- Discussion:
- pathoanatomy:
- fibular collateral ligament is made up of three separate structures;
- these are not as strong as medial ligaments, since lateral
support of ankle is
also provide by the fibula;
-
anterior talofibular ligament
-
calcaneofibular ligament
-
posterior talofibular Ligaments
- cervical ligaments:
- ref: Elongation behavior of calcaneofibular and cervical lig
during inversion loads applied in an open
chain kinetic chain. FAI Vol 19. No 4.
Apr 1998. p 232.
-
deltoid ligament resists abduction & lateral rotation of foot;
- sudden and forceful eversion, inverson, or rotation of the
foot may tear the ligament stressed, or by
acting through the ligament, may avulse the attached malleolus;
- in the vast majority of cases there will be a tear thru the
ligament mid-substance;
- associated talar compression of opposite malleolus may cause
frx;
-
anterior talofibular ligament:
- w/ inversion force of foot, there is injury to anterolateral
capsule,
ATFL,
& anterior tibiofibular ligament;
- about 40% of patients will have this injury type;
-
calcaneofibular: as force progresses, this ligament is injured as well;
- in about 58% of cases, there will be a tear of both the ATFL
and the CF ligament;
- finally in a small number of cases (3%) there will be tears of the
above two ligament and the posterior
talofibular ligaments;
-
differential diagnosis: ankle sprains:
-
anterior impingement snydrome of the ankle:
- calcaneocuboid joint injuries;
- type of inversion sprain that involves a portion of ligaments
overlying the calcaneocuboid joint;
- causes immediate severe disability with pain, swelling, and
tenderness that is localized to the
region of the joint;
-
frx of anterior process of calcaneus:
-
frx of the lateral talar processes:
-
frx of the posterior process:
-
syndesmotic sprain (high ankle sprain)
-
midtarsal frx:
-
subtalar joint sprain;
-
osteochondral lesions of talus
-
peroneal tendon disruption:
-
tarsal coaliltion
-
Physical Exam:
- be sure to look for concomitant
syndesmotic
and
subtalar
instability;
- note any dysesthesia from the peroneal nerves, and point this out to the
patient;
-
Radiographic Studies for Ankle Sprains:
-
tibiotalar tilt
- Non Operative Treatment:
- non operative treatment is indicated for the majority of severe ankle
sprains, and most patients w/ significant
sprains will be back to work with in
10 days;
- prognosis (from Gerber et al 1998)
- factor most predictive of delayed recovery and residual symptoms
is concomitant
syndesmotic sprain;
- most patients will be back to playing sports at 6 weeks, but about
1/2 will continue to significant
symptoms even at 6 months;
- prognosis of tibiotalar tilt:
- despite the fact that most severe ankle sprains will initially
demonstrate 15-18 deg of tibio-talar tilt
(and in some cases will be as large as 40 deg), in most cases the ankle will
stabilize down to 6 deg
with conservative treatment;
- in patients w/ less than 15 deg of initial tibiotalar tilt,
approximately 13% will have a poor result;
- in patients w/ more than 15 deg of initial tibiotalar tilt,
approximately 22% will have a poor result;
- references:
-
Management and rehabilitation of ligamentous injuries to the ankle.
-
Radiological and muscular status following injury to the lateral ligaments
of the ankle.
Follow-up of 144 patients treated conservatively.
-
Clinical and social status following injury to the lateral ligaments of the
ankle.
Follow-up of 144 patients treated conservatively.
- Persistent disability associated with ankle sprains: A prospective
examination of an athletic
population. Gerber FAI Vol 19. No 10. Oct. 1998 p
653.
- Functional properties of adhesive ankle taping: Neuromuscular and
mechanical effects before and
after exercise. FAI Vol 20. No 4. Apr. 1999. p
238.
-
Spraining the Ankle Without Straining Credulity
- Operative Management:
- indications:
- in the meta-analysis report by Pijnenburg MD et al, the authors
concluded that a no-treatment
strategy for ruptures of the lateral ankle ligaments leads to more residual
symptoms.
- operative treatment leads to better results than functional
treatment, and functional treatment leads
to better results than cast
immobilization for six weeks;
- reference:
- Treatment of Ruptures of the Lateral Ankle Ligaments: A
Meta-Analysis. J Bone Joint Surg [Am]
82-A: 761-73, 2000 ACM Pijnenburg et al.
- prior to considerations for surgery, ensure that subtalar instability is
not present;
-
Modified Brostrom Procedure:
- generally operative treatment is considered when there is a
persistant
tibiotalar
tilt greater than 20 deg;
- EDB transfer for chronic lateral ankle instability:
- EDB is detached proximally from the calcaneus and is sutured to the
periosteum of the fibula;
- procedure helps to restore proprioception to the ankle;
-
associated injuries which may require treatment:
- in report by
DIGiovanni et al (Foot and Ankle Internat 2000), the authors sought to
determine
injuries associated with lateral instability at the time of surgery;
- 61 patients underwent a primary ankle lateral ligament
reconstruction for chronic instability between
1989 and 1996;
- in addition to the ligament reconstruction, all patients
had evaluation of the peroneal retinaculum,
peroneal tendon inspection by routine opening of the tendon sheath,
and ankle joint inspection
by arthrotomy;
- at surgery no patients were found to have isolated lateral
ligament injury;
- injuries found most often by direct inspection included:
- peroneal tenosynovitis, 47/61 patients (77%);
- anterolateral impingement lesion, 41/61 (67%);
- attenuated peroneal retinaculum, 33/61 (54%);
- ankle synovitis, 30/61 (49%);
- intra-articular loose body, 16/61 (26%); peroneus
brevis tear, 15/61 (25%);
- talus osteochondral lesion, 14/61 (23%); medial
ankle tendon tenosynovitis, 3/61 (5%);
-
peroneal tendon disruption:
-
peroneus brevis tear:
- longitudinal tears of the peroneus brevis are associated w/
ankle sprains;
- look for tendon tear at the level of the distal fibula;
- persistent swelling along the peroneal tendon sheath is a
reliable sign for peroneus brevis tendon tear;
- this injury tends to occur from peroneal tendon subluxation
over the posterolateral edge of the fibula;
- inciting cause is incompetence of the superior peroneal
retinaculum;
- this allows subluxation of the peroneal tendons and
mechanical attrition of the peroneus brevis
tendon against the posterior ridge of the fibula;
- treatment: needs to address the tear and the
peroneal subluxation;
- w/ damage of less than 50% tendon substance, consider
tendon debridment;
- w/ damage of more than 50% of the tendon cross
sectional area, consider excision of the
damaged segment and tenodesis to the
peroneus longus;
- valgus osteotomy:
- Idiopathic cavovarus and lateral ankle instability:
Recognition and treatment implications relating to
ankle arthritis. Foot Ankle
Int 2002;23:1031-1037.
- references:
-
Ruptures of the fibular collateral ligaments of the ankle. Result study of
immediate surgical treatment.
-
Static or dynamic repair of chronic lateral ankle instability. A prospective
randomized study.
-
Reconstruction of the lateral ligaments of the ankle for chronic lateral
instability.
-
Reconstruction of the lateral ligaments of the ankle using the plantaris
tendon.
-
Long-term results of the Chrisman-Snook operation for reconstruction of the
lateral ligaments of the ankle.
-
Lateral ligament reconstruction of the ankle with a modified Watson-Jones
operation.
-
Results of Watson-Jones ankle reconstruction for instability. The influence
of articular damage.
-
A new operation for chronic lateral ankle instability.
-
Static or dynamic repair of chronic lateral ankle instability. A prospective
randomized study.
-
Secondary reconstruction of the lateral ligaments of the ankle.
-
Long-term results of the Evans procedure for lateral instability of the ankle.
- The effect of EDB transfer for chronic ankle instability.
S.
Vammen MD et al. JBJS. Vol 19. No 8. Aug 1998. p 563.
- Associated injuries found in chronic lateral ankle instability.
Foot Ankle Int 2000 Oct;21(10):809-15 DIGiovanni BF, Fraga CJ, Cohen BE, Shereff
MJ