0198-0211/90/1102-0107$02.00/0 FOOTa ANKLE Copyright 0 1990 by the American Orthopaedic Foot and Ankle Society, Inc.
Foot Fellows Review Acute Lateral Ankle Ligament Injuries: A Literature Review Peter M. Boruta, M.D.,* John 0. Bishop, M.D.t, W. Grant Braly, M.D.,*, and Hugh S. Tullos, M.D.9 Houston, Texas
terior talofibular (PTF) ligaments. Included in this group should be the lateral talocalcaneal (LTC) ligament.’ The ATF is a thickening of the anterior ankle joint capsule, and blends its fibers intimately with the CF and LTC ligaments. A rupture of the ATF will produce a tear in the joint capsule with concomitant hemarthrosis of the ankle joint and ecchymoses from the subcutaneous extravasation of hemorrhage. The CF ligament is extra-articular, but is closely associated with the peroneal tendon sheath. A rupture of this ligament will often tear the tendon sheath and occasionally damage the peroneal tendons. The PTF connects the posterolateral tubercle of the talus to the medial aspect of the lateral malleolus. The LTC ligament extends from the talus to the calcaneus and blends its fibers with those of the CF and ATF. Any discussion of the lateral stability of the ankle joint can be confined to the three major lateral ligaments, but one must realize that lateral stability is only part of a continuum of total ankle integrity. With increasing force, other ligaments become damaged. It has been noted that lateral ligament injuries can be associated with disruption of the anterior tibiofibular, the interosseous, and deltoid ligament^.^' This spectrum may end with peritalar dislocation.
ABSTRACT The average general orthopaedic surgeon examines and treats a considerable number of acute lateral ankle ligament sprains in a busy office practice. A cursory review of recent articles published on this subject will present a confusing picture regarding diagnosis and treatment of Grade 111 injuries. An air of controversy surrounds the interpretation of diagnostic x-rays, and the management of these common ankle problems. This review article is presented to summarize current thoughts on the anatomy, biomechanics, diagnosis, and treatment of acute lateral ankle ligament sprains. INCIDENCE
Ankle ligament sprains are the most common musculoskeletal complaint in the emergency room, and comprise a goodly portion of private office practice. Most ankle sprains occur in the 15- to 35-year-old athlete involved in basketball,’ football, and womens’ cross country. They produce fully 25% of all time-loss injuries in these events. Ankle ligament injury is the most common trauma in modern dance and classical ballet.36One-third of West Point cadets can expect an ankle sprain during their 4-year term.4 In a large series correlating trauma and different sports, only tennis produced no ankle inj~ries.~‘
MECHANICS
ANATOMY
When the ankle joint is in neutral position, the CF ligament is almost perpendicular to the long axis of the talus. Its anterior fibers are under tension, which increases with dorsiflexion. The ATF ligament in this position is parallel to the long axis of the talus, and is not under tension. As the ankle is plantarflexed, the CF fibers become more relaxed, while the ATF fibers become more tense.” The ATF and CF ligaments are synergistic; when one ligament is relaxed, the other is tense, and vice versa.63 Under dynamic load testing, the ATF was found to
The lateral ankle ligament complex consists of the anterior talofibular (ATF), calcaneofibular (CF), and posFrom the Baylor College of Medicine, Division of Orthopedic Surgery, Houston, Texas. Fellow, Section of Foot and Ankle Surgery. t’ Chief, Section of Foot and Ankle Surgery. Clinical instructor. 5 Head, Division of Orthopedic Surgery. To whom all correspondence should be sent at: Baylor College of Medicine, Division of Orthopedic Surgery, 6550 Fannin, Suite 2625, Houston, Texas
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have the weakest tensile strength, followed by the PTF and CF ligaments. The deltoid ligament has the highest load to f a i l ~ r e . ~ The ATF is the primary stabilizer to ankle inversion in plantar flexion in the unloaded joint. It is the first ligament to be torn in an inversion injury regardless of the position of the ankle. When the ankle joint is subjected to an inversion, plantar flexion moment, the lateral joint capsule tears first, followed by rupture of the ATF.66After complete tear of the ATF, the CF fibers will be disrupted, followed by a variable injury to the PTF, and, with increasing force, the deltoid ligament. In neutral position, under an inversion force, a partial tear of the CF may O C C U ~ . ’ ~ C O X ’thought ~ that the anterior tibiofibular ligament would sustain a variable injury before the CF was involved. Brostromghad noted similar rupture patterns in his series. In 1985, the work of Stormont et al.75 demonstrated the relationship between articular restraint, and primary and secondary ligament restraints. They found that ankle joint stability is composed of the mortise and tenon interlocking of the articular surfaces and the load strength of the supporting ligaments. The joint and ligaments alternate roles, being primary or secondary stabilizers, depending on ankle position and load. They stated that in unloaded internal rotation the ATF and deltoid ligaments are primary restraints. However, under load, the articular surface provides nearly as much stability as either primary restraint. In unloaded external rotation the CF is the only primary restraint. The PTF can function as a primary stabilizer, but only in the plantarflexed position. With loading in external rotation the articular surface again becomes important. In unloaded inversion the CF is the primary restraint, and the ATF is secondary in all tested positions. In loaded inversion no ligament contributed to stability; all restraint was articular. Unloadedeversion revealed the deltoid as the primary restraint in all positions. With loading all stability was, again, articular. The authors concluded that with physiologic weightbearing the articular surface could provide 30% of stability in rotation and 100% stability in version. This information suggests that rotation, rather than inversion displacement, may account for some types of clinically symptomatic ankle instability. It now appears that ankle destabilization occurs during loading and unloading, but the joint is stable once it is fully loaded. Other authors have also shown that ankle stability is enhanced by axial loading.56This stability is a function not only of the axial load, but also the “close-packed p ~ s i t i o n . ” ~When ’ - ~ ~ a joint is close-packed, its articular surfaces are compressed and fully congruent with maximal contact area. In the ankle joint full dorsiflexion
produces the close-packed Smith and Reisch17’ concluded in 1988 that maximum apposition of a divided ATF occurred with the ankle in dorsiflexion and not in eversion. Dorsiflexion also reduced and maintained the reduction of an anteriorly subluxed talus. DIAGNOSIS Physical Examination
Most patients with a sprain of the ankle will describe a “popping” or tearing sensation which was felt at the time of injury. Examination will reveal variable amounts of tenderness to palpation over the different ligaments. Ecchymoses may or may not be present.” Gentle stress maneuvers using the talar tilt test (TTT) and the anterior drawer test (ADT) may add more information regarding the extent of injury. Some authors feel that the ATF ligament can usually be accurately evaluated by clinical examination alone; stress x-rays are used when necessary to confirm clinical impression^.^^^^^^^^ Funder et aL3‘ in 1982 stated that swelling over the lateral malleolus was the most valuable diagnostic sign, especially if it was increased by 4 cm beyond the circumference of the normal ankle. With this amount of edema the probability of ligament rupture was 70%. If palpation of the CF produced pain, the chance of rupture was 72%. Tenderness of the ATF revealed 52% incidence of rupture. If both the CF and ATF were tender, and the swelling was greater than 4 cm, the possibility of major ligament damage increased to 91‘10. Funder et placed little value on the TTT and ATF. Other surgeons29feel that the amount of swelling does not correlate with the degree of injury, and pain response to palpation is too subjective. Hence, they perform stress x-rays to delineate the degree of ligament pathology. It has been proposed” that lateral ankle sprains be classified as: Grade I, mild stretching of the ligament and no instability; Grade 11, moderate but incomplete tear and mild instability; or Grade Ill, complete tear of the ATF and CF with gross laxity and instability. X-Ray Evaluation
Routine x-ray evaluation of the injured ankle generally provides few clues in determining the extent of llgament damage. in 1986, and Lindstrand et al.,54 in Simon et 1978, had stated that there is no clinically significant measurement oh plain ankle x-rays which could accurately differentiate between GrNe II and Grade Ill injuries.
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Eyring and G ~ t h r i e 'reported ~ that 2 to 3" of talar tilt could be noted on plain anteroposterior films without application of any stress. Glasgow et al.33explained that a chip fracture from the tip of the lateral malleolus implied avulsion of the CF ligament. Talar Tilt Test
This test is defined as the angle produced by the tibia1 plafond and the dome of the talus in response to forceful inversion of the hindfoot. The stress should be applied at the level of the calcaneocuboid or cubotarsal joints. This study is designed to reveal an incompetent CF ligament. There is wide disagreement on what constitutes normal tilt of the talus in the ankle. No consensus exists regarding abnormal tilt nor the methods of obtaining either value. A sampling of the literature displays the following range for normal talar tilt.
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B0nnin7: 0 to 15" indicated ATF rupture, 15 to 30" indicates ATF and CF rupture, >30" indicates ATF, CF, and PTF rupture. Cass and Morrey": 5" relative. Korkala et a/.44.45: 15" absolute, 10" relative. K r i ~ f i a n s e ngreater ~~: than 3" relative.
Seligson et aL6' concluded that the TTT was not reliable due to the wide range of normal and abnormal values and possible differences from left to right. Anterior Drawer Test
This study was designed to measure the integrity of the ATF. It is performed by producing anterior movement of the ankle relative to the distal tibia. Any subluxation is measured from the posterior lip of the tibia to the nearest articular surface of the talus. Some writers state that the test should be done with manual stress, others use sandbags or weights applied to the distal tibia for varying lengths of time. The use of a jig to position the ankle may produce more accurate results. Rubin and Witten64:Up to 23" in a normal ankle. The values for accepted normal subluxation are as Chrisman and Sn00ki5: 10" is the limit of normal. 9 'mm; Glasgow et al.336 mm; Gould follows: L a ~ r i n , ~ Cox and Hewes17:Talar tilt over 5" would indicate 3 ~to~4 mm; Johannsen4' and et al.344 mm; H a r ~ i n g t o n significant injury. Lightowler5' 2 mm. Seligson et al." reported that the ADT appears to The method of applying inversion stress also varies evaluate lateral ligament integrity of the ankle more considerably. Most writers recommend manual stress critically than the TTT. His studies were performed with to the point of patient pain tolerance." Cox and electromyogram monitoring of muscle activity. He deHewes17showed that the results obtained in this mancided that TTT and ADT evaluation was not a function ner do not vary in the same patient with different of muscle relaxation or of ankle position. Lindstrand examiners applying different amounts of force. Howand M o r t e n s ~ o nevaluated ~~ his patients with a disever, earlier authors26had stated that different examplacement index formulated for both TTT and ADT. iners produced variable results. Different authors indicate that the ADT is more reliable Discrepancy is found in the positioning of the lower than the TTT. Lahde et ah4' concluded that the ADT extremity for TTT. Published reports indicate that the was too unreliable for any decision regarding surgical ankle should be plantarflexed;2s38,25 others state that it repair. He endorsed the arthrogram as the study of should be kept at n e ~ t r a l . ~Many ~ ' ~ ' disagreements choice. about procedure exist. The knee must be f l e ~ e d ' . ' ~ . ~ ~ to relax the gastrocnemius, or the knee can be Ankle Arthrography extended33because tight gastrocs make no difference. In an effort to better quantify lateral ligament damage, The patient should be sitting2', or the patient lies supine various investigators recommend ankle arthr~graphy.~.~ on the table. The test is performed by the surgeon This involves injection of contrast material into the ankle himself7' or by a trained t e ~ h n i c i a neither ~ ~ , manually or joint. The timing of this study is critical; it should be in a special jig,49instrumented or not. Anesthesia is not performed within 24 hours, and certainly no later than req~ired~ to~obtain , ~ ~ useful , ~ ~ information, or meaning5 days after injury. Beyond this time frame the tear in ful values require anesthesia to limit muscle spasm and the joint capsule may be closed with blood clots or guarding.47Infiltration of local anesthetic33should suffibrin tissue, preventing extravasation of dye. It is noted, fice, but peroneal nerve b l o ~ k ~ ~at" the ~ ~ fibular ' head however, that Dory'' performed his studies as late as is better. Of course, the best relaxation and cooperation 2 to 4 weeks after injury. He could not correlate arthrois available only with genera126,28or anesgraphic findings with surgical lesions. thesia for stress testing. The disputes go on and on. Normally the injected contrast will remain within the The foregoing summary may explain the published joint capsule. In 6 to 10% of cases, the dye may flow values for abnormal talar tilt, either as an absolute into the tendon sheaths of the flexor hallucis longus, number or relative to the uninjured ankle.
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flexor digitorum longus, and the subtalar joint. Opacification of these structures is not pathological.'' The dye should not extend beyond the distal end of the lateral malleolus, nor should it flow more proximally than 5.5 cm22above the distal tip of the fibula. Any extravasation of contrast into the peroneal tendon sheath is abnormal. This occurs because of the close proximity of the CF to the joint capsule. In most ruptures of the CF, the medial layer of the peroneal tendon sheath is split longitudinally. If both the CF and ATF are torn, dye injected into the ankle cavity may flow into the peroneal structures. Sometimes the tear in the capsule is so large that there is insufficient pressure to force contrast into the sheath. At other times, the disruption of the sheath is small and dye will not enter. This explains the high incidence of false negative evaluation of the CF during ankle arthrography. However, contrast instilled into the peroneal tendon sheath will seep into the ankle joint if both the CF and ATF are torn. The test is negative if the dye remains within the sheath and does not extravasate. Kelikian and Kelikian43felt that the TTT has been replaced largely by the ADT and ankle arthrography. The TTT requires either special equipment or manual stress by the examiner, who exposes himself to ionizing radiation. Maximum talar tilt can only be obtained with general anesthesia. The TTT does not provide information regarding the ATF, the most commonly torn ligament. The talar tilt must be twice the physiological talar tilt of the normal opposite ankle before a diagnosis of lateral ligament disruption can be made. The ADT is more reliable and specific with respect to ATF damage, and no anesthetic is needed for the study. A positive ADT along with 15' of TTT strongly suggests double ligament rupture. Ankle a r t h r ~ g r a p h y , peroneal ~ ~ . ~ ~ tenography, along with TTT and ADT stress testing, may help to elucidate a confusing clinical presentation. Dye escaping from, or flowing into, the peroneal tendon sheath during contrast studies is the only valid evidence of a torn CF ligament.'I8 TREATMENT
Treatment options vary greatly among the various groups and individuals reporting their experience with acute lateral ankle injuries. Grade I sprain is defined as an injury in which some fibers within the ligament are stretched, but the ligament itself remains intact with no evidence of laxity. These sprains usually present clinically with no evidence of ecchymoses. This level of sprain can be expected to do well regardless of treatment. This includes rest, protected weight bearing, compression air Unna boots," and adhesive trapping.^^,^' In the past, some clinicians had treated
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this grade of ligament damage with Novocaine," lidocaine-hyaluronidase, and hydrocortisone injection^.^' This is no longer generally rec~mmended.'~ Grade II sprains involve partial tear of the fibers of the CF and ATF with some sign of mild laxity, but overall good stability. Accepted treatment uses some form of immobilization for varying lengths of time, followed by aggressive rehabilitation with peroneal strengthening and proprioceptive exercises. Grade Ill sprains reveal a complete rupture of the CF and ATF ligaments with extensive swelling and ecchymoses. It has been described as a self-reduced dislocation. The ankle joint is unstable and the extent of damage is readily apparent with stress testing and contrast studies. A brief survey of the literature from the last 30 years gives one an appreciation of the trends in conservative and surgical management of these substantial injuries. Ruth,65 in 1961, recommended surgical repair of acutely ruptured ligaments followed by 6 weeks of cast immobilization. On follow-up examination 2% years later, 73% of the operative and 37% of the conservative groups returned for evaluation. He concluded that overall surgical repair yielded better results. in 1965, proposed 6 weeks of cast treatment; in 1972 he reported that 59% of the patients treated in plaster were totally In 1975, dissatisfied with his earlier results, he recommended open repair in young, serious athletes. With this protocol he achieved 89% total recovery.74 Brostrom, in 1966," wrote a classic series of articles regarding ankle ligament injuries. He noted that although surgical repair gave the best long-term results, it could not be recommended for routine treatment. He stated that a secondary repair could be performed even years later. He felt operative repair should be reserved for athletes. Niedermanet al.,58in 1981, studied 209 patients with acute ligament injury. All had positive arthrograms which verified complete rupture of the lateral complex. A short-leg nonweight-bearing cast was worn for 5 weeks in 107 cases. Immediate surgical repair was undertaken in 102 patients, followed by a short-leg cast for 5 weeks. Good results were found in 76% of the nonoperative cases and 81O/O of the injuries treated with surgery. Brand and Collins,' in 1982, proposed open repair if there was significant talar tilt, avulsion fracture from the tip of the fibula, osteochondral fracture of the talus, or if the patient was an athlete. Only 12% of the patients treated in his private practice required surgery. Evans et al.,24in 1984, published a prospective study to determine whether operative repair of a fresh lateral ankle ligament injury had any advantage over treatment in a short-leg walking cast.
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He used stress tenography to identify rupture of the ATF and CF ligaments. His population of 100 patients was divided into two closely matched groups of 50 patients. One group was treated with surgical repair and a short-leg cast, while the other group was treated in a short-leg cast without surgery. Both groups were allowed to bear weight as tolerated. He concluded that at the end of 2 years there was no evidence that operative repair offered improved symptomatic or functional benefit. Kelikian and Kelikian,43in 1985, suggested that the torn margins of a ligament that spans only one joint and has a good supply from fusion with the joint capsule will heal faster when the edges are brought together than a discrete, rounded, extra-articular ligament which spans two joints. He prescribed cast immobilization for 5 weeks for ATF injury and added another 3 weeks if the CF was ruptured. He kept the foot everted and at right angles to the leg. Arendt,‘ in 1989, recommended that all ankle ligament injuries, regardless of the grade of instability, should be treated with immobilization for a variable amount of time depending on the examination of the ankle on routine office visits. She felt that stress films might be more meaningful at the end of treatment. Aggressive rehabilitation in the form of peroneal strengthening and proprioceptive exercises was part of the postinjury management. Other writers have agreed with these Vahvanen et al.77,78published two reports in 1983 and 1984 in the European literature regarding open repair of ligament injuries in children. His patients ranged in age from 5 to 14 years. His previous experience had revealed that 42% of conservatively treated cases continued to have functional instability at 18 month follow-up. His operative criteria included severe swelling, pain over the ATF, limping, a displaced avulsion fracture from the distal tip of the fibula, and clinical instability. Only three ankles were examined with arthrography. Surgery was always indicated if the fibular avulsion fracture was present. In 40 acutely injured ankles, he found avulsion fragments in 19 and isolated ruptures of the ATF without bone or cartilage involvement in 17. All operated ankles were symptom-free by 6 to 21 months. Hamilton,35in 1982, described the particular problems in managing lateral ankle ligament injuries in ballet dancers and members of the performing arts. He indicated that these performers placed a high demand on their joints and required maximum opportunity for healing with no residual instability. The career of a professional dancer could be terminated with a disabling ankle injury. He recommended open repair of Grade Ill
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sprains. Another factor leading toward open repair is the inadvisability of using a dancer’s peroneus brevis tendon for reconstruction in chronic instability. His program included open repair, cast immobilization, and rehabilitation for peroneal strengthening. Cetti14 placed all his patients with Grade Ill sprains on nonweight-bearing crutches for 3 weeks. He reported good results with this program. He and other a u t h o r ~ ~subscribe ~ , ~ ’ to the theory that an ankle sprain is primarily a proprioceptive defect and will respond well to early mobilization followed by protected weight bearing as tolerated. CONCLUSIONS
In a busy general orthopaedic practice, acute sprains of the lateral ankle ligament complex are a frequent, if not daily, patient complaint. Often, these injuries are added onto an already overloaded office schedule. It behooves the practitioner to be able to efficiently evaluate these injuries and propose a rational treatment plan. Often, the ankle will be quite swollen with generalized tenderness to palpation. The trauma may have occurred several days before the patient finally is examined by an orthopaedist. He may have been placed into a splint in the emergency room, or he may have limped on the ankle since the sprain. Under these circumstances, stress x-rays under general anesthesia, arthrograms, and peroneal tenograms may be impractical. There is simply not enough time in the average practice to perform extensive evaluation on patients who often are quite uncomfortable. Hospital x-ray facilities usually cannot provide contrast studies on frequent short notice. Since a large majority of Grade 111 sprains do well without surgery,5~’3~‘5*’8~24.28-30~37.52 the following treatment protocol is submitted. In those patients in whom the ankle has little or no evidence of clinical instability implying a Grade I or a Grade II sprain, treatment would consist of some form of immobilization and protected weight bearing for an amount of time determined by the patient’s clinical improvement. This period of protection would be followed by a program of range of motion exercises and peroneal strengthening. When a Grade Ill sprain is suspected, stress x-rays and contrast studies can be performed on an individual basis, depending on how much information the surgeon requires to establish prudent treatment for that particular ~ a t i e n t . ~ ’ The ankle should then be immobilized in a short-leg walking cast or cast-brace for 3 to 6 weeks.69If the joint is placed into neutral or slight dorsiflexion, it will allow better coaptation of the damaged ligaments.
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After appropriate immobilization, rehabilitation becomes a significant factor in returning an injured ankle to full functional capacity. The lateral ankle ligaments do not have sufficient strength to provide complete joint stability without the Together the support of the peroneal lateral ligaments and the lateral compartment muscles resist inversion stresses. The peroneal complex is often stretched and torn with severe sprains and will atrophy after injury. It has been shown5' that more than 50% of patients with multiple ankle sprains do not have ligament laxity, but have instead peroneal weakness. Patients, whose ankle laxity has been confirmed by x-ray studies, become more stable and comfortable by peroneal strengthening alone.29s3o The concept of inversion restraint provided by the lateral peroneal complex is augmented by electromyogram studies documenting an 80% incidence of peroneal nerve damage in Grade Ill sprains. The trauma from nerve stretching produced denervation potentials that lasted up to 6 months postinjury.60 A modified R ~ m b e r gtest ~ ~ (balancing ,~~ on one leg with eyes closed), is helpful in diagnosing peroneal muscle weakness and decreased proprioception. For these reasons, physical therapy should be directed toward inversion-eversion strengthening and neuromuscular coordination. The goal is to decrease muscle weakness and re-establish protective reflexes. In summary, the tide of orthopaedic knowledge has carried the treatment of acute ankle sprains from primary surgical repair to primarily aggressive rehabilitation after conservative treatment. The majority of patients with lateral restraint damage seem to do well with this protocol. Surgical treatment of Grade Ill sprains should be reserved for competitive athletes and members of the performing art^.'^,''^^^,^^ Surgical indications must be individualized. The European experience with open repair of acute ligament injury in children has not been matched in North America and the advisability of surgical repair in this age group is not yet resolved. REFERENCES Anderson, K. J., and Lecocq, J. F.: Operative treatment of injury to the fibular collateral ligament of the ankle. J. Bone Joint Surg., 36A:825-832,1954. Arendt, E.: Inversion injuries to the ankle. Surgical Rounds for Orthopaedics, June:l5-22, 1989. Attarian, D. E., McCrackin, H. J., DeVito, D. P., McElhaney, J. H., and Garrett, W. E.: Biomechanical characteristics of human ankle ligaments. Foot Ankle, 6(2):54-58, 1985. Balduini, F. C., Vegso, J. J., Torg, J. S., and Torg, E.: Management and rehabilitation of ligamentous injuries to the ankle. Am. J. Sports Med., 4:365-380, 1987.
Foot & Ankle/Vol. 11, No. 2lOctober 1990 5. Black, H.: Roentgenographic considerations. Am. J. Sports Med., 5(6):238-240, 1977. 6. Black, H. M., Brand, R. L., and Eichelberger,M. R.: An improved technique for the evaluationof ligamentousinjury in severe ankle sprains. Am. J. Sports Med., 6(5):276-282, 1978. 7. Bonnin, J. F.: Radiologic diagnosis of recent lesions of the lateral ligament of the ankle. J. Bone Joint Surg., 31B:478, 1949. 8. Brand, R. L., and Collins, M. D. F.: Operative management of ligamentous injuries to the ankle. Clinics in Sports Medicine, 1(1):117-130, 1982. 9. Brostrom, L.: Sprained ankles I-Anatomic lesions in recent sprains. Acta Chir. Scand., 128:483-495, 1964. 10. Brostrom, L.: Sprained ankles Ill-Clinical observationsin recent ligament ruptures. Acta Chir. Scand., 130560-569, 1965. 11. Brostrom, L.: Sprained ankles IV-Treatment and prognosis in recent ligament ruptures. Acta Chir. Scand., 132537-550,1966, 12. Cass, J. R., and Morrey, B. F.: Ankle instability: current concepts, diagnosis, and treatment. Mayo Clinic Proc., 59:165-170, 1984. 13. Cass, J. R., Morrey, 8. F., Yoshihisa, K., and Chao, E. Y. S.: Ankle instability: comparison of primary repair and delayed reconstruction after long-term follow-up study. Clin. Orthop., 198:llO-117,1985. 14. Cetti, R.: Conservativetreatment of injury to the fibular ligaments of the ankle. Br. J. Sports Med., 16(1):47-52, 1982. 15. Chrisman, 0. D., and Snook, G. A.: Reconstruction of lateral ligament tears of the ankle. J. Bone Joint Surg., 51A904-912, 1969. 16. Cox, J. S.: Surgical treatment of ankle sprains. Am. J. Sports Med. 5(6):250-251, 1977. 17. Cox, J. S., and Hewes, T. F.: "Normal" talar tilt angle. Clin. Orthop., 14037-41,1979, 18. Cox, J. S.: Surgical and nonsurgical treatment of acute ankle sprains. Clin. Orthop., 198:118-126, 1985. 19. Dias, L. S.: The lateral ankle sprain: an experimental study. The Journal of Traums, 19(4):266-269, 1979. 20. Dory, M. A.: Arthrography of the ankle joint in chronic instability. Skeletal Radiology, 15291-294, 1986. 21. Drez, D., Young, J. C., Waldman, D., Shackleton, R., and Parker, W.: Nonoperative treatment of double lateral ligament tears of the ankle. Am. J. Sport Med., 10:197-200, 1982. 22. Emerson, R.: Surgical treatment of third degree lateral ankle ligament ruptures to ensure stability. J. Am. Orthop. Assoc., 78:273-280, 1978. 23. Evans, G. A., and Frenyo, S. D.: The stress tenogram in the diagnosis of ruptures of the lateral ligament of the ankle. J. Bone Joint Surg., 6183347-351, 1979. 24. Evans, G. A., Hardcastle, P., and Frenyo, A. D.: Acute rupture of the lateral ligament of the ankle. J. Bone Joint Surg., 668:209212, 1984. 25. Eyring, E. J., and Guthrie, W. D.: A surgical approach to the problem of severe lateral instability at the ankle. Clin. Orthop., 206~185-191,1986. 26. Fordyce, A. J. W., and Horn, C. V.: Arthrography in recent injuries of the ligaments of the ankle. J. Bone Joint Surg., 548:116-121, 1972. 27. Fowler, P. J.: Ligamentous anatomy and physical examination. Am. J. Sports Med., 5(6):229-230, 1977. 28. Freeman, M. A. R.: Instability of the foot after injuries to the lateral ligament of the ankle. J. Bone Joint Surg., 47B669-676, 1965. 29. Freeman, M. A. R.: Treatment of ruptures of the lateral ligament of the ankle. J. Bone. Joint Surg., 47B661-668, 1965. 30. Freeman, M. A. R., Dean, M. R. E., and Hanham, 1. W. D.: The etiology and prevention of functional stability of the foot. J. Bone Joint Surg., 47B678-685, 1965.
Foot & AnkleJVol. 11, No. 2JOctober 1990 31. Funder, V., Jorgensen, J. P., Andersen, A., Andersen, S. B., Lindholmer, E., Niedermann, B., and Vuust, M.: Ruptures of the lateral ligaments of the ankle. Acta Orthop. Scand., 534:9971000,1982. 32. Garrick, J. G.: The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am. J. Sports Med., 5(6):241242,1977. 33. Glasgow, M., Jackson, A., and Jamieson, A. M.: Instability of the ankle after injury to the lateral ligament. J. Bone Joint Surg., 628196-200,1980, 34. Gould, N., Seligson, D., and Gassman, J.: Early and later repair of lateral ligament of the ankle. Foot Ankle, 1(2):84-89, 1980. 35. Hamilton, W. G.: Sprained ankles in ballet dancers. Foot Ankle, 3(2):99-104, 1982. 36. Hardaker, W. T., Margello, S., and Goldner, J. L.: Foot and ankle injuriesin theatrical dancers. Foot Ankle, 6(2):59-69,1985. 37. Harrington, K. D.: Chronic ankle instability: what it is and what can be done for it. J. MusculoskeletalMed., April:36-63,1989. 38. Henning, C. E., and Egge, L. N.: Cast brace treatment of acute unstable lateral ankle sprain. Am J. Sports Med., 5(6):252-255, 1977. 39. Henry, J. H.: Lateral ligament tears of the ankle. Orthop. Rev., 12(10):31-39, 1983. 40. Jackson, J. P., and Hutson, M. A.: Cast brace treatment of ankle sprains. Injury, 17(4):251-255, 1986. 41. Johannsen, A.: Radiological diagnosis of lateral ligament lesion of the ankle. Acta Orthop. Scand., 49:295-301, 1978. 42. Johnson, E. E., and Markolf, K. L.: The contribution of the anterior talofibular ligament to ankle laxity. J. Bone Joint Surg., 65A:81-88, 1983. 43. Kelikian, H., and Kelikian, A. S.: Disorders of the Ankle. Philadelphia, W. B. Saunders, 1985. 44. Korkala, D., Lauttamus, L., and Tanskanen, P.: Lateral ligament injuries of the ankle. Results of primary surgical treatment. Annales Chirurgiae et Gynaecologiae, 71:161-163, 1982. 45. Korkala, D., Rusanen, M., Jokipii, P., Kytomaa, J., and Avkianen, V.: A prospective study of the treatment of severe tears of the lateral ligament of the ankle. SCOT, 11:13-17, 1987. 46. Kostiainen, S., Ylonen, K., and Merikoski, Y.: Primary operative treatment of the ruptured lateral ligament of the ankle. Annales Chirugiae et Gynaecologiae, 70:313-315, 1981. 47. deleted in press. 48. Lahde, S., Putkonen, M., Puranen, J., and Raatikainen, T.: Examination of the sprained ankle: anterior drawer test. Eur. J. Radiol., 8255-257, 1988. 49. Laurin, C. A., Ouellet, R., and St.-Jacques, R.: Talar and subtalar tilt: An experimental investigation. Can. J. Surg., 2(2):270-279, 1968. 50. Lightowler, C. D. R.: Injuries to the lateral ligament of the ankle. Br. Med. J., 289:1247, 1984. 51. Linde, F., Hvass, I., Jurgensen, U., and Madsen, F.: Early mobilizing treatment in lateral ankle sprains. Scand. J. Rehab. Med., 18:17-21, 1986. 52. Lindenfield, T. N.: The differentiation and treatment of ankle sprain. Orthopaedics,2(1):203-106, 1988. 53. Lindstrand, A., and Mortensson, W.: Anterior instability in the ankle joint following acute lateral sprain. Acta RadiologicaDiagnosis, 18:FASC 5529-539, 1977. 54. Linstrand, A., Mortensson, W., and Norman, 0.: Talofibular compartment of the ankle joint after recent ankle sprain. Acta Radiologica Diagnosis, 19:FASC 52347-852, 1978. 55. MacCartee, C. C.: Taping treatment of severe inversion sprains of the ankle. Am. J. Sports Med., 5(6):246-247, 1977. 56. McCullough, C. J.: Rotatory stability of the load-bearing ankle.
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J. Bone Joint Surg., 628:460-464, 1980. 57. Muwanga, C. L., Quinton, D. N., Sloan, J. P., Gillies, P., and Dove, A. F.: A new treatment of stable lateral ligament injuries of the ankle joint. Injury, 17(6):380-382, 1986. 58. Niedermann, B., Andersen, A., Andersen, S. B., Funder, V., Jorgensen, J. P., Lindholmer, E., and Vuust, M.: Rupture of the lateral ligaments of the ankle: operation or plaster cast? Acta Orthop. Scand., 52:579-567,1981. 59. Nilsson, S.: Sprains of the lateral ankle ligaments. Journal of the Oslo City Hospitals, Jan-Mar:l6-36, 1983. 60. Nitr, A. J., Dobner, and J. J., Kersey, D.: Nerve injury and grades II and 111 ankle sprains. Am. J. Sports Med., 13(3):177182,1985. 61. Olson, R. W.: Ankle arthrography. Radiologic Clinics of North America, 19(2):255-268, 1981. 62. Pointer, J.: Using an Unna's boot in treating ligamentous ankle injuries. The Western Journal of Medicine, Augusk257-259, 1983. 63. Rengstrom, P., Wertz, M., Incavo, S., Pope, M., Ostgaard, H. C., Arms, S., and Haugh, L.: Strain in the lateral ligaments of the ankle. Foot Ankle, 9(2):59-63, 1988. 64. Rubin, G., and Witten, M.: The talar tilt angle and the fibular collateral ligaments. J. Bone Joint Surg., 42A:311-326, 1960. 65. Ruth, C. J.: The surgical treatment of injuries of the fibular collateral ligaments of the ankle. J. Bone Joint Surg., 43A229239, 1961. 66. St. Pierre, R., Allman, F., Bassett, F. H., Goldner, J. L., and Fleming, L. L.: A review of lateral ankle ligamentous reconstructions. Foot Ankle, 3(2):114-123, 1982. 67. Sammarco, J.: Biomechanics of the ankle. Am. J. Sports Med., 5(6):231-234, 1977. 68. Seligson, D., Gassman, J., and Pope, M.: Ankle instability: Evaluationof the lateral ligaments. Am. J. Sports Med., 8(1):3942, 1980. 69. Simon, R. R., Hoffman, J. R., and Smith, M.: Radiographic comparison of plain films in second and third degree ankle sprains. Am. J. Emergency Med., 4(5):387-389, 1986. 70. Smith, R. W., and Reischl, S. F.: Treatment of ankle sprains in young athletes. Am. J. Sports Med., 14(6):465-471, 1986. 71. Smith, R. W., and Reischl, S.: The influence of dorsiflexion in the treatment of severe ankle sprains: an anatomical study. Foot Ankle, 9( 1):28-33, 1988. 72. Staples, 0. S.: Ligamentous injuries of the ankle joint. Clin. Orthop., 42:21, 1965. 73. Staples, 0. S.: Result study of ruptures of lateral ligaments of the ankle. Clin. Orthop., 8550-58, 1972. 74. Staples, 0. S.: Ruptures of the fibular collateral ligaments of the ankle. J. Bone Joint Surg., 57A:101-107, 1975. 75. Stormont, D. M., Morrey, B. F., An, K. N., and Cass, J. R.: Stability of the loaded ankle. Am. J. Sports Med., 13(5):295300,1985. 76. Stover, C. N.: Air stirrup management of ankle injuries in the athlete. Am. J. Sports Med., 8(5):360-365, 1980. 77. Vahvanen, V., Westerlund, M., and Kajanti, M.: Sprained ankle in children. Annales Chirugiae et Gynaecologiae, 72:71-75, 1983. 78. Vahvanen, V., Westerlund, M., and Nikku, R.: Lateral ligament injury of the ankle in children. Acta Orthop. Scand., 5521-25, 1984. 79. Walsh, W. M., and Blackburn, T.: Prevention of ankle sprains. Am. J. Sports Med., 5(6):243-245, 1977. 80. Zoltan, J. D.: Treatment of ankle sprains with joint aspiration, Xylocaine infiltration, and early mobilization. J. Trauma, 17(2):93-96, 1977.
Foot Fellows Review Acute Lateral Ankle Ligament Injuries: A Literature Review Peter M. Boruta, M.D.,* John 0. Bishop, M.D.t, W. Grant Braly, M.D.,*, and Hugh S. Tullos, M.D.9 Houston, Texas
terior talofibular (PTF) ligaments. Included in this group should be the lateral talocalcaneal (LTC) ligament.’ The ATF is a thickening of the anterior ankle joint capsule, and blends its fibers intimately with the CF and LTC ligaments. A rupture of the ATF will produce a tear in the joint capsule with concomitant hemarthrosis of the ankle joint and ecchymoses from the subcutaneous extravasation of hemorrhage. The CF ligament is extra-articular, but is closely associated with the peroneal tendon sheath. A rupture of this ligament will often tear the tendon sheath and occasionally damage the peroneal tendons. The PTF connects the posterolateral tubercle of the talus to the medial aspect of the lateral malleolus. The LTC ligament extends from the talus to the calcaneus and blends its fibers with those of the CF and ATF. Any discussion of the lateral stability of the ankle joint can be confined to the three major lateral ligaments, but one must realize that lateral stability is only part of a continuum of total ankle integrity. With increasing force, other ligaments become damaged. It has been noted that lateral ligament injuries can be associated with disruption of the anterior tibiofibular, the interosseous, and deltoid ligament^.^' This spectrum may end with peritalar dislocation.
ABSTRACT The average general orthopaedic surgeon examines and treats a considerable number of acute lateral ankle ligament sprains in a busy office practice. A cursory review of recent articles published on this subject will present a confusing picture regarding diagnosis and treatment of Grade 111 injuries. An air of controversy surrounds the interpretation of diagnostic x-rays, and the management of these common ankle problems. This review article is presented to summarize current thoughts on the anatomy, biomechanics, diagnosis, and treatment of acute lateral ankle ligament sprains. INCIDENCE
Ankle ligament sprains are the most common musculoskeletal complaint in the emergency room, and comprise a goodly portion of private office practice. Most ankle sprains occur in the 15- to 35-year-old athlete involved in basketball,’ football, and womens’ cross country. They produce fully 25% of all time-loss injuries in these events. Ankle ligament injury is the most common trauma in modern dance and classical ballet.36One-third of West Point cadets can expect an ankle sprain during their 4-year term.4 In a large series correlating trauma and different sports, only tennis produced no ankle inj~ries.~‘
MECHANICS
ANATOMY
When the ankle joint is in neutral position, the CF ligament is almost perpendicular to the long axis of the talus. Its anterior fibers are under tension, which increases with dorsiflexion. The ATF ligament in this position is parallel to the long axis of the talus, and is not under tension. As the ankle is plantarflexed, the CF fibers become more relaxed, while the ATF fibers become more tense.” The ATF and CF ligaments are synergistic; when one ligament is relaxed, the other is tense, and vice versa.63 Under dynamic load testing, the ATF was found to
The lateral ankle ligament complex consists of the anterior talofibular (ATF), calcaneofibular (CF), and posFrom the Baylor College of Medicine, Division of Orthopedic Surgery, Houston, Texas. Fellow, Section of Foot and Ankle Surgery. t’ Chief, Section of Foot and Ankle Surgery. Clinical instructor. 5 Head, Division of Orthopedic Surgery. To whom all correspondence should be sent at: Baylor College of Medicine, Division of Orthopedic Surgery, 6550 Fannin, Suite 2625, Houston, Texas
*
77030. 107
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have the weakest tensile strength, followed by the PTF and CF ligaments. The deltoid ligament has the highest load to f a i l ~ r e . ~ The ATF is the primary stabilizer to ankle inversion in plantar flexion in the unloaded joint. It is the first ligament to be torn in an inversion injury regardless of the position of the ankle. When the ankle joint is subjected to an inversion, plantar flexion moment, the lateral joint capsule tears first, followed by rupture of the ATF.66After complete tear of the ATF, the CF fibers will be disrupted, followed by a variable injury to the PTF, and, with increasing force, the deltoid ligament. In neutral position, under an inversion force, a partial tear of the CF may O C C U ~ . ’ ~ C O X ’thought ~ that the anterior tibiofibular ligament would sustain a variable injury before the CF was involved. Brostromghad noted similar rupture patterns in his series. In 1985, the work of Stormont et al.75 demonstrated the relationship between articular restraint, and primary and secondary ligament restraints. They found that ankle joint stability is composed of the mortise and tenon interlocking of the articular surfaces and the load strength of the supporting ligaments. The joint and ligaments alternate roles, being primary or secondary stabilizers, depending on ankle position and load. They stated that in unloaded internal rotation the ATF and deltoid ligaments are primary restraints. However, under load, the articular surface provides nearly as much stability as either primary restraint. In unloaded external rotation the CF is the only primary restraint. The PTF can function as a primary stabilizer, but only in the plantarflexed position. With loading in external rotation the articular surface again becomes important. In unloaded inversion the CF is the primary restraint, and the ATF is secondary in all tested positions. In loaded inversion no ligament contributed to stability; all restraint was articular. Unloadedeversion revealed the deltoid as the primary restraint in all positions. With loading all stability was, again, articular. The authors concluded that with physiologic weightbearing the articular surface could provide 30% of stability in rotation and 100% stability in version. This information suggests that rotation, rather than inversion displacement, may account for some types of clinically symptomatic ankle instability. It now appears that ankle destabilization occurs during loading and unloading, but the joint is stable once it is fully loaded. Other authors have also shown that ankle stability is enhanced by axial loading.56This stability is a function not only of the axial load, but also the “close-packed p ~ s i t i o n . ” ~When ’ - ~ ~ a joint is close-packed, its articular surfaces are compressed and fully congruent with maximal contact area. In the ankle joint full dorsiflexion
produces the close-packed Smith and Reisch17’ concluded in 1988 that maximum apposition of a divided ATF occurred with the ankle in dorsiflexion and not in eversion. Dorsiflexion also reduced and maintained the reduction of an anteriorly subluxed talus. DIAGNOSIS Physical Examination
Most patients with a sprain of the ankle will describe a “popping” or tearing sensation which was felt at the time of injury. Examination will reveal variable amounts of tenderness to palpation over the different ligaments. Ecchymoses may or may not be present.” Gentle stress maneuvers using the talar tilt test (TTT) and the anterior drawer test (ADT) may add more information regarding the extent of injury. Some authors feel that the ATF ligament can usually be accurately evaluated by clinical examination alone; stress x-rays are used when necessary to confirm clinical impression^.^^^^^^^^ Funder et aL3‘ in 1982 stated that swelling over the lateral malleolus was the most valuable diagnostic sign, especially if it was increased by 4 cm beyond the circumference of the normal ankle. With this amount of edema the probability of ligament rupture was 70%. If palpation of the CF produced pain, the chance of rupture was 72%. Tenderness of the ATF revealed 52% incidence of rupture. If both the CF and ATF were tender, and the swelling was greater than 4 cm, the possibility of major ligament damage increased to 91‘10. Funder et placed little value on the TTT and ATF. Other surgeons29feel that the amount of swelling does not correlate with the degree of injury, and pain response to palpation is too subjective. Hence, they perform stress x-rays to delineate the degree of ligament pathology. It has been proposed” that lateral ankle sprains be classified as: Grade I, mild stretching of the ligament and no instability; Grade 11, moderate but incomplete tear and mild instability; or Grade Ill, complete tear of the ATF and CF with gross laxity and instability. X-Ray Evaluation
Routine x-ray evaluation of the injured ankle generally provides few clues in determining the extent of llgament damage. in 1986, and Lindstrand et al.,54 in Simon et 1978, had stated that there is no clinically significant measurement oh plain ankle x-rays which could accurately differentiate between GrNe II and Grade Ill injuries.
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Eyring and G ~ t h r i e 'reported ~ that 2 to 3" of talar tilt could be noted on plain anteroposterior films without application of any stress. Glasgow et al.33explained that a chip fracture from the tip of the lateral malleolus implied avulsion of the CF ligament. Talar Tilt Test
This test is defined as the angle produced by the tibia1 plafond and the dome of the talus in response to forceful inversion of the hindfoot. The stress should be applied at the level of the calcaneocuboid or cubotarsal joints. This study is designed to reveal an incompetent CF ligament. There is wide disagreement on what constitutes normal tilt of the talus in the ankle. No consensus exists regarding abnormal tilt nor the methods of obtaining either value. A sampling of the literature displays the following range for normal talar tilt.
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B0nnin7: 0 to 15" indicated ATF rupture, 15 to 30" indicates ATF and CF rupture, >30" indicates ATF, CF, and PTF rupture. Cass and Morrey": 5" relative. Korkala et a/.44.45: 15" absolute, 10" relative. K r i ~ f i a n s e ngreater ~~: than 3" relative.
Seligson et aL6' concluded that the TTT was not reliable due to the wide range of normal and abnormal values and possible differences from left to right. Anterior Drawer Test
This study was designed to measure the integrity of the ATF. It is performed by producing anterior movement of the ankle relative to the distal tibia. Any subluxation is measured from the posterior lip of the tibia to the nearest articular surface of the talus. Some writers state that the test should be done with manual stress, others use sandbags or weights applied to the distal tibia for varying lengths of time. The use of a jig to position the ankle may produce more accurate results. Rubin and Witten64:Up to 23" in a normal ankle. The values for accepted normal subluxation are as Chrisman and Sn00ki5: 10" is the limit of normal. 9 'mm; Glasgow et al.336 mm; Gould follows: L a ~ r i n , ~ Cox and Hewes17:Talar tilt over 5" would indicate 3 ~to~4 mm; Johannsen4' and et al.344 mm; H a r ~ i n g t o n significant injury. Lightowler5' 2 mm. Seligson et al." reported that the ADT appears to The method of applying inversion stress also varies evaluate lateral ligament integrity of the ankle more considerably. Most writers recommend manual stress critically than the TTT. His studies were performed with to the point of patient pain tolerance." Cox and electromyogram monitoring of muscle activity. He deHewes17showed that the results obtained in this mancided that TTT and ADT evaluation was not a function ner do not vary in the same patient with different of muscle relaxation or of ankle position. Lindstrand examiners applying different amounts of force. Howand M o r t e n s ~ o nevaluated ~~ his patients with a disever, earlier authors26had stated that different examplacement index formulated for both TTT and ADT. iners produced variable results. Different authors indicate that the ADT is more reliable Discrepancy is found in the positioning of the lower than the TTT. Lahde et ah4' concluded that the ADT extremity for TTT. Published reports indicate that the was too unreliable for any decision regarding surgical ankle should be plantarflexed;2s38,25 others state that it repair. He endorsed the arthrogram as the study of should be kept at n e ~ t r a l . ~Many ~ ' ~ ' disagreements choice. about procedure exist. The knee must be f l e ~ e d ' . ' ~ . ~ ~ to relax the gastrocnemius, or the knee can be Ankle Arthrography extended33because tight gastrocs make no difference. In an effort to better quantify lateral ligament damage, The patient should be sitting2', or the patient lies supine various investigators recommend ankle arthr~graphy.~.~ on the table. The test is performed by the surgeon This involves injection of contrast material into the ankle himself7' or by a trained t e ~ h n i c i a neither ~ ~ , manually or joint. The timing of this study is critical; it should be in a special jig,49instrumented or not. Anesthesia is not performed within 24 hours, and certainly no later than req~ired~ to~obtain , ~ ~ useful , ~ ~ information, or meaning5 days after injury. Beyond this time frame the tear in ful values require anesthesia to limit muscle spasm and the joint capsule may be closed with blood clots or guarding.47Infiltration of local anesthetic33should suffibrin tissue, preventing extravasation of dye. It is noted, fice, but peroneal nerve b l o ~ k ~ ~at" the ~ ~ fibular ' head however, that Dory'' performed his studies as late as is better. Of course, the best relaxation and cooperation 2 to 4 weeks after injury. He could not correlate arthrois available only with genera126,28or anesgraphic findings with surgical lesions. thesia for stress testing. The disputes go on and on. Normally the injected contrast will remain within the The foregoing summary may explain the published joint capsule. In 6 to 10% of cases, the dye may flow values for abnormal talar tilt, either as an absolute into the tendon sheaths of the flexor hallucis longus, number or relative to the uninjured ankle.
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flexor digitorum longus, and the subtalar joint. Opacification of these structures is not pathological.'' The dye should not extend beyond the distal end of the lateral malleolus, nor should it flow more proximally than 5.5 cm22above the distal tip of the fibula. Any extravasation of contrast into the peroneal tendon sheath is abnormal. This occurs because of the close proximity of the CF to the joint capsule. In most ruptures of the CF, the medial layer of the peroneal tendon sheath is split longitudinally. If both the CF and ATF are torn, dye injected into the ankle cavity may flow into the peroneal structures. Sometimes the tear in the capsule is so large that there is insufficient pressure to force contrast into the sheath. At other times, the disruption of the sheath is small and dye will not enter. This explains the high incidence of false negative evaluation of the CF during ankle arthrography. However, contrast instilled into the peroneal tendon sheath will seep into the ankle joint if both the CF and ATF are torn. The test is negative if the dye remains within the sheath and does not extravasate. Kelikian and Kelikian43felt that the TTT has been replaced largely by the ADT and ankle arthrography. The TTT requires either special equipment or manual stress by the examiner, who exposes himself to ionizing radiation. Maximum talar tilt can only be obtained with general anesthesia. The TTT does not provide information regarding the ATF, the most commonly torn ligament. The talar tilt must be twice the physiological talar tilt of the normal opposite ankle before a diagnosis of lateral ligament disruption can be made. The ADT is more reliable and specific with respect to ATF damage, and no anesthetic is needed for the study. A positive ADT along with 15' of TTT strongly suggests double ligament rupture. Ankle a r t h r ~ g r a p h y , peroneal ~ ~ . ~ ~ tenography, along with TTT and ADT stress testing, may help to elucidate a confusing clinical presentation. Dye escaping from, or flowing into, the peroneal tendon sheath during contrast studies is the only valid evidence of a torn CF ligament.'I8 TREATMENT
Treatment options vary greatly among the various groups and individuals reporting their experience with acute lateral ankle injuries. Grade I sprain is defined as an injury in which some fibers within the ligament are stretched, but the ligament itself remains intact with no evidence of laxity. These sprains usually present clinically with no evidence of ecchymoses. This level of sprain can be expected to do well regardless of treatment. This includes rest, protected weight bearing, compression air Unna boots," and adhesive trapping.^^,^' In the past, some clinicians had treated
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this grade of ligament damage with Novocaine," lidocaine-hyaluronidase, and hydrocortisone injection^.^' This is no longer generally rec~mmended.'~ Grade II sprains involve partial tear of the fibers of the CF and ATF with some sign of mild laxity, but overall good stability. Accepted treatment uses some form of immobilization for varying lengths of time, followed by aggressive rehabilitation with peroneal strengthening and proprioceptive exercises. Grade Ill sprains reveal a complete rupture of the CF and ATF ligaments with extensive swelling and ecchymoses. It has been described as a self-reduced dislocation. The ankle joint is unstable and the extent of damage is readily apparent with stress testing and contrast studies. A brief survey of the literature from the last 30 years gives one an appreciation of the trends in conservative and surgical management of these substantial injuries. Ruth,65 in 1961, recommended surgical repair of acutely ruptured ligaments followed by 6 weeks of cast immobilization. On follow-up examination 2% years later, 73% of the operative and 37% of the conservative groups returned for evaluation. He concluded that overall surgical repair yielded better results. in 1965, proposed 6 weeks of cast treatment; in 1972 he reported that 59% of the patients treated in plaster were totally In 1975, dissatisfied with his earlier results, he recommended open repair in young, serious athletes. With this protocol he achieved 89% total recovery.74 Brostrom, in 1966," wrote a classic series of articles regarding ankle ligament injuries. He noted that although surgical repair gave the best long-term results, it could not be recommended for routine treatment. He stated that a secondary repair could be performed even years later. He felt operative repair should be reserved for athletes. Niedermanet al.,58in 1981, studied 209 patients with acute ligament injury. All had positive arthrograms which verified complete rupture of the lateral complex. A short-leg nonweight-bearing cast was worn for 5 weeks in 107 cases. Immediate surgical repair was undertaken in 102 patients, followed by a short-leg cast for 5 weeks. Good results were found in 76% of the nonoperative cases and 81O/O of the injuries treated with surgery. Brand and Collins,' in 1982, proposed open repair if there was significant talar tilt, avulsion fracture from the tip of the fibula, osteochondral fracture of the talus, or if the patient was an athlete. Only 12% of the patients treated in his private practice required surgery. Evans et al.,24in 1984, published a prospective study to determine whether operative repair of a fresh lateral ankle ligament injury had any advantage over treatment in a short-leg walking cast.
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He used stress tenography to identify rupture of the ATF and CF ligaments. His population of 100 patients was divided into two closely matched groups of 50 patients. One group was treated with surgical repair and a short-leg cast, while the other group was treated in a short-leg cast without surgery. Both groups were allowed to bear weight as tolerated. He concluded that at the end of 2 years there was no evidence that operative repair offered improved symptomatic or functional benefit. Kelikian and Kelikian,43in 1985, suggested that the torn margins of a ligament that spans only one joint and has a good supply from fusion with the joint capsule will heal faster when the edges are brought together than a discrete, rounded, extra-articular ligament which spans two joints. He prescribed cast immobilization for 5 weeks for ATF injury and added another 3 weeks if the CF was ruptured. He kept the foot everted and at right angles to the leg. Arendt,‘ in 1989, recommended that all ankle ligament injuries, regardless of the grade of instability, should be treated with immobilization for a variable amount of time depending on the examination of the ankle on routine office visits. She felt that stress films might be more meaningful at the end of treatment. Aggressive rehabilitation in the form of peroneal strengthening and proprioceptive exercises was part of the postinjury management. Other writers have agreed with these Vahvanen et al.77,78published two reports in 1983 and 1984 in the European literature regarding open repair of ligament injuries in children. His patients ranged in age from 5 to 14 years. His previous experience had revealed that 42% of conservatively treated cases continued to have functional instability at 18 month follow-up. His operative criteria included severe swelling, pain over the ATF, limping, a displaced avulsion fracture from the distal tip of the fibula, and clinical instability. Only three ankles were examined with arthrography. Surgery was always indicated if the fibular avulsion fracture was present. In 40 acutely injured ankles, he found avulsion fragments in 19 and isolated ruptures of the ATF without bone or cartilage involvement in 17. All operated ankles were symptom-free by 6 to 21 months. Hamilton,35in 1982, described the particular problems in managing lateral ankle ligament injuries in ballet dancers and members of the performing arts. He indicated that these performers placed a high demand on their joints and required maximum opportunity for healing with no residual instability. The career of a professional dancer could be terminated with a disabling ankle injury. He recommended open repair of Grade Ill
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sprains. Another factor leading toward open repair is the inadvisability of using a dancer’s peroneus brevis tendon for reconstruction in chronic instability. His program included open repair, cast immobilization, and rehabilitation for peroneal strengthening. Cetti14 placed all his patients with Grade Ill sprains on nonweight-bearing crutches for 3 weeks. He reported good results with this program. He and other a u t h o r ~ ~subscribe ~ , ~ ’ to the theory that an ankle sprain is primarily a proprioceptive defect and will respond well to early mobilization followed by protected weight bearing as tolerated. CONCLUSIONS
In a busy general orthopaedic practice, acute sprains of the lateral ankle ligament complex are a frequent, if not daily, patient complaint. Often, these injuries are added onto an already overloaded office schedule. It behooves the practitioner to be able to efficiently evaluate these injuries and propose a rational treatment plan. Often, the ankle will be quite swollen with generalized tenderness to palpation. The trauma may have occurred several days before the patient finally is examined by an orthopaedist. He may have been placed into a splint in the emergency room, or he may have limped on the ankle since the sprain. Under these circumstances, stress x-rays under general anesthesia, arthrograms, and peroneal tenograms may be impractical. There is simply not enough time in the average practice to perform extensive evaluation on patients who often are quite uncomfortable. Hospital x-ray facilities usually cannot provide contrast studies on frequent short notice. Since a large majority of Grade 111 sprains do well without surgery,5~’3~‘5*’8~24.28-30~37.52 the following treatment protocol is submitted. In those patients in whom the ankle has little or no evidence of clinical instability implying a Grade I or a Grade II sprain, treatment would consist of some form of immobilization and protected weight bearing for an amount of time determined by the patient’s clinical improvement. This period of protection would be followed by a program of range of motion exercises and peroneal strengthening. When a Grade Ill sprain is suspected, stress x-rays and contrast studies can be performed on an individual basis, depending on how much information the surgeon requires to establish prudent treatment for that particular ~ a t i e n t . ~ ’ The ankle should then be immobilized in a short-leg walking cast or cast-brace for 3 to 6 weeks.69If the joint is placed into neutral or slight dorsiflexion, it will allow better coaptation of the damaged ligaments.
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After appropriate immobilization, rehabilitation becomes a significant factor in returning an injured ankle to full functional capacity. The lateral ankle ligaments do not have sufficient strength to provide complete joint stability without the Together the support of the peroneal lateral ligaments and the lateral compartment muscles resist inversion stresses. The peroneal complex is often stretched and torn with severe sprains and will atrophy after injury. It has been shown5' that more than 50% of patients with multiple ankle sprains do not have ligament laxity, but have instead peroneal weakness. Patients, whose ankle laxity has been confirmed by x-ray studies, become more stable and comfortable by peroneal strengthening alone.29s3o The concept of inversion restraint provided by the lateral peroneal complex is augmented by electromyogram studies documenting an 80% incidence of peroneal nerve damage in Grade Ill sprains. The trauma from nerve stretching produced denervation potentials that lasted up to 6 months postinjury.60 A modified R ~ m b e r gtest ~ ~ (balancing ,~~ on one leg with eyes closed), is helpful in diagnosing peroneal muscle weakness and decreased proprioception. For these reasons, physical therapy should be directed toward inversion-eversion strengthening and neuromuscular coordination. The goal is to decrease muscle weakness and re-establish protective reflexes. In summary, the tide of orthopaedic knowledge has carried the treatment of acute ankle sprains from primary surgical repair to primarily aggressive rehabilitation after conservative treatment. The majority of patients with lateral restraint damage seem to do well with this protocol. Surgical treatment of Grade Ill sprains should be reserved for competitive athletes and members of the performing art^.'^,''^^^,^^ Surgical indications must be individualized. The European experience with open repair of acute ligament injury in children has not been matched in North America and the advisability of surgical repair in this age group is not yet resolved. REFERENCES Anderson, K. J., and Lecocq, J. F.: Operative treatment of injury to the fibular collateral ligament of the ankle. J. Bone Joint Surg., 36A:825-832,1954. Arendt, E.: Inversion injuries to the ankle. Surgical Rounds for Orthopaedics, June:l5-22, 1989. Attarian, D. E., McCrackin, H. J., DeVito, D. P., McElhaney, J. H., and Garrett, W. E.: Biomechanical characteristics of human ankle ligaments. Foot Ankle, 6(2):54-58, 1985. Balduini, F. C., Vegso, J. J., Torg, J. S., and Torg, E.: Management and rehabilitation of ligamentous injuries to the ankle. Am. J. Sports Med., 4:365-380, 1987.
Foot & Ankle/Vol. 11, No. 2lOctober 1990 5. Black, H.: Roentgenographic considerations. Am. J. Sports Med., 5(6):238-240, 1977. 6. Black, H. M., Brand, R. L., and Eichelberger,M. R.: An improved technique for the evaluationof ligamentousinjury in severe ankle sprains. Am. J. Sports Med., 6(5):276-282, 1978. 7. Bonnin, J. F.: Radiologic diagnosis of recent lesions of the lateral ligament of the ankle. J. Bone Joint Surg., 31B:478, 1949. 8. Brand, R. L., and Collins, M. D. F.: Operative management of ligamentous injuries to the ankle. Clinics in Sports Medicine, 1(1):117-130, 1982. 9. Brostrom, L.: Sprained ankles I-Anatomic lesions in recent sprains. Acta Chir. Scand., 128:483-495, 1964. 10. Brostrom, L.: Sprained ankles Ill-Clinical observationsin recent ligament ruptures. Acta Chir. Scand., 130560-569, 1965. 11. Brostrom, L.: Sprained ankles IV-Treatment and prognosis in recent ligament ruptures. Acta Chir. Scand., 132537-550,1966, 12. Cass, J. R., and Morrey, B. F.: Ankle instability: current concepts, diagnosis, and treatment. Mayo Clinic Proc., 59:165-170, 1984. 13. Cass, J. R., Morrey, 8. F., Yoshihisa, K., and Chao, E. Y. S.: Ankle instability: comparison of primary repair and delayed reconstruction after long-term follow-up study. Clin. Orthop., 198:llO-117,1985. 14. Cetti, R.: Conservativetreatment of injury to the fibular ligaments of the ankle. Br. J. Sports Med., 16(1):47-52, 1982. 15. Chrisman, 0. D., and Snook, G. A.: Reconstruction of lateral ligament tears of the ankle. J. Bone Joint Surg., 51A904-912, 1969. 16. Cox, J. S.: Surgical treatment of ankle sprains. Am. J. Sports Med. 5(6):250-251, 1977. 17. Cox, J. S., and Hewes, T. F.: "Normal" talar tilt angle. Clin. Orthop., 14037-41,1979, 18. Cox, J. S.: Surgical and nonsurgical treatment of acute ankle sprains. Clin. Orthop., 198:118-126, 1985. 19. Dias, L. S.: The lateral ankle sprain: an experimental study. The Journal of Traums, 19(4):266-269, 1979. 20. Dory, M. A.: Arthrography of the ankle joint in chronic instability. Skeletal Radiology, 15291-294, 1986. 21. Drez, D., Young, J. C., Waldman, D., Shackleton, R., and Parker, W.: Nonoperative treatment of double lateral ligament tears of the ankle. Am. J. Sport Med., 10:197-200, 1982. 22. Emerson, R.: Surgical treatment of third degree lateral ankle ligament ruptures to ensure stability. J. Am. Orthop. Assoc., 78:273-280, 1978. 23. Evans, G. A., and Frenyo, S. D.: The stress tenogram in the diagnosis of ruptures of the lateral ligament of the ankle. J. Bone Joint Surg., 6183347-351, 1979. 24. Evans, G. A., Hardcastle, P., and Frenyo, A. D.: Acute rupture of the lateral ligament of the ankle. J. Bone Joint Surg., 668:209212, 1984. 25. Eyring, E. J., and Guthrie, W. D.: A surgical approach to the problem of severe lateral instability at the ankle. Clin. Orthop., 206~185-191,1986. 26. Fordyce, A. J. W., and Horn, C. V.: Arthrography in recent injuries of the ligaments of the ankle. J. Bone Joint Surg., 548:116-121, 1972. 27. Fowler, P. J.: Ligamentous anatomy and physical examination. Am. J. Sports Med., 5(6):229-230, 1977. 28. Freeman, M. A. R.: Instability of the foot after injuries to the lateral ligament of the ankle. J. Bone Joint Surg., 47B669-676, 1965. 29. Freeman, M. A. R.: Treatment of ruptures of the lateral ligament of the ankle. J. Bone. Joint Surg., 47B661-668, 1965. 30. Freeman, M. A. R., Dean, M. R. E., and Hanham, 1. W. D.: The etiology and prevention of functional stability of the foot. J. Bone Joint Surg., 47B678-685, 1965.
Foot & AnkleJVol. 11, No. 2JOctober 1990 31. Funder, V., Jorgensen, J. P., Andersen, A., Andersen, S. B., Lindholmer, E., Niedermann, B., and Vuust, M.: Ruptures of the lateral ligaments of the ankle. Acta Orthop. Scand., 534:9971000,1982. 32. Garrick, J. G.: The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am. J. Sports Med., 5(6):241242,1977. 33. Glasgow, M., Jackson, A., and Jamieson, A. M.: Instability of the ankle after injury to the lateral ligament. J. Bone Joint Surg., 628196-200,1980, 34. Gould, N., Seligson, D., and Gassman, J.: Early and later repair of lateral ligament of the ankle. Foot Ankle, 1(2):84-89, 1980. 35. Hamilton, W. G.: Sprained ankles in ballet dancers. Foot Ankle, 3(2):99-104, 1982. 36. Hardaker, W. T., Margello, S., and Goldner, J. L.: Foot and ankle injuriesin theatrical dancers. Foot Ankle, 6(2):59-69,1985. 37. Harrington, K. D.: Chronic ankle instability: what it is and what can be done for it. J. MusculoskeletalMed., April:36-63,1989. 38. Henning, C. E., and Egge, L. N.: Cast brace treatment of acute unstable lateral ankle sprain. Am J. Sports Med., 5(6):252-255, 1977. 39. Henry, J. H.: Lateral ligament tears of the ankle. Orthop. Rev., 12(10):31-39, 1983. 40. Jackson, J. P., and Hutson, M. A.: Cast brace treatment of ankle sprains. Injury, 17(4):251-255, 1986. 41. Johannsen, A.: Radiological diagnosis of lateral ligament lesion of the ankle. Acta Orthop. Scand., 49:295-301, 1978. 42. Johnson, E. E., and Markolf, K. L.: The contribution of the anterior talofibular ligament to ankle laxity. J. Bone Joint Surg., 65A:81-88, 1983. 43. Kelikian, H., and Kelikian, A. S.: Disorders of the Ankle. Philadelphia, W. B. Saunders, 1985. 44. Korkala, D., Lauttamus, L., and Tanskanen, P.: Lateral ligament injuries of the ankle. Results of primary surgical treatment. Annales Chirurgiae et Gynaecologiae, 71:161-163, 1982. 45. Korkala, D., Rusanen, M., Jokipii, P., Kytomaa, J., and Avkianen, V.: A prospective study of the treatment of severe tears of the lateral ligament of the ankle. SCOT, 11:13-17, 1987. 46. Kostiainen, S., Ylonen, K., and Merikoski, Y.: Primary operative treatment of the ruptured lateral ligament of the ankle. Annales Chirugiae et Gynaecologiae, 70:313-315, 1981. 47. deleted in press. 48. Lahde, S., Putkonen, M., Puranen, J., and Raatikainen, T.: Examination of the sprained ankle: anterior drawer test. Eur. J. Radiol., 8255-257, 1988. 49. Laurin, C. A., Ouellet, R., and St.-Jacques, R.: Talar and subtalar tilt: An experimental investigation. Can. J. Surg., 2(2):270-279, 1968. 50. Lightowler, C. D. R.: Injuries to the lateral ligament of the ankle. Br. Med. J., 289:1247, 1984. 51. Linde, F., Hvass, I., Jurgensen, U., and Madsen, F.: Early mobilizing treatment in lateral ankle sprains. Scand. J. Rehab. Med., 18:17-21, 1986. 52. Lindenfield, T. N.: The differentiation and treatment of ankle sprain. Orthopaedics,2(1):203-106, 1988. 53. Lindstrand, A., and Mortensson, W.: Anterior instability in the ankle joint following acute lateral sprain. Acta RadiologicaDiagnosis, 18:FASC 5529-539, 1977. 54. Linstrand, A., Mortensson, W., and Norman, 0.: Talofibular compartment of the ankle joint after recent ankle sprain. Acta Radiologica Diagnosis, 19:FASC 52347-852, 1978. 55. MacCartee, C. C.: Taping treatment of severe inversion sprains of the ankle. Am. J. Sports Med., 5(6):246-247, 1977. 56. McCullough, C. J.: Rotatory stability of the load-bearing ankle.
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J. Bone Joint Surg., 628:460-464, 1980. 57. Muwanga, C. L., Quinton, D. N., Sloan, J. P., Gillies, P., and Dove, A. F.: A new treatment of stable lateral ligament injuries of the ankle joint. Injury, 17(6):380-382, 1986. 58. Niedermann, B., Andersen, A., Andersen, S. B., Funder, V., Jorgensen, J. P., Lindholmer, E., and Vuust, M.: Rupture of the lateral ligaments of the ankle: operation or plaster cast? Acta Orthop. Scand., 52:579-567,1981. 59. Nilsson, S.: Sprains of the lateral ankle ligaments. Journal of the Oslo City Hospitals, Jan-Mar:l6-36, 1983. 60. Nitr, A. J., Dobner, and J. J., Kersey, D.: Nerve injury and grades II and 111 ankle sprains. Am. J. Sports Med., 13(3):177182,1985. 61. Olson, R. W.: Ankle arthrography. Radiologic Clinics of North America, 19(2):255-268, 1981. 62. Pointer, J.: Using an Unna's boot in treating ligamentous ankle injuries. The Western Journal of Medicine, Augusk257-259, 1983. 63. Rengstrom, P., Wertz, M., Incavo, S., Pope, M., Ostgaard, H. C., Arms, S., and Haugh, L.: Strain in the lateral ligaments of the ankle. Foot Ankle, 9(2):59-63, 1988. 64. Rubin, G., and Witten, M.: The talar tilt angle and the fibular collateral ligaments. J. Bone Joint Surg., 42A:311-326, 1960. 65. Ruth, C. J.: The surgical treatment of injuries of the fibular collateral ligaments of the ankle. J. Bone Joint Surg., 43A229239, 1961. 66. St. Pierre, R., Allman, F., Bassett, F. H., Goldner, J. L., and Fleming, L. L.: A review of lateral ankle ligamentous reconstructions. Foot Ankle, 3(2):114-123, 1982. 67. Sammarco, J.: Biomechanics of the ankle. Am. J. Sports Med., 5(6):231-234, 1977. 68. Seligson, D., Gassman, J., and Pope, M.: Ankle instability: Evaluationof the lateral ligaments. Am. J. Sports Med., 8(1):3942, 1980. 69. Simon, R. R., Hoffman, J. R., and Smith, M.: Radiographic comparison of plain films in second and third degree ankle sprains. Am. J. Emergency Med., 4(5):387-389, 1986. 70. Smith, R. W., and Reischl, S. F.: Treatment of ankle sprains in young athletes. Am. J. Sports Med., 14(6):465-471, 1986. 71. Smith, R. W., and Reischl, S.: The influence of dorsiflexion in the treatment of severe ankle sprains: an anatomical study. Foot Ankle, 9( 1):28-33, 1988. 72. Staples, 0. S.: Ligamentous injuries of the ankle joint. Clin. Orthop., 42:21, 1965. 73. Staples, 0. S.: Result study of ruptures of lateral ligaments of the ankle. Clin. Orthop., 8550-58, 1972. 74. Staples, 0. S.: Ruptures of the fibular collateral ligaments of the ankle. J. Bone Joint Surg., 57A:101-107, 1975. 75. Stormont, D. M., Morrey, B. F., An, K. N., and Cass, J. R.: Stability of the loaded ankle. Am. J. Sports Med., 13(5):295300,1985. 76. Stover, C. N.: Air stirrup management of ankle injuries in the athlete. Am. J. Sports Med., 8(5):360-365, 1980. 77. Vahvanen, V., Westerlund, M., and Kajanti, M.: Sprained ankle in children. Annales Chirugiae et Gynaecologiae, 72:71-75, 1983. 78. Vahvanen, V., Westerlund, M., and Nikku, R.: Lateral ligament injury of the ankle in children. Acta Orthop. Scand., 5521-25, 1984. 79. Walsh, W. M., and Blackburn, T.: Prevention of ankle sprains. Am. J. Sports Med., 5(6):243-245, 1977. 80. Zoltan, J. D.: Treatment of ankle sprains with joint aspiration, Xylocaine infiltration, and early mobilization. J. Trauma, 17(2):93-96, 1977.
