NONOPERATIVE TREATMENT FOR GRADE III LATERAL ANKLE SPRAIN IN A PRO - PowerPoint PPT Presentation

NONOPERATIVE TREATMENT FOR GRADE III LATERAL ANKLE SPRAIN IN A PRO ATHLETE SAM A. LABIB, MD FAOA Emory University. Atlanta, GA e mo ryhe a lthc a re .o rg / o rtho

Disclosures • Research/Fellowship Funding: Arthrex Ossur Linvatec • Consultant: Arthrex Stryker

ANKLE INJURIES IN SPORTS: STATS ANKLE SPRAIN #1 Men B-ball > 25% Women B-ball Soccer/ Lacrosse • NBA: 40-50% • NFL: 17-24% • NCAA: 20% e mo ryhe a lthc a re .o rg / o rtho

Severe Ankle Sprain in a Professional Athlete Mid-Season: DIAGNOSIS • History/ Mechanism High Ankle Sprain / Syndesmotic :Tenderness above joint line. Deltoid Injury / Grade? Low Ankle Sprain • Sport/ Position/ Game Selection e mo ryhe a lthc a re .o rg / o rtho

LATERAL ANKLE SPRAINS: ALL-COMERS 80% INVERSION MECHANISM • Look For EVERSION TYPE SYNDESMOSIS • HIGH ANKLE SPRIAN, SQUEEZE SIGN, > 6 MONTHS ONE WEEK OF HEALING PER INCH OF SYNDESMOSIS TENDERNESS + FRACTURE/ TENDON TEAR • +KNEE MCL INJURY e mo ryhe a lthc a re .o rg / o rtho

On Examination: Don’t Miss: Bony Anatomy • Varus Plafond and Varus Hindfoot predisposed to ankle instability Myerson, 1993 • Varus Hindfoot Unstable > Controls CCVA angle 4 0 Van Bergeyk, F&A Int 2002

On Examination: Don’t Miss: Bony Anatomy • Varus Plafond and Varus Hindfoot predisposed to ankle instability Myerson, 1993 • Varus Hindfoot Unstable > Controls CCVA angle 4 0 Van Bergeyk, F&A Int 2002

Don’t Miss: Subtalar Injuries • Dorsiflexion- inversion • Tender sinus tarsi • Difficulty with uneven terrain/ At night • Provocative Test: 0 Dorsiflexion/ 10 Forefoot adduction Thermann et al, F&A Int 1997

Don’t Miss: Subtalar Injuries • Dorsiflexion- inversion • Tender sinus tarsi • Difficulty with uneven terrain/ At night • Provocative Test: 0 Dorsiflexion/ 10 Forefoot adduction Thermann et al, F&A Int 1997

Do Not Miss: Fractures !!

Do Not Miss: Peroneal Tendon Dislocation • Acute – Sudden dorsiflexion with firing of peroneal tendons – back side of a mogul while skiing – Inversion with the foot in plantarflexion • Chronic – Repeated sprains, varus hindfoot lead to attenuation of SPR and synovitis

Imaging: MRI – Indications In Pros? Acute Sprain : • Loose body Occult fracture Peroneal tears Ligament disruption • Chronic Instability : Same + OCL

Stress X-rays Stress views: AP/ LAT/ Broden > 15 degrees of talar tilt angle > 5 mm of anterior Talar translation > 7 mm of Talo Calcaneal gapping • Compare with normal side Anterior drawer difference > 4 mm Talar tilt difference > 6 degrees 100 Normal Volunteers: 11% Asymmetric Ankle Laxity Scranton et al F&A Int. 2000

Stress X-rays Broden View Lateral Tilt

Kaplan LD, Jost PW, Honkamp N, Norwig J, West R, Bradley JP. Incidence and variance of foot and ankle injuries in elite college football players . American journal of orthopedics (Belle Mead, NJ). 2011 Jan;40(1):40-4. NFL Combine 2006: • 287 foot and ankle injuries (1.24 • injuries/player injured). The most common injuries were • lateral ankle sprain (115= 40%). Syndesmotic sprain (50= 17.5%), • metatarsophalangeal dislocation/turf toe (36), and fibular fracture (25). Foot and ankle injuries were most • common in kickers/punters (100% incidence), special teams (100%), running backs (83%), wide receivers (83%), and offensive linemen (80%). Lateral ankle sprains, the most • common injuries, were treated surgically only 2.6% of the time .

Beynnon BD, Renström PA, Haugh L, Uh BS, Barker H. A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. The American journal of sports medicine. 2006 Sep;34(9):1401-12. 1993-1996: 212 patients experienced their first ankle • sprain. This group comprised 64 (30%) grade I sprains, 116 (55%) grade II sprains, and 32 (15%) grade III sprains. Patients suffering a grade III ankle sprain had no difference • between treatment with the Air-Stirrup brace and cast immobilization for 10 days followed by the use of an elastic wrap in time required to return to normal walking (P = .918) and stair climbing (P = .802). Subjects treated with the Air- Stirrup brace required 18.56 days to return to normal walking and 18.31 days to return to normal stair climbing for the cast treatment group. For the subjects who suffered grade III sprains, there was • no difference between the treatments in time to return to pain-free weightbearing, full function at work or school, and full capability during normal activities of daily living and athletic or recreational activity, these values were 19 days and 21.08 days, respectively.

NONOPERSTIVE vs. OPERATIVE e mo ryhe a lthc a re .o rg / o rtho

Takao, Masato, et al. Functional treatment after surgical repair for acute lateral ligament disruption of the ankle in athletes. AJSM 40.2 (2012): 447-451. • Comparative study: Functional (PT) Treatment with and without surgery. • 132 Patients: 2 groups • Non op group: 10% failure and Longer return to sports (16 wks versus 10 wks) • Operative group: Better Lateral Tilt and Anterior drawer. • Other parameters No Difference.

Pijnenburg, A. C. M., et al. Treatment of Ruptures of the Lateral Ankle Ligaments: A Meta-Analysis. The Journal of Bone & Joint Surgery 82.6 (2000): 761-761. • 27 Randomized, controlled trials (RCT)reported between 1966 and 1998 Time lost from work, residual pain, and giving-way • • No-treatment strategy lead to more residual symptoms. • Operative treatment > functional treatment > cast immobilization for six weeks..

Kerkhoffs, G. M. M. J., et al. Surgery versus conservative treatment for acute ankle sprains in adults. (2010). Cochrane Review • 20 RCTs reviewed • Methodological flaws in 8 studies Return to pre-injury level of sports Ankle sprain recurrence Long-term pain Subjective or functional instability Positive Trend - No Stat Significance

Thordarson, David B. "Operative versus Functional Treatment of Ruptures of the Lateral Ankle Ligaments." The Journal of Bone & Joint Surgery 83.8 (2001): 1275-1277. • Letter to editor • Agreed with Brostrom: “ when conservative treatment fails, secondary operative reconstruction of the ruptured ligaments can be performed, with similar good results, even years after the initial injury. ”

Beynnon BD, Renström PA, Haugh L, Uh BS, Barker H. A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. The American journal of sports medicine. 2006 Sep;34(9):1401-12. 1993-1996: 212 patients experienced their first ankle • sprain. This group comprised 64 (30%) grade I sprains, 116 (55%) grade II sprains, and 32 (15%) grade III sprains. Patients suffering a grade III ankle sprain had no difference • between treatment with the Air-Stirrup brace and cast immobilization for 10 days followed by the use of an elastic wrap in time required to return to normal walking (P = .918) and stair climbing (P = .802). Subjects treated with the Air- Stirrup brace required 18.56 days to return to normal walking and 18.31 days to return to normal stair climbing for the cast treatment group. For the subjects who suffered grade III sprains, there was • no difference between the treatments in time to return to pain-free weightbearing, full function at work or school, and full capability during normal activities of daily living and athletic or recreational activity, these values were 19 days and 21.08 days, respectively.

White WJ, McCollum GA, Calder JD. Return to sport following acute lateral ligament repair of the ankle in professional athletes . Knee Surgery, Sports Traumatology, Arthroscopy. 2016 Apr 1;24(4):1124-9. A consecutive series of 42 athletes underwent modified Broström repair • for clinically and radiologically confirmed acute grade III lateral ligament injury. Of 42, 30 had isolated complete rupture of ATFL and CFL. Of 42, 12 had additional injuries (osteochondral lesions, deltoid ligament injuries). All patients received minimum of 2 years post-operative assessment. The median return to training and sports for isolated injuries was 63 days • (49–110) and 77 days (56–127), respectively. However, for concomitant injury results were 86 days (63–152) and 105 days (82–178). This delay was significant (p < 0.001) Combined injuries had significantly lower FAOS pain and symptoms sub- • scores post-operatively (p = 0.027, p < 0.001) No patient developed recurrent instability. All returned to their pre-injury • level of professional sports.

Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy W, Richie D. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. Journal of athletic training. 2013 Jul;48(4):528-45.

Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy W, Richie D. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. Journal of athletic training. 2013 Jul;48(4):528-45.