentare favourable.Acute surgical repair has no bene-fits over functional treatment, eitherin terms of repeat injury or onreturn to activity.Athletes who develop chronic prob-lems can be managed withstrengthening and proprioceptivetraining in conjunction with tapingor bracing.Athletes who fail to respond to func-tional treatment can undergodelayed anatomical repair, withgood results.IN A NUTSHELLTable II. Differential diagnosis for the difficult ankleFractures Calcaneus anterior processTalusLateral processPosterior processOsteochondral lesionsTibial plafond lesionsBase fifth metatarsalImpingements AnteriorPosteriorAnterior lateralTendon injuries Peroneal tendon DislocationSubluxationWeaknessTibialis posteriorDislocationRuptureSprains Medial ligamentSyndesmosisSubtalarOther Sinus tarsi syndromeComplex regional pain syndromeFig. 8. Surgical repair of liga-ment tear.

Approach to and management of acute ankle ligamentous injuries

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Approach to and management of acute ankle ligamentous injuries

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