Donald Stewart, MD Arlington Orthopedic Associates Lateral ligament injuries Chronic lateral ligament instability Syndesmosis Injuries Anatomy Mechanism of Injury Classification Diagnostic Tests Management 1
Ankle sprain is most common time loss injury in sports Estimated incidence = 1 in 10,000 persons per day Vast majority are lateral ligament sprains resulting from inversion of a plantar-flexed foot Persistent instability in 15-20% Lateral ligamentous complex of the ankle Anterior talofibular ligament (ATFL) Calcaneofibular ligament (CFL) Posterior talofibular ligament (PTFL) Lateral ligamentous complex of the ankle» Anterior talofibular ligament (ATFL) Calcaneofibular ligament (CFL) Posterior talofibular ligament (PTFL) 2
Lateral ligamentous complex of the ankle» Anterior talofibular ligament (ATFL)» Calcaneofibular ligament (CFL) Posterior talofibular ligament (PTFL) History Description of the injury Position of the ankle during the injury Able to continue to play or bear weight Previous injury Site of injury 3
Physical Exam Palpation over medial and lateral malleoli Palpation over deltoid ligament Palpation over ATFL, CFL, and PTFL Palpate anterior process of calcaneus, base of 5 th metatarsal Palpate peroneal tendons Neurovascular exam CRPS Anterior drawer test for ATFL Talar tilt to assess CFL Squeeze test to look for syndesmotic injury Test peroneal eversion strength Physical Exam ATFL Knee flexed and ankle plantar flexed anterior stress on the ankle Positive suction sign Increased talar translation Increased talar internal rotation CFL Ankle in 0 degrees of dorsiflexion and apply varus stress Increased talar varus Subtalar instability may mimic CFL disruption Ottawa Criteria Guideline to order x-ray This does not apply for syndesmotic injury 4
No clear consensus AMA standard nomenclature system Grade I: Ligament stretched Grade 2: Ligament partially torn Grade 3: Ligament completely torn Anatomic system Grade 1: ATFL sprain Grade 2: ATFL and CFL sprains Grade 3: ATFL, CFL, PTFL sprains RICE (Rest, Ice, Compression, Elevation) with ankle brace initially and protected weight bearing ROM exercises Ice Electrical stim Peroneal strengthening and proprioceptive training Bracing or taping for 4-6 weeks depending on activity Return to sports when able to cut without pain Severe sprain may require up to 6 months of protective bracing Grade III sprain may require a walking boot or a cast for up to 4 6 weeks Start Ankle sprain functional rehab when can weight bear without pain and ligament exam is more stable I revisit the athlete in 2-3 weeks Extended period of protective bracing may be warranted Recommend 6 months with full practice/ play Return to play criteria remain the same 5
Lateral Ankle Sprain- Surgery Acute surgical repair not supported by literature Symptomatic chronic instability may require surgical intervention Anatomic Brostrom repair Brostrom with Internal Brace Cadaveric Allograft Reconstruction 87% success nonop vs 60% success with surgery Persistent instability of the ankle joint develops after acute rupture in up to 20% of patients Recurrent sprains may or may not be painful difficulty running on uneven surfaces difficulty jumping or cutting Treatment: supervised rehabilitation program focusing on peroneal strengthening, proprioception, and coordination Symptomatic chronic instability may require surgical intervention 6
the occurrence of recurrent joint instability and the sensation of joint instability due to the contributions of any neuromuscular deficits. Hertel: J: Functional instability following lateral ankle sprain. Sports Med 29:361-371, May 2000 Injury to the joint mechanoreceptors and afferent nerves impaired balance reduced joint position sense slower firing of the peroneal muscles in response to inversion stress slowed nerve conduction velocity impaired cutaneous sensation strength deficits decreased ankle dorsiflexion range of motion laxity of a joint due to structural damage to ligamentous tissues which support the joint. Hertel: J: Functional instability following lateral ankle sprain. Sports Med 29:361-371, May 2000 Stretched out ligaments of the ankle i.e., a mechanical problem requiring a mechanical solution! Poor quality or stretched lateral ligaments Chronic ligamentous laxity, e.g. collagen disease Tarsal coalition Hindfoot varus Young to middle-aged active individual Failure of conservative treatment program with exercises and bracing Positive anterior drawer and/or talar tilt tests by physical examination or radiographs Other injuries around the ankle Peroneal injury Osteochondral lesion + anterior drawer 7
Radiographic criteria Anterior drawer > 1 cm Side-to-side difference > 3 mm Talar tilt > 15 degrees Side-to-side difference > 10 degrees + anterior drawer + talar tilt Anatomic Brostrom repair Brostrom with Internal Brace Cadaveric Allograft Reconstruction 8
Bell SJ, Mologne TS, Sitler DF, Cox JS. Twenty-six-year results after Brostrom procedure for chronic lateral ankle instability. Am J Sports Med. 2006;34:975-978. 90% good functional results Only ATFL primarily repaired 51 90 AOFAS score 8/38 athletes clinical failures 6/38 abandoned sports because they did not feel safe 30% had x-ray advancement of arthritic changes Level IV study No transosseous sutures or bone tunnels ATFL/ CFL RELEASED ATFL/ CFL ADVANCED 9
PUSHLOCKS ADD 25% STRENGTH GOULD MODIFICATION Stronger Repair No postoperative restrictions on motion Start full functional rehab when incision healed Return to play 6-12 weeks Patients/ therapists report improved stability initially 10
Clinically faster return to training 2 vs 6-10 weeks Improved Proprioception Initially Depend on the internal brace to provide feedback Consistent repair strength despite tissue quality Patients are happy You look smarter?? Poor tissues are protected and can remodel without stretching over time 11
Failed previous surgeries Hyperlax patients No definable tissue for repair intraoperatively CFL Instability? 12
Start full range motion and weight bearing 2 weeks Return to full play 3 months without restriction Brace for 6 months with full play Chronic ankle instability can be caused by functional or mechanical causes Nonoperative treatment is the first line Whenever possible an anatomic repair/reconstruction should be performed Must recognize and correct other mechanical problems or risk a poor outcome 13
Most difficult injury to treat in the high performance athlete (survey of NFL athletic trainers) Considered a continuum of injury ranging from a minor sprain to a frank diastasis of the distal tibiofibular complex INCIDENCE reported rates are between 1-18% of all patients with ankle sprains injury rate seems highly dependent on definition of the injury as well as the method of diagnosis frequently missed initially and subsequently identified because many patients have prolonged disability ~30% unable to return to activity for > 6mos (Gerber et al) 14
Three definable ligaments connect the tibia and fibula at the ankle and make up part of the syndesmotic complex: anterior inferior tibiofibular ligament (AITF) posterior inferior tibiofibular ligament (PITF) interosseous ligament In addition the interosseous membrane connect the two bones throughout their length. Cutting Studies: Relative contribution of various ligaments to stability (Ogilvie- Harris, 1994) AITF = 35% IO = 22% superficial PITF = 9% deep PITF = 33% Rupture of AITF can lead to separation between the tibia and fibula of 4 to 12 mm AITF rupture also leads to increased rotational moment and more AP translation of the fibula Most significant force is external rotation Another force is abduction and causes a tear of deltoid ligament or fracture of the medial malleolus Order of injury: AITF --> IO ligament - -> IO membrane PITF ligament is usually preserved Peel sign on scope Hyperdorsiflexion has also been proposed as a possible mechanism of injury Ski racing and bull riding identified as unique situations for the external rotation mechanism 15
Correct early dx Mechanism of injury Tenderness Syndesmosis- 83% Most specific is 5mm proximal to fibula Swelling May be less than lateral sprain Squeeze test-89% specific External rotation test Cotton test medial-lateral shift test AP view 5 mm gap b/w fibula and tibia 10 mm overlap anterior tibial tubercle Mortise View < 4 mm medial clear space look for continous line Most reliable is tib fib clear space less than 6 mm INCREASED TIB CLEAR SPACE LATERAL SHIFT OF TALUS 16
Can get detail down to 1-2 mm Downside is that you cannot detect a dynamic injury Can compare to opposite side Grade Injury based on ligaments injured AITFL- stable AITFL +IOL-?? AITFL+IOL+PITFLunstable Does not dynamically test the ligaments Current test of choice MRI as reference with documented AITFL injury 100% sensitive and specific for injury if 1mm change tib fib clear space from neutral to external rotation compared to opposite side 17
Group 1- no dissection Group 2-AITFL + IOL Group 3-AITFL/IOL/ATFL/CFL Group 4-AITFL/IOL/ATFL/CFL/PITFL/TOL 4 force planes tested Transverse-ER external rotation stress test sagittal-anterior Sagittal-posterior Coronal- cotton Think it is most helpful for the subtle syndesmotic injuries in a high level athlete FAI 2015 18
Grade I- Sprains without diastasis Grade II- Sprains with latent diastasis Grade III- Sprains with frank diastasis Sprain without diastasis Symptomatic treatment J. ATHLETIC TRAUMA 1999 NO CONSENSUS Ice, stim, tape, brace, boot +/- steroid injection Return to play 30 days 19
Level II study 16 athletes isolated AITFL and U/S evaluated day 0 and 6 weeks PRP vs. no PRP Return to play: 40 vs. 60 days Decreased pain 12% vs. 62% when returned to play 15 days return to play syndesmotic injury vs. 6.5 days lateral ankle sprain Nonoperative treatment for isolated syndesmotic treatment 20 single leg hop test If there is a syndesmotic injury then they will not try this or will not be able to complete this Also my criteria for return to full practice and play Other tests are taping the syndesmosis Evaluate the athlete Cutting and pushoff will be painful Many times there will be minimal pain with walking or standing 20
Boot and RICE Get further imaging (MRI or CT or stress xrays of ankle) if Inability to bear weight after injury Positive midshaft fibular squeeze test Tenderness 5cm or greater above the ankle mortise Pain with external rotation stress test NSAID Management Consider PRP injection Start functional modalities once can bear weight without pain and wean boot to brace and tape Estimate return to play 2-4 weeks if grade I No ORIF required if anatomic reduction confirmed by CT or MRI Cast immobilization NWB X 4 weeks Repeat CT/MRI at 4 weeks to confirm reduction Progress WB at 4 weeks PROS No surgery-avoid surgical risks Possible faster return to play CONS 30% fail nonop treatment Early repair with transyndesmotic button fixation may allow equally fast return to play 2-6 weeks Harder to fix if surgery delayed 3 or more weeks Open repair usually required after 3 weeks No reliable test exists radiographically or clinically to determine which injuries are unstable 21
Get further imaging (MRI or CT or stress xrays of ankle) if Inability to bear weight after injury Positive midshaft fibular squeeze test Tenderness 5cm or greater above the ankle mortise Pain with external rotation stress test Abnormal weight bearing x rays? If MRI has tear of 2 or more ligaments **Recommend evaluation under anesthesia and ankle arthroscopy Dynamically test the ankle while looking at the syndemosis Repair if torn and unstable Debridement and lavage of ankle if stable and closure Theoretical faster return to play Some argue to leave alone unless there is deltoid injury and talar shift Division I football player defensive end Mechanism: foot was planted and he was hit and rotated on his foot and the cleats would not unstick Exam Unable to continue play Unable to bear weight initially Pain 5 cm above the syndesmosis Pain with external rotation stress Mild swelling Treated nonoperative for syndesmotic sprain on opposite ankle in the past 22
INJURED SIDE UNINJURED SIDE 23
PREOPERATIVE POSTOPERATIVE Surgical Repair Anterolateral incision Reduce and place syndesmosis screw or transsyndesmotic fixation Confirm stability & anatomic reduction Repair torn syndesmosis ± Clear debris from medial joint ± Deltoid repair Postop CT; 2mm was cutoff 24% diastasis 52% incongruity within the incisura 24
These studies are humbling Good technique Consider some secondary measure of reduction CT Arthroscopy Open evaluation 23 tightropes vs. 23 screw fixations; 2.5 year follow up 21% 5/27 malreduced in the screw fixation 0% malreduced in the endobutton fixation No difference in AOFAS scores overall Malreduction was the only clinical variable to determine clincial outcome NO STRESS GRAVITY STRESS TEST 25
UNSTABLE SYNDESMOSIS BEFORE FIXATION SYNDESMOSIS TIGHTROPES ADDED AITFL STILL UNSTABLE 26
ADDED INTERNAL BRACE STABLE EXAM 27
Lateral ankle sprains Most are nonoperative and will heal with the tincture of time and activity modification Functional rehabilitation and proprioceptive exercises are key In severe sprains when the patient cannot weight bear it is okay to immobilize with the ankle in dorsiflexion for 4-6 weeks There is no substitute for a good physical exam Always get weight bearing x-rays if possible ***Do not get an MRI without doing the basics Feel free to call or refer your patient to an orthopedic surgeon if it seems out of the ordinary There is NO literature to support early fixation of torn lateral collateral ligaments of the ankle *****ATFL is not the ACL-please let the patients and their parents know this Severity of the tear does not predict either a good or bad nonsurgical or surgical outcome Beneficial for mechanical instability or in conjunction other associated injuries such as the peroneal tendons or osteochondral lesions Usually attempt 10-12 weeks of nonoperative care My go to surgery is now the Brostrom with internal brace Allows earlier rehab and is stronger than the native ligaments Take 2-3 times as long to recover Physical exam should raise your level of suspicion Squeeze test, external rotation stress test; pain above the joint line on the fibula or between the tibia and fibula X rays are critical If the tib fib clear space is greater than 6mm on any view, your spider senses should tingle MRI is my first test of choice now CT if there is question or to compare axial views of opposite syndesmosis You must not miss a diastasis This can doom the patient s life 28
Type I- no surgery Type II I scope these and repair if unstable with transyndesmotic suture button; I have started to add the internal brace for certain cases I rarely use screw fixation I recommend surgical treatment in the elite athlete but nonsurgical may be appropriate for casually active people Type III I recommend fixation for all of these 29