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Preventing Chronic Ankle Instability After a Sprain

Posted on: 10/14/2008
In the sports world, an ankle sprain is big news. Such injuries account for many days missed in training and in competition. An acute ankle sprain that isn't treated properly can result in chronic weakness, pain, and instability. In such cases, recurring sprains are common and can lead to disability and the end of a promising career.

But what is proper care for this type of ligamentous injury? In this article, orthopedic surgeons from the United Kingdom describe a classification system to grade acute lateral ankle sprain. A lateral ankle sprain describes a ligamentous sprain along the outside of the ankle. Three grades are included based on degree of injury and severity of symptoms.

Grade I reflects the fact that the anterior talofibular ligament (ATFL) is stretched. Some of the fibers are torn but not ruptured. There is mild swelling and tenderness but no loss of ankle motion. Grade II means there is a moderate injury to the lateral ligaments. Usually, there's a partial tear of the calcaneofibular ligament (CFL) and a full-tear (rupture) of the ATFL. Swelling, pain, and loss of motion are common.

Grade III is divided into three parts or subgroups: III, IIIA, and IIIB. Grade III sprains are severe but on a continuum from bad to worse. Grade III is a complete rupture of the ATFL and CFL. There is diffuse swelling, bruising, and tenderness along the front and outside of the ankle. With a Grade IIIA injury, there is at least a 10-degree loss of ankle motion. Swelling is measured as being more than two centimeters. X-rays of joint gapping when under stress are negative.

Grade IIIB injuries present with more than a 10-degree loss of motion, more than two centimeters of edema, and more than three millimeters distance between the joints when compared on X-rays to the normal (uninjured) ankle.

There are many contributing factors to chronic ankle instability. These could be mechanical such as ligamentous laxity (looseness) or degenerative changes that occur over time. They could be functional including loss of joint proprioception (sense of joint position), muscular imbalance due to weakness, and problems with motor control.

Ankle rehab has a major role in restoring normal joint function. The patient's ankle may be taped or supported in an Air-cast, or lace-up support. Or the injured athlete can be put in a cast for a few weeks to allow for healing and prevent reinjury before ankle proprioception can be restored. Most high-performance athletes would like to avoid delays in getting back to play. They may not want to spend any amount of time immobilized. But if they can't put weight on the foot, some type of rigid support may be necessary.

From there, they attend a 10 to 12 week long rehab period. During this time, a physical therapist helps them regain proprioceptive sense, motion, and strength. Early in the recovery phase, the principles of rest, ice, compression, and elevation (R.I.C.E.) are followed closely.

Once the athlete has progressed past the acute phase, then specific training can begin for balance, postural control, and proprioception drills with the ultimate goal of getting back into the game. This phase is referred to as functional training. With this type of management, patients return to sports and/or work faster with fewer symptoms. They report higher levels of personal satisfaction with their results.

Conservative care isn't always effective. A study of overall results from many trials has not been able to show clear support for one method of nonoperative care over another. In the end, chronic pain, the ankle giving way, and recurrent sprains may lead to a more aggressive approach.

Surgery may be needed to repair the damage and restore ankle stability. There are many different possible surgical techniques for this problem. The authors provide a drawing and description of the most common anatomic repairs. These include the Broström repair, Gould modification, and Karlsson modification. These are ways to reattach and reinforce the ligament. The torn ends of the tendon may be sewn to the bone and/or to the nearby connective tissue.

If repair isn't enough and a reconstruction of the ankle is needed, the Watson-Jones, Evans, or Chrisman-Snook procedures may be used. The authors provide illustrations of these techniques. The main reason reconstruction is done instead of repair is because the tendons have ruptured and frayed. The ragged ends may have retracted too far to pull back far enough to reattach them.

There have been several short- to long-term studies done on each of these surgical techniques. The results of studies reporting long-term outcomes are summarize for each one. The results are good-to-excellent for all but the Evans technique. Only one-third of the patients treated with this reconstructive method had a positive result.

There were more complications with the Chrisman-Snook method of repair than any other surgical approach. A significant number of patients reported wound complications, nerve injuries, a sensation that the repair was too tight, or weakness and instability.

Sometimes more involved techniques are needed to reconstruct the ankle. The surgeon may have to create a periosteal (bone) flap or use tendon grafts from elsewhere to reinforce the torn tendon. Tendon material taken from some other part of the foot and/or ankle must be strong enough to function as a graft. Grafts are held in place with screws or inserted through holes drilled in the bone. The graft is wrapped around or threaded through the bone to get just the right amount of tension. The goal is to preserve ankle biomechanics as much as possible.

Current management suggests that the surgeon perform an arthroscopic examination of the joint. Once the location and extent of damage is assessed, then the best management plan can be established. If necessary, the ankle can be repaired or reconstructed at the same time. The authors do not recommend the Evans procedure in high-demand athletes. Loss of normal ankle and hindfoot biomechanics can put them at risk for failure of the repair over time.

Nicola Maffulli, MD, MS, PhD, FRCS, and Nicholas A. Ferran, MBBS, MRCSEd. Management of Acute and Chronic Ankle Instability. In Journal of the American Academy of Orthopaedic Surgeons. October 2008. Vol. 16. No. 10. Pp. 608-615.

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