Ankle Sprains – What to do it it is recurrent and unstable?


Ankle Sprains

Some interesting statistics about Ankle Sprains:
•1/10,000 persons/day
•23,000 ankle sprains in the U.S. each day
•40-45% of sports injuries are ankle injuries
•85% of ankle injuries are sprains
•85% of sprains are due to inversion with injury to the lateral ligaments
Inversion sprains (where the foot turns inwards) are the most common form of ankle sprain.
It damages the lateral ligaments of the ankle joint.
Lateral Ankle Ligaments
ATFL
–anterior talo-fibular ligament
– this is the most important ligament that is injured in an inversion ankle sprain.
•CFL
–calcaneo-fibular ligament

•PTFL

–Posterior talo-fibular ligament
The Anterior Talofibular Ligament (ATFL) is the main determinant of whether one will get recurrent inversion sprains in the future. The Calcaneofibular Ligament (CFL) is the 2nd important structure that provides ankle stability.
A grade I sprain is when the ATFL and CFL  are stretched but not torn. This type of sprain is usually not seen in the clinic.
A grade II sprain is when the ATFL and CFL are partially torn. This is a common problem which presents in our clinic.
A grade III sprain is when the ATFL and CFL are completely ruptured.
Severity of Ankle Inversion Sprains
Treatment of Acute Ankle Sprains
PRICEM
Protection: (orthosis or brace)
Rest: limit weight bearing until not painful
Ice, Compression, and Elevation
–Most important component acutely
–Limiting inflammation and swelling has been shown to speed recovery
Mobilize
–early range of motion has also been shown to speed recovery
Prognosis is Related to the Grade of the Ankle Sprain
Grade I
–Require an average 11.7 days before full resumption of athletic activity
Grade II
–Require approximately 2-6 weeks
Grade III
–Average duration of disability ranges 4.5-26 wks
–Only 25-60% being symptom free 1-4 yrs after injury
Chronic Ankle Instability
A condition characterized by a recurring “giving way” of the outer (lateral) side of the ankle
–Repeated turning of the ankle, especially on uneven surfaces or when participating in sports
–Persistent discomfort and swelling
– Pain
These patients have ligaments that were torn and have not healed properly, leaving the ankle joint too loose.
Treatment
•Physiotherapy
–Re-train nerves to respond to movements of the ankle
–Strengthen the muscles around the ankle
–Stretch out stiff ankle or stiff Achilles tendon
•Bracing
•Surgery
Surgery for Chronic Ankle Instability
I prefer the Bostrum-Gould Procedure.
Case Study:
A 23 year old man sustained an inversion sprain to his right ankle 4 months ago. He has persistent swelling and pain in his right ankle especially over the outer aspect. His right ankle felt unstable when walking on uneven ground. He inverted the same ankle on a few occasions.
His condition did not improve despite maximal conservative treatment.
An MRI scan of his right ankle confirmed a complete tear of the ATFL.
He went for the Bostrum-Gould reconstruction surgery to his right ankle.
Figure 1. The ATFL, CFL and lateral ankle capsule was incised to expose the ankle joint.
Figure 2.  The ATFL, CFL and capsule is plicated (stitched in a manner that results in shortening).
Figure 3. The stitches are tied. The Bostrum part of the surgery is completed.
Figure 4. The inferior extensor retinaculum is prepared for advancement onto the lateral malleolus for the Gould part of the surgery.
Figure 5. The inferior extensor retinaculum is stitched to the lateral malleolar tip.
Post-Surgery
The ankle is casted for about 4 to 6 weeks to allow soft tissue healing.
The cast is removed thereafter and the patient is allowed to walk on that leg and has to start a course of physiotherapy.
Most patients can return to sports involving running and cutting at about 3 to 6 months after the surgery.
For more information on ankle instability or ankle sprains, please contact Dr HC Chang at 683 666 36 or 6694 1928.

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