Ankle Ligament Injuries Br J Sports Med: First Published As 10.1136/Bjsm.31.1.11 on 1 March 1997

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Br_j Sports Med 1997;31:1 1-20 1 1 Ankle ligament injuries Br J Sports Med: first published as 10.1136/bjsm.31.1.11 on 1 March 1997. Downloaded from

Per A F H Renstr6m, Lars Konradsen

Injuries to the ligaments of the ankle are often ligament, the interosseous ligament, and the called "low ankle sprains". If the tibiofibular ligaments spanning the calcaneocuboid and the ligament or the syndesmosis is injured it is talonavicular joints, also have to be considered. called a "high ankle sprain". Many studies have been done on talotibial Inversion sprains with injury to the lateral ligaments to gain insight into how they ligaments of the ankle/foot complex are by far function together to stabilise the joint. Of the the most common. They occur with an talotibial ligaments, the ATFL is a thin 6-10 estimated frequency of one injury per 10 000 mm wide, 20 mm long, and 2 mm thick'6 weak people per day, amounting to about 27 000 ligament, being essentially a thickening of the injuries each day in the United States.' 2 anterior ankle joint capsule. It passes from the Although many injuries are treated outside distal anterior origin of the lateral malleolus to medical establishments, 7-10% of those who the talus in front of the proximal part of the are visiting the emergency departments of the lateral articular surface. In neutral position its hospitals in Scandinavia have sprained ankles.3 direction is parallel to a long axis of the foot Ankle injuries are the most common injuries and in full plantar flexion it is more parallel in sports and recreational activity.i"12 For this with the tibia (fig 1). The CFL is a 20-25 mm reason, probably, these injuries tend to occur long rounded ligament with a diameter of 6-8 primarily to young people.'3 The sprained mm.'6 It is an extra-articular ligament closely ankle also remains the most common injury associated with the peroneal tendon sheath. It regardless of whether the sport is primarily an runs obliquely downwards and backwards to upper or a lower extremity sport. Garrick7 be attached to the lateral surface of the noted that injuries to the ankle accounted for calcaneus. There is a great variety in its 53% of injuries occurring during basketball direction and in its attachment sites."' A and for 31 % of those occurring during soccer. rupture to this ligament will also cause a Reviewing 41 soccer teams, Ekstrand and rupture of the tendon sheath, and occasionally Tropp'4 found ankle sprains to account for 17 to also damage the peroneal tendons. 21% ofthe injuries. The "high ankle sprain" usu- The ATFL acts as a primary restraint against

ally occurs as the result of an eversion injury in plantar flexion, as well as internal rotation of http://bjsm.bmj.com/ combination with fractures or lesions to the the foot.'7 In strain studies Renstrom et al" deltoid ligament. Isolated syndesmosis injuries found that the strain of the ATFL significantly occur in 3% of the cases. This article will deal increases with increasing plantar flexion. In the mainly with the lateral ligament complex. neutral position the ligament is relaxed.'9 The CFL does not have an independent role Ankle biomechanics in talotibial joint stability, but acts instead as a The passive stability of the ankle is the respon- guide for the axis ofsubtalar motion.'7 In dorsi- sibility of the ligaments and the bony con- flexion the ligament has increased strain.'8 In a on October 2, 2021 by guest. Protected copyright. straints of the ankle joint, while the active sta- normal standing position the ligaments remain bility depends on muscular support. The talus relaxed. has no muscular insertion. Active motion The lateral talocalcaneal (LTCL) extends Department of depends on the long foot muscles inserting into from the talus to the calcaneus and blends its and Orthopaedics other tarsal or metatarsal bones. Dorsiflexion fibres with CFL and ATFL fibres. The exact Rehabilitation, incidence of injury to this ligament is not McClure and inversion are effected by the extensor hal- Musculoskeletal lucis longus and the anterior tibial muscles. known. Transecting the subtalar ligaments Research Center, The Dorsiflexion and eversion are guided by the results in very limited increase in motion when University of Vermont, peroneus tertius muscles and extensor digito- measured in degrees, but as they have very lim- Stafford Hall 428B, rum longus and brevis muscles. Plantar flexion ited motion in the first place the increase after Burlington, Vermont and eversion are effected by the peroneus lon- rupture is about 40%.2° The incidence of rup- 05405-0084 USA ture here is also unknown. P A F H Renstr6m gus and brevis muscles. Plantar flexion and inversion are regulated by the flexor hallucis The PTFL connects the posterolateral tu- Department of longus, the flexor digitorum, and the posterior bercle of the talus to the medial aspect of the Orthopaedics, tibial muscles.'5 lateral malleolus. The PTFL has an average Gentofte Hospital, The ligaments of the ankle can be divided diameter of 6 mm. In plantar flexion and in the University of into the lateral group, the medial group, and neutral position the ligament is relaxed, Copenhagen, whereas in Copenhagen, Denmark the ligaments of the syndesmosis. dorsiflexion the ligament is L Konradsen The lateral ankle ligament complex is tensed.'5 The clinical significance of PTFL traditionally considered to consist of the injuries is somewhat unclear, but it is not com- Correspondence to: anterior talofibular (ATFL), the calcaneofibu- monly damaged. The ATFL, CFL, and PTFL Dr Renstrom. lar (CFL), and the posterior talofibular ligaments function as a unit for the talotibial Accepted for publication (PTFL) ligaments. However, in inversion the complex, though one may resist a specific 17 December 1996 subtalar ligaments, especially the cervical motion depending upon foot position.2' 12 Renstrom, Konradsen

B Frequency of lesions caused by inversion sprains Owing to the ATFL's vulnerable position in Br J Sports Med: first published as 10.1136/bjsm.31.1.11 on 1 March 1997. Downloaded from plantar flexion, it is the most commonly ruptured ligament in a lateral ankle sprain..323 29-34 In 1964 Brostrdm'6 surgically explored 105 sprained ankles and found an isolated ATFL tear present in about two thirds of the cases. The second most common injury was a combined rupture of the ATFL and CFL, occurring in about 20 to 25% of the cases.'3 1634 Other isolated ligamentous injuries are relatively uncommon.'316 The PTFL, for instance, is a very strong ligament and is rarely injured except in severe ankle trauma.2935 Ligamentous lesions after acute inversion sprains cannot, however, be seen in such a limited scope. Thus Brostr6m'3 noted that in a Figure 1 (A) Anterior talofibular (at]) ligament runs parallel to the axis of the foot when group of 321 patients with acute ankle sprains, the foot is in neutral position. Cf = calcaneofibular ligament. (B) When the foot is in 19% had signs of injury to the bifurcate or the plantarflexion, the anterior talofibular ligament assumes a course parallel to the axis of the tibia andfibula. dorsal calcaneocuboid ligaments, or both. Gerner-Smidt36 in a combined study of chil- Through the full range of motion the ATFL dren and adults found that 22% of the patients and CFL act in synergy22"2 (fig 1). As the foot sustained lesions to the talonavicular or the plantar flexes, the strain in the ATFL increases calcaneocuboid ligaments, or both, and while the strain in the CFL decreases.'8 Shybut Holmer et alP7 found clinical evidence of et a125 measured ankle ligament loads directly isolated calcaneocuboid/calcaneocervical or by using implanted buckle transducers. The talonavicular ligament lesions in 15-25% of results indicated that ligament loads remain inversion injuries. Meyer et ar' evaluated 40 low within the functional range of motion (10 patients with acute ankle sprains (it is not degrees of dorsiflexion to 20 degrees of plantar mentioned, but they must have been consid- flexion). This supports the concept that ankle ered clinically grade II to III) with subtalar ligaments act as kinematic guides rather than arthrograms.39 Apart from lesions to the lateral primary restraints during normal activity. tibiotalar joint ligaments, 17 patients (43%) Stormont et al26 studied the stabilising showed contrast leaks into the sinus tarsi, sug- capacity of the ligaments and articular surface gesting interosseous ligament rupture. Some of in the ankle with and without physiological these patients were operated on and the cervi-

loading. With loading, the results indicated cal ligament was often found to be severed too. http://bjsm.bmj.com/ that the articular surface becomes an impor- Chondral or osteochondral lesions of the tant stabiliser, accounting for 30% of stability talar dome have been noted by Taga et al'0 in in rotation and 100% of stability in inversion. 89% and by van Dijk'` in 66% of acute Without loading, the results indicated that the inversion injuries. In 1991 Grana"4 found primary and secondary ligamentous con- chondral lesions in 80% and osteochondral straints vary with testing modes and ankle lesions in 6.5% of acute ankle injuries. Lesions position. to peroneal tendons ranging from total tendon rupture or insertion site fracture to longitudi- on October 2, 2021 by guest. Protected copyright. nal slits occur, and the tendon injuries are often overlooked.42 Injury to the superficial and Mechanism of injury deep peroneal nerves ranging from the rare The extent of tissue damage that will occur condition of complete nerve palsy4344 to, what with the trauma depends not only on the seems to be much more common, discrete mechanism and magnitude of the forces that conduction velocity changes have been act on the ankle but also on the position of the noted.4546 In rarer cases fractures to the cuboid, foot and ankle during the trauma.'5 the anterior process of the calcaneus, and the The most common mechanism causing lateral process of the talus have been diagnosed lateral ligament injuries is a situation where the after an inversion injury.4749 ankle goes into a combination of plantar flexion and inversion. The ATFL tears first followed by rupture of the anterolateral capsule. With further inversion, the CFL will be Grading lateral ligament injury ruptured followed by variable injury to the Clinically, sprains of the lateral ankle have been PTFL and the anterior part of the deltoid liga- classified in three groups based on severity.4 A ments.27 grade I injury involves stretch of the ligament With weight bearing, the articular surface without macroscopic tearing, little swelling or can provide 30% of stability in rotation, and tenderness, slight or no functional loss, and no 100% stability in inversion.26 This ability is a mechanical instability of the joint. A grade II function not only of the axial load but also of injury is a partial macroscopic tear of the liga- the close packed position.28 Ankle destabilisa- ment with moderate pain, swelling, and tion thus occurs during loading and unloading, tenderness over the affected structures. Some but the joint is stable once it is fully loaded. loss of motion and mild or moderate instability Ankle ligament injuries 13

ofthe joint occurs. In a grade III injury, there is navicular tuberosity or at the base of the fifth complete rupture of the ligament with severe metatarsal, or if the patient is unable to bear

swelling, haemorrhage, and tenderness. There weight immediately after injury and at the ini- Br J Sports Med: first published as 10.1136/bjsm.31.1.11 on 1 March 1997. Downloaded from is loss of ability to bear weight on the foot, lim- tial examination. With these rules the authors ited function, and considerable abnormal could reduce the use of radiographs from 80% motion and instability of the joint. An im- to 63% of the injuries. proved and validated classification of ankle sprains is needed. The terms mentioned above Treatment of lateral ligament lesions were validated by Lindenfeld50 and found to be TREATMENT OF GRADE I AND II SPRAINS quite subjective. Others prefer to classify lateral In the presence of a grade I or grade II injury it ligament injuries as single or double ligament is universally agreed that recovery is fast with tears. A single injury would imply lesions to non-operative management and the prognosis only the ATFL, a double injury would affect is good.455'5 Jackson et at5 found that early both the ATFL and the CFL. The distinction mobilisation resulted in a disability of eight in clinical terms is difficult here also. days for a grade I and 15 days for a grade II injury. Functional treatment including early motion and use of ankle support and early weight bearing is today the accepted Diagnosis treatment for grade I and II ankle sprains. Diagnosing the extent of an acute lateral ligament injury is not considered very accurate because of pain, swelling, and muscle tender- TREATMENT OF GRADE III SPRAINS ness.'5 In the first few days after injury local In the case of grade III lateral ligament lesions palpational pain is often diffuse, with no maxi- the treatment of choice that is, whether to mal point of tenderness.' 5152 The extent of operate, to immobilise in a cast, or to allow swelling does not depend only on the magni- early controlled mobilisation, is more contro- tude of the ligamental injury but also on the versial. The key consideration being the initial treatment. Extensive swelling is a predic- question of whether ligament healing with tor of ligament rupture, but the positive adequate tension can be achieved equally well predictive value has been found to be only with early controlled mobilisation as with 60-70%.5 The characteristic haematoma direct visualisation and suturing. suggesting ligament rupture usually does not If the ankle is kept from excess inversion or develop during the first few days, and joint dorsal or plantar flexion the strain in the lateral range of motion is mainly determined by the ligaments remains low,'8 allowing for adequate severity of pain and does not differ between healing conditions without elongation within simple sprains and ligament rupture.5455 Fur- this range of guided motion. With the develop- thermore, the interobserver variation of the ment of lower extremity magnetic resonance acute examination concerning tenderness, imaging scanning, studies have visualised that swelling, discoloration, and the anterior drawer total ligament (grade III) ruptures do heal with http://bjsm.bmj.com/ sign is considerable.56 The anterior drawer sign ligamental continuity if there is early mobilisa- seems to be a good predictor of lateral ligament tion. There is thus experimental evidence sup- disruption. Brostrom30 found that the anterior porting ankle ligament healing in the presence drawer sign was positive in all of 239 patients of early mobilising treatment. with ligament rupture. His examination was, Clinically many uncontrolled, non- however, done with general or local anaesthe- randomised studies have shown mechanical sia. Without anaesthesia he could only elicit a stability and satisfactory subjective results after positive drawer sign in two patients. Based on both operative and conservative treatment. Of on October 2, 2021 by guest. Protected copyright. these results van Dijk57 suggests that the the many papers available, only 12 could be physical examination should be delayed considered prospective and randomised30 55 60-69 four to five days after the initial injury. when a comparison between operative and The specificity and sensitivity of delayed physi- conservative treatments was performed by cal examination for the presence or absence of Kannus and Renstr6m.35 Six of these consid- a rupture to the ATFL were found to be 84% ered the three treatment groups in question: and 96% respectively, and the delayed examin- operation, immobilising and early mobilising ation, done by observers of varying degrees of modalities30 62 63 65 66 69 and the results and con- experience, gave information of ligament qual- clusions based on these reports will be ity that equalled that of arthrography. After mentioned in the following. Duration of follow four to five days a combination of tenderness at up ranged from six months to 3.8 years, which the level of the anterior talofibular ligament, is considered adequate time to identify persist- lateral haematoma discoloration, and a positive ent disability. Results were evaluated using drawer sign indicated a ligament lesion in 95% selected outcome parameters. Return to work of the cases. A negative drawer test and the or physical activity was reported in four of the absence of discoloration always indicated an studies that included three treatment modali- intact ligament. ties.30 6166 69 They concluded that return to work Radiographs to exclude fractures are sug- was two to four times faster after functional gested according to the Ottowa strategy for treatment than after operation or immobilisa- ankle injury.58 Plain radiographs are taken if tion in a cast. Return to pre-injury level of there is bone tenderness at the tip or posterior activity was found to be faster after conserva- aspect of the lateral malleolus, at the tip or tive treatment than after operative treatment in posterior aspect of the medial malleolus, at the four cases.6 62 66 69 The opposite was found in 14 Renstrom, Konradsen

three studies.0 5563 and no difference was found be eight million American dollars. The treat- in the remaining five. ment of choice thus remains functional treat- Pain, swelling, or stiffness with activity could ment. Br J Sports Med: first published as 10.1136/bjsm.31.1.11 on 1 March 1997. Downloaded from be evaluated in four of the studies involving If acute surgery is considered necessary the three treatment groups.62636669 The studies indications could according to Leach and failed to show any differences. In the three Schepsis78 be (a) a history of momentary studies that included three therapy groups and talocrural dislocation with complete ligamen- included mobility of the ankle,306669 mobility tous disruption, (b) a major clinical anterior was found to be superior after functional treat- drawer sign, (c) 10 degrees more tilt on the ment compared with the other two methods. affected side with stress inversion testing, (d) Better mechanical stability has been the pri- clinical or radiographic suspicion of tears in mary argument for operation. Assessment of both the ATFL and CFL, and (e) osteochon- mechanical stability calls for an objective dral fracture. Most techniques described for measurement with the evaluation of talar tilt repair of acute ligament injuries are similar to and anterior drawer on stress radiographs. that of Brostr6m.'0 The results after acute sur- Based on five studies evaluating the three gery are in general very good with return to different treatments,62 65 66 68 69 equal stability sport in 10 to 12 weeks. This must still be results were found. compared with the three to six weeks after Functional instability is not a well defined functional treatment. entity but designates repeated inversion injuries that are either unprovoked or the result of Acute treatment protocol very little provocation. Functional instability BIOLOGICAL BACKGROUND seems to be a late disability in 15 to 60% of lat- In the post-injury phases of an acute severe eral ligament injuries depending on the defini- ankle injury, an ideal treatment and rehabilitation applied. In the studies that reported on tion programme should fulfil four require- functional instability'062666971 opinions di- ments'5: verged, but no one treatment seemed superior 1 The RICE principle: rest, ice (cold), to the others in minimising the chances of late compression, and elevation aims to minimise instability. The scientific basis for treating haemorrhage, swelling, inflammation, cellu- chronic functional instability is discussed later lar metabolism, and pain in order to offer the in this review. best possible conditions for the healing The review of Kannus and Renstrom35 process.s780 concludes that functional treatment is the 2 Protection of the injured ligaments during treatment of choice when treating grade the first one to three weeks is required. In III acute lesions of the lateral ligaments. this phase of healing (the proliferation Recent comparative studies do not change this phase), protective ankle support is followed view. Konradsen et af2 and Eiff et al3 by undisturbed fibroblast invasion of the in injured area, which leads to undisturbed concluded that first time lateral ankle http://bjsm.bmj.com/ sprains, although both immobilisation and proliferation and production of collagen early mobilisation prevent late residual prob- fibres. Mobilisation too early in inversion lems and ankle instability, early mobilisation leads to more prolonged type III collagen allows early return to work and, possibly, is formation with weaker healing tissue than more comfortable for patients. In a recent pro- during optimal immobilisation.8"8' Protec- spective study comparing surgery with function is also needed to prevent secondary tional treatment in ankle ligament tears Kaik- injuries and early distension and lengthening

konen and coworkers74 found that early of the injured ligaments. on October 2, 2021 by guest. Protected copyright. mobilisation gave better results than surgery 3 About three weeks after the injury the plus mobilisation in treatment of complete maturation phase of the collagen and the tears of lateral ligaments of the ankle. Nine formation of final scar tissue begins."8'- In months after injury excellent to good scores this phase the injured ligaments need were achieved in 87% of the functionally controlled mobilisation, and perhaps even treated patients and 60% of the surgically more importantly, the ankle itself must avoid treated patients respectively. In a meta- the deleterious effects of immobilisation on analytical article Schrier75 found functional joint cartilage, bone, muscles, tendons, and treatment was superior to immobilisation in ligaments.8 8390 Controlled stretching of casts, reducing both ankle instability and the muscles and movement of the joint enhance cost of treatment. the orientation of collagen fibres parallel Sommer and Schreiber76 considered the with the stress lines (that is, the normal col- cost-benefit aspects by comparing immobilisa- lagen fibres of the ligaments), and they can tion in a plaster cast followed by immobilisa- prevent the atrophy caused by immobilisation with a brace, with early mobilisation using tion.8°82 Repeated exercises will also increase a brace only. Early functional therapy proved to the mechanical and structural properties of be the treatment with the least direct costs. the ligaments.9' Leanderson and Wredmark77 in a study of 73 4 About four to eight weeks after the injury patients with grade II and III sprains treated the new collagen fibres begin to withstand with either early mobilisation or immobilisa- almost normal stress, and the goal for reha- tion found that the socioeconomic savings were bilitation is rapid recovery and full return to potentially significant with ankle brace treat- work and sports. ment. Nationally, the potential yearly savings in If treated according to the guidelines men- Sweden using this treatment were estimated to tioned above, each component of the ankle is Ankle ligament injuries 15

ready for a gradually increasing mobilisation ever, clear that functional instability is a and rehabilitation programme, keeping in complex syndrome where mechanical, proprio- mind that final maturation and remodelling of ceptive, and muscular disabilities either alone Br J Sports Med: first published as 10.1136/bjsm.31.1.11 on 1 March 1997. Downloaded from the injured ligaments takes a long time-from or in combination are at fault. Known factors six to 12 months. include mechanically insufficient ligaments, peroneal muscle weakness,95 subtalar instabil- Residual disability after inversion injury ity,97 and proprioceptive deficit.996 Inadequate rehabilitation is the primary cause Although increased postural swaying has of residual disability after ankle sprains. Many been used as a measure for a proprioceptive athletes return to sports before they are fully deficit, there is no direct causal connection rehabilitated and therefore they are often between swaying with an increased amplitude subjected to reinjury or additional injury. when balancing on one foot and sustaining Examination may show loss of range of recurrent inversion injuries. Rather it seems motion, especially limited dorsiflexion, and reasonable to assume that a common and atrophy of lower leg muscles. superior deficit is responsible for both Residual disability after ankle inversion disabilities. The nature of such a disability injury can be divided into primarily instability remains unclear. The latency of the peroneal problems and pain-giving entities. muscles has been found to be significantly slower in functionally unstable ankles by CHRONIC ANKLE INSTABILITY some98.'00 but not by others.10'-'03 An increased Chronic ankle instability can be subdivided error in detecting ankle inversion movement or into mechanical, functional, and subtalar insta- in matching ankle inversion angles has again bility and the sinus tarsi syndrome. been found by some'04-'06 but not by others.'07 There is, however, evidence that (a) a proprio- Mechanical instability ceptive deficit may result after an acute ankle Mechanical instability is characterised by ankle inversion injury,46 70 108 (b) proprioceptive de- mobility beyond the physiological range of fects measured in different ways are seen in motion, which is identified on the basis of a subjects with functional instability, and (c) positive anterior drawer or talar tilt test, or models exist that may explain how measurable both.92 The radiographic criteria for mechani- kinaesthetic deficits may cause an increased cal instability vary. Most authors agree, how- frequency of ankle inversion injuries (Konrad- ever, that mechanical instability is present sen et al, unpublished data). when there is more than 10 mm of anterior translation on one side or the side-to-side Subtalar instability difference is over 3 mm or the talar tilt is more The incidence of subtalar sprains is unknown, than 9 degrees on one side, or the side-to-side but it is widely accepted that most subtalar difference is more than 3 degrees.93 Pure ligamentous injuries occur in combination with

mechanical instability of the ankle is seldom injuries of the lateral ligaments of the ankle (fig http://bjsm.bmj.com/ the sole independent reason for the develop- 2). Subtalar instability is estimated to be ment of late symptoms. Mann et al, showed present in about 10% of patients with lateral that 81% of patients with radiographically ankle instability. The symptoms of chronic documented instability experienced recurrent subtalar instability include giving way episodes sprains.94 during activity and a feeling of instability when walking on uneven ground. These symptoms Functional instability may coincide with chronic talocrural instability

Functional instability is the chronic disability and therefore careful clinical examination is on October 2, 2021 by guest. Protected copyright. after an ankle inversion injury that can be necessary. Localised tenderness on palpation attributed to lateral ankle ligament deficiency over the subtalar joint is suggestive of a sub- and is characterised by "giving way" problems. talar sprain. The diagnosis can be verified with Forty eight per cent of patients with an acute subtalar arthrography38 or a subtalar stress view first time sprain have recurrent sprains and or stress tomography. 26% report frequent sprains.94 The definition Functional treatment similar to the regimen of the symptom is ambiguous and the patho- used for lateral sprains is the treatment of genesis is unclear. It does not seem to be choice. Surgery with non-anatomical proce- dependent on the grade of the initial injury69 dures has been described.'09110 Anatomical nor does it correlate with the degree of initial repairs, however, show equally good re- mechanical instability.6' 64 69-95 No histological sults.97 "'I ligamentous changes except scarring have been found in chronic ankle disability.30 Sinus tarsi syndrome As anatomical studies showed the presence The sinus tarsi syndrome is often accompanied of mechanoreceptors in joint ligaments and by a feeling of instability and giving way of the capsule, and clinical studies showed decreased ankle. Seventy per cent ofthe patients will have postural control in patients with functional experienced a severe inversion sprain.92 If the instability, Freeman et al suggested that func- calcaneofibular ligament is torn the interos- tional instability was due to motor incoordina- seous talocalcaneal ligament occupying the tion secondary to a proprioceptive disorder.96 sinus will often also be sprained. This sprain Postural control was later measured objectively will cause synovitis in the sinus tarsi with rather using stabilometry by Tropp95 who, like Free- localised pain. The diagnosis can be made man, found increased postural sway in subjects based on a complaint ofpain and tenderness of with functionally unstable ankles. It is, how- the sinus tarsi combined with the giving way 16 Renstrom, Konradsen Br J Sports Med: first published as 10.1136/bjsm.31.1.11 on 1 March 1997. Downloaded from

Figure 2 Forceful inversion of the hindfoot in neutral flexion. Tearing of the calcaneofibular, the cervical, and the interosseous ligaments. (From MeyerJM, Garcia J7, Hoffmeyer 1P Fritchy D. The subtalar sprain. A roentgenographic study. Clin Orthop 1988;226:169-73.)

Figure 3 Tilt board training is an excellent way to return feeling. The pain and the giving way feeling can neuromuscular control to the injured ankle. usually be relieved by local injections of anaes- thetic and corticosteroids. Excision of tissue filling the sinus tarsi can give good results if rehabilitation was as much a relearning pro- conservative treatment fails. gramme as it was a physical recovery after injury. Often the injured subjects themselves TREATMENT OF CHRONIC INSTABILITY have a clear feeling of a perception/ Rehabilitation proprioception deficit in the ankle joint area- With the uncertain pathogenesis of functional they cannot "feel" the ankle as they used to.

ankle instability the elements of treatment pro- When this feeling returns it seems to coincide http://bjsm.bmj.com/ tocols will rest primarily on personal experi- with complete rehabilitation. Leanderson et ences and not so much on scientific data. al'08 found that return of single limb balance to Before deciding upon surgical treatment, a well normal values coincided with a subjective feel- planned rehabilitation programme based on ing of full rehabilitation in dancers. It can, peroneal muscle strengthening and coordina- however, be argued that in this group balance tion training should be carried out. Regaining during single limb stance was as much a muscle strength is primarily achieved by specific functional test as an unspecific test for

increasing neural activation through function- ankle proprioception. on October 2, 2021 by guest. Protected copyright. ally oriented training and dynamometer train- In summary, training proprioceptive func- ing. '12 In functional training the patient is tion through coordination exercises using uni- required to activate his/her musculature in lateral balance boards, uniaxial and multiaxial normally occurring activities. Dynamic stabil- teeter boards, and jumping ropes relies prima- ity, including proprioceptive information, rily on empirical data but produces very motor control, and appropriate muscle force favourable results. Restitution of normal func- development, will be enforced by the training. tion relies on the individual's subjective feeling Treatment ofthe proprioceptive ankle deficit of return to normal sensation. Full effect of consists of a progressive series of coordination training is achieved within 10-12 weeks as exercises to re-educate the ankle. Tropp95 evaluated by postural sway.95 found a significant improvement in balance About 50% ofpatients with functional insta- during single limb stance in subjects with a bility will regain satisfactory functional stability functionally unstable ankle after six weeks of after such a programme."' balance board exercises (fig 3). The same group reported a decrease in the frequency of EXTERNAL SUPPORT inversion injuries and ankle giving way feelings When considering the mechanical effect of the when compared with an untrained control different external support modalities it is group with unstable ankles. Tropp9" also found important to remember that even though they that the subjects in question showed a change do increase the resistance to inversion, the in their strategy of single limb stance, going effect cannot be compared with that of active from a broken chain strategy before training to evertor muscles. Ashton-Miller et al'.' found the normal inverted pendulum strategy after that active evertor muscles, acting isometrically completed training. So it may well be, as on a 15 degrees inverted ankle, can provide suggested by Glencross and Thornton,'04 that more than three times the protection against Ankle ligament injuries 17

further ankle inversion than tape or an orthosis studies showing a smaller effect and others a worn inside a three-quarter-top shoe. larger detrimental effect of tape compared with braces. It must be noted that most of the stud- Br J Sports Med: first published as 10.1136/bjsm.31.1.11 on 1 March 1997. Downloaded from Tape ies were done on subjects with stable ankles. The primary purpose of taping is to provide The use of an ankle brace or taping, or increased stiffness to the ankle and a semirigid both, is recommended as they both give and sometimes rigid splinting around it. Stud- support against ankle inversion when the ies have shown that taping the ankle prevents evertor muscles are relaxed and increase ankle injuries. Garrick et al found that the the maximal resistance to inversion with combination of taping prophylactically and the evertor muscles activated. They do seem to use of high top shoes in basketball reduced the be able to enhance proprioceptive awareness, frequency of ankle sprains.' 4a Lindenberger et and to decrease the frequency of inversion all5 found that tape had a significant prophy- injuries and decrease the severity ofthe injuries lactic effect in handball team players who were in groups with functionally unstable ankles. studied prospectively for two full seasons. Six top level teams participated in the first year. In The role ofshoes three teams the players wore tape and in the Biomechanical studies support the use of high other three teams the players did not. During top shoes for ankle sprain prevention because the first season 13 ankle sprains occurred all they limit extreme range of motion, provide in the non-taped group. In the second season additional proprioceptive input, and decrease nine teams participated. Twenty one ankle external stress on joints.'29 Clinical trials, how- sprains occurred and 20 of these were in the ever, have not shown that the effect of this bio- non-taped group. mechanically improved stability translates into Contrary to this, several studies have shown a lower rate of ankle sprains in high top shoes. that tape loses as much as 50% of its support- Further studies are needed. ive effect after only 10 minutes of active exercise"'-"8 and offers virtually no support Supportive treatment modalities after one hour."9 The mechanism behind the Passive physical therapy modalities are often effect of ankle taping thus remains unclear. recommended to promote healing in the early However, tape does not only restrict extensive rehabilitation phase. The most commonly used joint motion but also enhances proprioceptive are ultrasound, temperature contrast baths, feedback mechanism and shortens the recruit- short waves, and various current treatments ment time of the dynamic ankle stabilisers.'20 including dynamic or interference current Many athletes may have a skin reaction to therapy, or electrogalvanic stimulations. Of tape and therefore skin protection may be these different types of passive physical used. There seems to be no difference in therapy, only cryotherapy has been proved to support between tape directly on the skin and be effective.130

tape with skin protections. Because of these Non-steroidal anti-inflammatory drugs have http://bjsm.bmj.com/ skin problems, tape is used mostly by top ath- been studied in prospective randomised double letes and not by recreational athletes. blind trials, and found to be more effective than placebo for ankle tenderness, swelling, Braces and pain, though the difference was not The use of ankle orthoses has increased over striking and seemed to disappear during an the past decade. In contrast with tape the extended follow up.3 130 mechanical effect of a brace does not wear off In subjects with chronic post-injury swelling,

with activity as shown by Shapiro et al.'2' moist heat packs, warm whirlpool baths, on October 2, 2021 by guest. Protected copyright. Not many clinical trials have been per- contrast baths, electrogalvanic stimulation, and formed judging the effect of ankle bracing on intermittent pneumatic compression have been the frequency of ankle inversion injuries. In a tried.4 Prospective randomised studies have retrospective trial Rovere et al'22 found a reduc- shown that only the last alternative has an tion of sprains in football using a lace-on cloth independent ability to reduce the amount of brace. Tropp et al5 in a prospective study swelling.131 132 showed the effect of a semirigid ankle brace in Table 1 Classification ofoperative treatments for chronic reducing the frequency of injuries in soccer ankle ligament injury players, and in a prospective randomised study Sitler et al'23 found that ankle stabilisers signifi- Non-anatomical reconstruction reduced the of ankle cantly frequency injuries Non-anatomical reconstruction but not their severity in a group of basketball Endogenous players at West Point, New York. The resist- Peroneal tendon moment seems to be the Watson-Jones ance to an eversion Evans same for ankle braces as that for newly applied Chrisman-Snook tape."4 Like tape, braces have been shown to Other Plantaris have a proprioceptive enhancing effect.'24 Partial Achilles tendon There have been discussions about the effect Free autogenous graft on performance of tape and braces. In Exogenous Carbon fibre sprinting a reduction in maximal speed has Bovine xenograft been found by most,'25 but not by all.'26 For Anatomical repair vertical jumping most studies also show that a Direct suture Imbrication and repair to bone brace decreases ability...2.'2 Opinions about Local tissue augmentation bracing compared with taping vary, with some 18 Renstrdm, Konradsen

good. Thus Karlsson et a193 found that the Evans static tenodesis was satisfactory in fewer than 50% of cases after a mean follow up Br J Sports Med: first published as 10.1136/bjsm.31.1.11 on 1 March 1997. Downloaded from period of 14 years. Anatomical reconstructions, in which the AS B tissues of the damaged ligaments are used, have become increasingly popular as they per- mit reconstruction without sacrificing any normal tissue.3093 14 Brostrdm in 196630 reported that direct suture repair of chronic ankle ligament injuries was possible even many years after the initial injuries and that the ends of the ligament could be found. Others reported that the elongated ligaments had healed encased in a fibrous scar tissue. Several authors have reported successful imbrication or shortening J~~ K~ and replantation of the ligaments to obtain a more anatomical reconstruction. We have obtained good results with a modified Bros- trom technique (Peterson procedure) that includes shortening of the ligament, repair through bony tunnels, and imbrication with local tissue93 14 (fig 4). This anatomical technique repairs both the ATFL and CFL. The non-anatomical reconstructions, except for the Chrisman-Snook modification of the Figure 4 Anatomical reconstruction ofchronic ankle ligament instability. (A) Elongated ligaments are divided 3 to 5 mm from insertion of thefibula. (B) Bone surace of the distal Elmslie procedure, repair only the ATFL. end of thefibula is roughened to form a trough to promote ligament healing. Holes are Repair of the CFL is important, because insuf- drilled through the distalfibula. (C) Mattress sutures are used to fix the distal stump of the ficiency of this ligament may be a factor in the ligaments and the capsule to thefibula. The sutures are tightened while thefoot is held in dorsiflexion and eversion. (D) The proimal ends of the ligaments are imbricated over the development of subtalar instability. The post- distal portion. operative treatment after an anatomical reconstruction is a splint for eight days to secure Surgery for chronic instability wound healing and, thereafter, a removable Chronic ankle instability, as demonstrated by walking boot for five weeks. The patient starts pain, recurrent giving way, and positive stress with dorsiflexion and plantar flexion exercises tests, is often treated surgically. A combination after eight days or as early as possible out of the of mechanical and functional instability is the boot two to three times a day. Return to sport most commonly reported indication for sur- in is usually possible three months. http://bjsm.bmj.com/ gery. More than 50 procedures or modifica- Anatomical repair ofboth the ATFL and tions have been described for treating chronic the CFL through bony tunnels produces ankle instability, and these can be loosely good long term results and is recom- grouped as non-anatomical reconstructions or mended as the initial procedure in most anatomical repairs (table 1). cases. If anatomical repair fails, a tenodesis Non-anatomical reconstructions use other procedure, such as the Chrisman-Snook re- structures or materials to substitute for the construction, is a good alternative. A non-

injured ligaments. Structures commonly used anatomical reconstruction is also indicated in on October 2, 2021 by guest. Protected copyright. for grafting are fascia late and the peroneus patients with moderate arthritis or lax joints. brevis tendons in procedures such as Watson- Jones, Evans, and Chrisman-Snook. Numer- ous modifications of these classic procedures have been described. The Chrisman-Snook'09 1 Makhani JS. Diagnosis and treatment of acute rupture of modification of the Elmslie procedure is the the various components of the lateral ligaments of the ankle. Am J Orthop 1962;4:224-30. most widely used non-anatomical reconstruc- 2 McCulloch PB, Holden P, Robson DJ, et al. The value of tion. In four clinical series with a total of 100 mobilisation and nonsteroidal anti-inflammatory analgesia in the management of inversion injuries of the ankle. BrJ7 ankles, more than 90% of patients had good or CGin Pract 1985;39:69-72. excellent results, and stability was more than 3 Viljakka T, Rokkanen P. The treatment of ankle sprain by bandaging and antiphlogistic drugs. Ann Chir Gynaecol 95% of the normal ankle. Reported complica- 1983;72:66-70. tions included neuromas in 0 to 16% of 4 Balduini FC, Vegso JJ, Torg JS, et al. Management and in rehabilitation of ligamentous injuries to the ankle. Sports patients, restricted dorsiflexion about 20%, Med 1987;4:364-80. and restricted inversion to some degree in all 5 Brand RL, Black HM, Cox JS. The natural history of inad- equately treated ankle sprain. Am -f Sports Med 1977;5: patients. An advantage of the Chrisman-Snook 248-9. procedure is that less lateral weakness is 6 Fiore RD, Leard JS. A functional approach in the rehabili- because half of the tation of the ankle and rear foot. Athletic Training 1980;15: produced only peroneus 231-5. brevis tendon is used for the graft. A criticism 7 Garrick JG. The frequency of injury, mechanism of injury of the procedure has been that it results in and epidemiology of ankle sprains. Am if Sports Med 1977; 5:241-2. restricted subtalar motion. Furthermore, 8 Garrick JG, Requa RK. The epidemiology of foot and these tenodesis procedures are non- ankle injuries in sports. CGin Sports Med 1988;7:29-36. 9 Glick JM, Gordon RB, Nashimoto D. The prevention and anatomical and do not restore normal treatment of ankle injuries. Am if Sports Med 1976;4: 136- Although short term results 41. biomechanics."33 10 Hardaker WT, Margello S, Goldner JL. Foot and ankle are excellent, long term results may not be as injuries in theatrical dancers. FootAnkle 1985;6:59-69. Ankle ligament injuries 19

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