SPORTS MEDICINE

ANKLE INJURY CONSERVATIVE TREATMENT

– Written by Cristiano Eirale, Johannes Tol, Qatar and Gino Kerkhoffs, The Netherlands

The majority of handball players with inconclusive. Hands, heads and have to differences in injury definition6. There acute lateral ligament injuries are also been reported as the most common are also differences in injury incidence now treated with functional treatment. The locations by different studies2. This between team positions, with back players decision for this approach as the first choice difference can mainly be explained by the most affected by injuries, followed by line is predominantly based on three factors: different injury definitions used. The ankle players. In handball, previous injuries are a 1. that the majority will recover without and are the most common locations risk factor for new lesions, with ankle sprain chronic complaints, when considering a time loss injury the most likely to recur7. 2. its cost effectiveness and definition – these are injuries that force 3. the absence of potential postoperative players to suspend sports activity. It has TRAUMA MECHANISM OF LATERAL risks. been estimated that 13.5% of the lesions of LIGAMENT INJURIES The impact therapy aims at an optimal handball players are located on the ankle3,4,5. When playing handball, landing on the return to play. The second aim is preventing Of these, Seil et al3 found that 100% of ankle lateral border of the is the most frequent functional instability-related symptoms. injuries in handball were sprains. In terms cause of acute ankle injury. With this trauma Persistent functional instability may lead to of incidence, ankle injuries in handball mechanism, there is forced plantarflexion ankle impingement, osteochondral defects have been found to occur between 0.4 to with an anterolateral internal rotational and, eventually, osteoarthritis. 1.6/1,000 hours of exposure1. movement of the foot. This mechanism Recent research undertaken at the elite causes traction lesions on the lateral aspect EPIDEMIOLOGY level revealed that an increased level of play of the foot and ankle, and compression The impact of ankle injuries, particularly leads to a higher incidence and increased lesions on the medial site. Experimental ankle sprains, is high in indoor team sports, risk of injury3. This has been explained studies have shown that this mechanism such as handball, basketball and volleyball1. by the higher speed of the game, tougher will first rupture the anterior tibiofibular can probably be considered the play and high number of matches during ligament, and subsequently the posterior most common location of injuries among a short period at elite level tournaments. tibiofibular ligament and calcaneo-fibular handball players, however the literature is However, these differences may also be due ligament. Another described mechanism is

148 forced plantarflexion and eversion that will grouped together, and the recommended generally accepted interventions during induce damage to the anterior tibiofibular conservative therapy is identical for these this inflammation phase. Although it ligament, then calcaneo-fibular ligament partial and complete ruptures. is suggested that ice application might and finally posterior tibiofibular ligament. reduce the degree of initial swelling, this Isolated adduction-induced calcaneo-fibular DELAYED CLINICAL EXAMINATION is not supported by scientific evidence10. ligament lesions are rare. Kannus and In the initial phase, clinical examination The major effect of icing during the initial Renström showed that there is no difference is unreliable due to the pain and swelling. phase is to reduce pain11. Three to four daily in outcome between single or combined After, when indicated, using an X-ray to sessions of 15 minutes of cooling with a lateral ligament ruptures8. This implies that exclude the possibility of a fracture, it is simple plastic bag with ice and water at a it is not the number of involved recommended to re-examine the ankle after temperature between 0 and 7°C will reduce that will have clinical consequences, but 4 to 7 days. During this delayed physical the pain without a significant risk of skin the degree of damage of the most severely examination, it is possible to differentiate damage or neurological complications. injured ligament. between an ankle sprain with or without There is conflicting evidence published lateral ligament ruptures. The sensitivity on the effect of compression to reduce GRADING OF LATERAL LIGAMENTS of detecting a lateral ligament injury is swelling during the first 48 hours. An A three-grade system is widely used 96% when there is pain on palpation of the elastic bandage during the first 24 hours to classify mild (grade I), moderate (grade lateral ligaments, haematoma and a positive is generally advised, and can be replaced II) and severe (grade III) ankle ligament anterior drawer sign. The 84% specificity for afterwards by a brace. Non-steroidal injuries. Grade I injuries are simple sprains these tests leads to the diagnosis of ankle anti-inflammatory drugs (NSAIDs) are of ligament stretch injuries, without injury without a lateral ligament rupture9. effective during the first 2 to 7 days for pain macroscopic rupture. In grade II, there reduction and are associated with initial is a partial rupture of at least one of the INITIAL PHASE improvement in the restricted range of ligaments. In grade III, there is a complete During the initial days after lateral ankle motion. However, in the long-term, there is rupture of at least one of the ligaments. ligament injury, the therapy aims to control no reported beneficial effect of NSAIDs on In daily practice and recent guidelines, the inflammatory response. In the absence functional improvement. The short-term grade II and III lesions are frequently of a fracture, rest and ice application are positive effects should be considered on an

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individual basis, with attention given to the protective brace. This allows a gradual Despite the evidence still being weak, potential side-effects12,13. increase of the functional range of motion it seems that manual therapy has a role in (plantar- and dorsiflexion) of the ankle. the management of acute ankle sprains, IMMOBILISATION OF LATERAL LIGAMENT After the acute phase, increased pain-free particularly during the early stages. The INJURIES exercises and proprioceptive exercises restoration of dorsal flexion is a critical In the past, 4 to 6 weeks of cast should be implemented, with a graduated indicator for returning to functional immobilisation was the treatment of choice evolution to increasing complexity, activities. Passive anteroposterior glide of for partial and complete lateral ligament functional movements and finally sport- the talus, osteopathic techniques, Mulligan’s ruptures. However, this intervention was specific activities. There is general consen- mobilisation with movements and frequently complicated by a decreased sus that proprioception training is an chiropractic techniques have been proven range of motion and physical impairments. effective rehabilitation strategy in reducing to be effective in increasing dorsal flexion There is still debate regarding whether a residual symptoms and preventing further and improving recovery. However, the effect short period of plaster immobilisation is injuries15. However, the exact dosage of these techniques on long-term outcomes beneficial. Some researchers have shown needed to cause balance improvements and appears to be limited23-26. its positive effect on swelling and pain decrease the risk of recurrences remains reduction, indicating that it might be unknown. Improvements in postural control SYNDESMOTIC INJURIES beneficial during the acute phase11,14. Ankle have been reported after a few days in some The majority of syndesmotic injuries are injuries without lateral ligament ruptures patients, and after weeks in others16. There is associated with ankle fractures. The trauma can be treated with solely functional evidence that the longer the proprioceptive mechanism of an isolated syndesmotic treatment, and a relatively quick return to training is performed, the greater the injury is a forced external rotation-dorsal sporting activities. Ruptured lateral ankle preventative effect obtained17. Early specific flexion trauma with axial compression. ligaments require 4 to 6 weeks of bracing functional training has been shown to be These injuries are prone to causing or taping to protect the range of motion of useful not only to accelerate return to play18, tibiofibular diastasis. Syndesmotic injuries the ankle and lateral ligaments. For athletes, but also to prevent re-injury19. secondary to an inversion trauma are less semi-rigid protection using a brace or tape The use of physical therapy devices, common. With this trauma mechanism, and is recommended because its outcome is such as electrotherapy, laser therapy in the presence of a lateral ligament rupture, superior to elastic bandages in terms of and ultrasound, is widespread in clinical the syndesmotic rupture is most frequently the time taken to return to sports and the practice, particularly during the first phases only partial. For daily practice, it is important prevention of future ankle instability11. of treatment, when the goal is to reduce to keep in mind that, in 40% of athletes swelling and inflammation. However, the with a classical inversion trauma, there FUNCTIONAL TREATMENT OF LATERAL evidence of their effectiveness is limited will be pain on palpation of the anterior LIGAMENT INJURIES and therefore, cannot be considered part syndesmotic area without the presence of a Guided by pain and swelling, the athlete of the gold standard treatment of ankle syndesmotic rupture on further imaging27. is encouraged to begin weight-bearing as injuries20-22. Further research, possibly Standard radiographs are recommended soon as possible. The first step of functional exploring different dosage and application for the detection of diastasis of the ankle treatment begins with walking with a methods, is warranted. mortise. Especially in elite athletes, MRI is increasingly used to detect syndesmotic injuries due to its high sensitivity and specificity. Stable syndesmotic injuries after inversion trauma with lateral ligament In the initial phase, injury can be treated in the same manner as a lateral ankle ligament injury. For athletes clinical examination with acute syndesmotic instability, there might be an indication for surgery (see is unreliable due to elsewhere in this issue). the pain and swelling. DELTOID LIGAMENT LESIONS The classical injury mechanism of a deltoid ligament lesion is forced eversion of It is recommended to the foot, such as a direct trauma to the lateral aspect of the foot and ankle. It is relatively re-examine the ankle after uncommon that an inversion trauma induces combined lateral ligament injury 4 to 7 days. and deltoid lesions. Physical examination reveals swelling and pain on palpation of the medial ligament with signs of talar

150 be considered on an individual basis, with attention given to the possible side- effects. While ankle injuries without lateral ligament ruptures can be treated solely with functional treatment, ruptured lateral ankle ligaments require 4 to 6 weeks of semi-rigid bracing or taping protection. Early functio- nal treatment should be encouraged, as it has shown an accelerate return to play and a decrease of reinjures. It consists of walking with a protective brace, proprioception (despite the exact dosage is still unknown) and exercises with a graduated evolution to increasing complexity, functional movements and finally sport-specific activities. The use of physical therapy devices and manual therapy may play a role in ankle injuries rehabilitation, but the scientific evidence is still limited. While lateral compartment sprains are generally treated conservatively, syndesmosis and deltoid ligament lesions deserve attention because surgical treatment may be subluxation in complete lesions. Standard has been shown to be more effective in indicated. Finally, having a previous ankle radiographs are frequently normal. The preventing secondary recurrences than sprain is a risk factor for a recurrent ankle sensitivity of MRI to detect deltoid lesions primary sprains19,30. There is some evidence injury, therefore the role of prevention is is high. However, there is a risk of over- that taping and bracing may play a significant. In this view, neuromuscular diagnosing deltoid ligament lesions – deltoid protective role in recurrent ankle sprains, and proprioceptive training, together with ligament abnormalities after a classical however, it is unclear which device gives taping and bracing, have shown to be inversion trauma (with lateral ligaments better results31-34. effective. injuries) are reported to be present in 60% of It has also been questioned whether the the cases, but this frequently does not align shoes can play a role in preventing ankle References at www.aspetar.com/journal with the clinical findings28,29. sprains; however, it appears that there is The therapy of deltoid lesions is no effect of shoe design on the risk of ankle dependent on associated injuries, such as sprains. Rather, the newness of the shoe syndesmotic injuries and ankle fractures. seems to have a greater effect than design Cristiano Eirale M.D. 35 Combined lateral and deltoid ligament on the incidence of ankle sprains . Sports Medicine Physician injuries can frequently be treated in the The best preventative treatment effect Aspetar – Qatar Orthopaedic and Sports same manner as a lateral ligament injury. will most likely be obtained by a combi- Medicine Hospital Simple isolated deltoid sprains can be treated nation of these strategies. with functional treatment. Isolated deltoid Doha, Qatar ruptures are mostly treated conservatively CONCLUSION by 4 to 6 weeks of immobilisation and Ankle injuries, in particular sprains, Johannes Tol M.D., Ph.D. progressive rehabilitation; however, high- are one of the most common injuries in Sports Medicine Physician level athletes can be advised to consider a handball. The most frequent mechanism Aspetar – Qatar Orthopaedic and Sports surgical option (see elsewhere in this issue). of acute ankle injury is landing on the Medicine Hospital lateral border of the foot, which implies a Doha, Qatar SECONDARY PREVENTION forced plantarflexion with an anterolateral After an acute ankle injury, the intrinsic internal rotational movement. Due to factors of reduced dorsal flexion, disturbed the unreliability of clinical examination Gino M Kerkhoffs M.D., Ph.D. propriocepsis and weakness of the peroneal immediately after the trauma, it is Department of Orthopaedic Surgery muscles are associated with an increased recommended to re-examine the ankle 4 Academic Medical Center risk of re-injury. A recent systematic to 7 days later. The initial phase treatment Amsterdam, The Netherlands review showed that neuromuscular and consists of icing, elastic bandage replaced proprioceptive training is an effective by a brace after 24 hours and NSAIDs. secondary preventative method. This However, short term positive effects should Contact:[email protected]

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