Conservative Treatment
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SPORTS MEDICINE ANKLE LIGAMENT 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 knees have to differences in injury definition6. There acute lateral ankle 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 knee 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 foot 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 Ankles 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 ligaments 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 SPORTS MEDICINE IN HANDBALL TARGETED TOPIC 149 SPORTS MEDICINE 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