Assessment of the lateral ligaments of the ankle after healed fractures

BACKGROUND: Lateral ligament complex injuries are difficult to diagnose immediately after ankle fracture, and treatment is focused on the fracture. This study examines the prevalence of ligamentous injuries after severe ankle fractures. METHODS: Lateral ligament instability can be revealed by inversion and anterior stress views after fracture healing. The results of 54 inversion and anterior stress examinations of the ankle after fracture healing, using a Telos stress device at 15 kPa force, were compared with uninjured ankles. RESULTS: No patient had 5 degrees or more of talar tilt or 6 mm or more of anterior displacement of the talus in uninjured ankles; however, in ankles with fractures, we found abnormal talar tilt angle in 12 and excessive anterior displacement in five. An abnormal inversion stress test was found to be considerably more common in the fractured ankles. CONCLUSION: Our study revealed that lateral ligament injuries may occur simultaneously with ankle fractures, with the most frequently injured being the calcaneofibular ligament.     

Lateral ankle triad: the triple injury of ankle synovitis, lateral ankle instability, and peroneal tendon tear

Many articles have been published that discuss various lateral ankle injuries and specific lateral ankle pathology. The purpose of this article is to explore and present a specific combination of findings that the author's multiphysician practice has noticed on a frequently recurring basis. The triple injury of ankle synovitis, ankle instability, and peroneal tendon tear can be termed the Lateral Ankle Triad. While it is common to find each of these specific injuries individually, they are often found in combination.     

Lauge-Hansen classification: a clockwork injury

The purpose of this article is to present the Lauge-Hansen classification of ankle injuries, in a simplified system according to clockwork function. By familiarization with this classification system, one will gain an invaluable tool in evaluating and treating ankle injuries.     

Behandlung akuter und chronischer Verletzungen der Peronäalsehnen

Peroneal tendon injuries are recognized with increasing frequency to be the cause of persistent lateral ankle symptoms. The lesions are frequently found in patients with concomitant anatomical or biomechanical abnormalities, such as chronic lateral instability or cavovarus deformity. The most common mechanism involves a sudden inversion injury or repetitive activities. Three categories of injuries can be distinguished: (1) tendinitis and tenosynovitis, (2) tendon subluxation and dislocation and (3) tendon tears and ruptures. Many of these conditions respond to conservative therapy. However, when left untreated, the disorders can lead to persistent lateral ankle pain and substantial functional deficits. This is particularly true in patients with an underlying anatomical predisposition to lesions.     

Delayed reconstruction of lateral complex structures of the ankle

Lateral ankle instability is one of the most common and well-recognized conditions presenting to foot and ankle surgeons. It may exist as an isolated entity or in conjunction with other concomitant pathology, making it important to appropriately diagnose and identify other conditions that may need to be addressed as part of treatment. These associated conditions may be a source of chronic pain, even when the instability has been appropriately treated, or may lead to failure of treatment by predisposing the patient to ankle inversion injuries. The primary goal of this editorial is to provide a brief summary of the common techniques used in the delayed reconstruction of lateral ankle ligamentous injuries and present a method we have successfully employed for over 15 years. We will also briefly discuss the diagnosis and treatment of the more common associated conditions, which are important to identify to achieve satisfactory results for the patient. We present the outcomes of 250 consecutive reconstructions performed over the last 10 years and describe our operative technique for addressing lateral ankle ligamentous injuries.     

Analysis of ankle-hindfoot stability in multiple planes: an in vitro study

BACKGROUND: It is necessary to have an understanding of ankle and hindfoot motion and stability to accurately diagnosis and treat ankle-hindfoot disorders. METHODS: We devised an ankle ligament testing apparatus to more critically determine ankle stability in all planes with a constant rotational force applied (inversion, eversion, internal rotation, external rotation) throughout the range of sagittal plane motion in 13 cadaver specimens. Three-dimensional kinematics were determined with a magnetic tracking device. RESULTS: With inversion force applied, calcaneal-tibial inversion was greatest in maximal plantarflexion (mean 22.1 +/- 6.0 degrees) and gradually decreased with dorsiflexion, which indicated that the ankle had the most inversion instability in plantarflexion. With eversion force applied, calcaneal-tibial eversion gradually increased with increasing dorsiflexion to 12.7 +/- 7.4 degrees indicating that the most eversion instability was in dorsiflexion. With internal rotation force applied, calcaneal-tibial internal rotation from plantarflexion to neutral ankle position increased. With external rotation force application, external rotation from neutral to maximal dorsiflexion increased. CONCLUSIONS: Ankle laxity was not constant but varied depending on the plantarflexion-dorsiflexion position and the direction of the applied force. The degree of ankle laxity was greater with inversion and internal rotation torque. Variation in laxity between specimens was observed, consistent with previous reports. These data indicate that the ankle is less stable in plantarflexion when inversion and internal rotation forces are applied. This may explain why the lateral ankle ligaments are most prone to injury in this position. The ankle was less stable in dorsiflexion when eversion and external rotation forces were applied. This is consistent with the observation that deltoid ligament injuries occur in the neutral to dorsiflexion position. The study demonstrates the importance of examining patients with suspected ankle ligament injuries in several ankle positions. The ankle testing device has potential application for in vivo testing of patients with suspected ankle ligament instability.     

Process and tubercle fractures of the hindfoot

Process and tubercle fractures of the talus and calcaneus can be a source of significant pain and dysfunction. Successful management requires extensive knowledge of the complex osseoligamentous anatomy of the hindfoot. The large posterior process of the talus is composed of a medial and a lateral tubercle; an os trigonum may exist posterior to the lateral tubercle. The talus has a lateral process that articulates with the fibula and subtalar joint; the calcaneus possesses a frequently injured anterior process that articulates with the cuboid. Injury to these hindfoot structures is caused by inversion and eversion of the ankle, which can occur during athletic activity. These injuries often are misdiagnosed as ankle sprains. A high degree of clinical suspicion is warranted, and specialized radiographs or other imaging modalities may be required for accurate diagnosis. Nonsurgical management with cast immobilization is frequently successful when the fracture is correctly diagnosed acutely. Large fragments may be amenable to open reduction and internal fixation. Untreated, chronic injuries can cause significant pain and functional impairment that may be improved substantially with late surgical intervention.     

Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series

STUDY DESIGN: Case series. BACKGROUND: Plantar flexion/inversion ankle sprains are one of the most frequently occurring sports injuries. Cuboid syndrome, which is difficult to diagnose, may result from a plantar flexion/ inversion ankle injury and could become the source of lateral ankle/midfoot pain. The objective of this case series is to describe the examination, evaluation, and treatment of the cuboid syndrome following a lateral ankle sprain. CASE DESCRIPTION: Seven patients were seen in our clinic 1 to 8 weeks following a lateral ankle sprain with a chief complaint of lateral ankle/midfoot pain. In these 7 patients, the presence of cuboid syndrome was identified independently by 2 examiners. Treatment consisted of a cuboid manipulation. OUTCOMES: All 7 patients returned to sports activities following 1 to 2 treatments consisting of the "cuboid whip" manipulation. No recurrence of symptoms was reported upon immediate return to competition or during the remainder of the season (mean follow-up, 5.7 months; range, 2 to 8 months). DISCUSSION: Based on those 7 patients, our results suggest that patients who are properly diagnosed with cuboid syndrome and receive the cuboid manipulation can return to competitive activity within 1 or 2 visits without injury recurrence.     

Isolated calcaneofibular ligament injuries treated with osteopathic manipulative treatment: A case series

This case series addresses several examples of isolated calcaneofibular ligament (CFL) injuries and potential mechanisms of injury. Though previously assumed to be an uncommon injury, it should be considered in patients that have ankle inversion injuries or post-inversion sequelae that do not fit the classic inversion sprain criteria. To injure only the CFL, the foot must be maximally stressed in dorsiflexion and pronation. Post-injury, the patient would have to use the foot in dorsiflexion and/or pronation to feel the injury, which is not part of a normal gait cycle. The application of Osteopathic Manipulative Treatment (OMT) to treating isolated calcaneofibular ligament injuries is instructive of the efficacy of the osteopathic approach in these cases and suggests that further research is warranted. It is possible that these injuries may be underreported. The data in one practice are analyzed.     

An alternative management protocol for lateral ankle sprains*

Soft tissue ankle injuries, particularly lateral ligament sprains, cause considerable disability and loss of time from activities. These injuries are commonly and frequently treated by physical therapists. Controversy exists over the efficacy of various methods for the nonoperative management of these injuries. A comprehensive program for the management of the lateral ankle sprain, involving the fabrication of a thermoplastic ankle stirrup and the initiation of a selfdirected home program of ankle rehabilitation using surgical tubing, is detailed. Based upon the experimental work of Brostrom, Noyes, and others, the early application of stress with protective motion has been found to facilitate the strength and structural integrity of healing ligaments. The ankle stirrup regimen allows weight bearing and easy removal for treatment or exercise. Joint stiffness, muscular atrophy, and circulatory stasis are minimized. The ankle stirrup provides an aggressive yet therapeutically sound approach to the management of this injury. J Orthop Sports Phys Ther 1981;2(4):187-190.     

Concomitant Lateral Ankle and Peroneal Tendon Instability Treated With Simultaneous Arthroscopic Broström and Tendoscopic Superior Peroneal Retinaculum Repair: A Case Report

Chronic lateral ankle instability is a prevalent condition, and it is commonly associated with other foot and ankle injuries. Among the associated injuries, peroneal tendon pathologies and anterolateral ankle impingement are frequently encountered. In this report, a case of concomitant chronic lateral ankle instability and dislocation of the peroneal tendons is described. While this combination of injuries is not uncommon, the method of treatment entailed arthroscopic repair of the anterior talofibular ligament and endoscopic repair of the superior peroneal retinaculum, procedures that eliminated the anterior drawer instability that had been present, and the patient remained symptom free after 24 months of follow-up.     

Ankle Fracture Associated With Rupture of the Achilles Tendon: Case Report and Review of the Literature

Solitary ankle fracture or Achilles Tendon (AT) rupture might not be an uncommon injury. However, concomitant ipsilateral ankle fracture with AT rupture is rare. The present report discusses this rare combination. A 30-year-old female had fallen while rock climbing and sustained a closed fracture of the medial malleolus with an ipsilateral complete AT rupture. Most of the reported cases had similar patterns, not only in terms of history, but also in terms of a similar fracture pattern. This rare combination of orthopedic injuries tends to occur when an abrupt excessive force is applied to the forefoot, with subsequent ankle hyperextension or hindfoot inversion. Imaging studies are useful both for confirming the injuries and for medicolegal and research purposes. Definitive treatment of the AT rupture is usually surgical in young active patients. Concomitant malleolar fractures can be managed conservatively or surgically, depending on the fracture configuration and degree of displacement. The importance of a thorough clinical examination in assessing the musculoskeletal and neurovascular structures in ankle injuries cannot be overemphasized. Knowledge of these injury patterns is crucial to reducing the incidence of residual morbidity such as ankle and foot weakness and loss of motion.     

Sports injuries in children and adolescents: etiology, epidemiology, and risk factors

Growing participation of children in sports has resulted in an increased incidence of sports injuries. Although methodological differences in epidemiologic studies largely prevent precise comparisons, it appears that young athletes participating in combat and contact sports seem to be more prone to injuries. Knee and ankle injuries are the most commonly encountered problems and chronic events are more prevalent than acute ones. The occurrence of athletic injuries is multifactorial and may present differences with respect to sex and the sports branch involved. An analytical approach of all relevant groups (parents, coaches, physical education teachers, health personnel) is necessary to understand, treat, and prevent athletic injuries in children.     

Assessment of acute ankle sprain with os subfibularein children

Children commonly present with acute inversion injuries of the ankle. Radiographs occasionally show small fragments under the tip of the lateral malleolus. The purpose of our study was to clarify their origin. A prospective standardized clinical examination and a magnetic resonance imaging were carried out. Among the 116 included patients, seven of them showed an os subfibulare. They presented more pains on the lateral ankle area than the other children. We found also more injuries on the anterior talofibular ligament. The os subfibulare could be secondary to an accessory ossification but the lateral area of the ankle would be likely to be injured.     

Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention

Syndesmosis injuries are rare, but very debilitating and frequently misdiagnosed. The purpose of this clinical commentary is to review the mechanisms of syndesmotic injuries, clinical examination methods, diagnosis, and management of the injuries. Cadaveric studies of the syndesmosis and deltoid ligaments are also reviewed for further understanding of stress transmission and the roles of different structures in stabilizing the distal syndesmosis. External rotation and excessive dorsiflexion of the foot on the leg have been reported as the most common mechanisms of injury. The injury is most often incurred by individuals who participate in skiing, football, soccer, and other sport activities played on turf. The external rotation and squeeze tests are reliable tests to detect this injury. The ability of imaging studies to assist in an accurate diagnosis may depend on the severity of the injury. The results of cadaveric studies indicate the importance of the deltoid ligament in maintaining stability of the distal tibiofibular syndesmosis and the congruency of the ankle mortise. Intervention programs with early rigid immobilization and pain relief strategies, followed by strengthening and balance training are recommended. Heel lift and posterior splint intervention can be used to avoid separation of the distal syndesmosis induced by excessive dorsiflexion of the ankle joint. Application of a rigid external device should be used with caution to prevent medial-lateral compression of the leg superior to the ankle mortise, thereby inducing separation of the distal syndesmosis articulation. Surgical intervention is an option when a complete tear of the syndesmotic ligaments is present or when fractures are observed.     

Acute rupture of the lateral ligaments of the ankle joint, diagnosis and surgical treatment.

A useful method for the diagnosis of acute rupture of the lateral ligament of the ankle joint is presented. Twenty-three patients with ruptures of the lateral ligament of the ankle joint were treated surgically with suture of the lateral ligaments of the ankle. Accurate preoperative diagnosis with stress films and arthrography under local anesthesia of the ankle joint is imperative. No instances of infection or other complications were observed. All patients achieved a normal range of ankle function within three to six months. Radiograhs of the injured ankle in the forced inversion position following operation showed full stability of the ankle joint. In our opinion, all ankle injuries should be examined roentgenographically with forced inversion of the foot. Tilting of the talus of at least 10 degrees must be followed by arthrography of the ankle joint under local anesthesia. If there is leakage of contrast material along the peroneal tendon sheaths and around the joint cavity, the lateral ligament of the ankle must be sutured immediately in order to regain stability of the ankle joint.     

Outcome of the functional treatment of first-time ankle inversion injury

Background  

Avulsion fractures of the lateral malleoli in ankle inversion injuries are often undetected on routine radiographs. Undetected avulsion fractures have been managed as ankle sprain, which may affect the outcome of the treatment of the ankle sprain. The purposes of this study are to compare the outcomes of functional treatment between the first-time severe ligament injury and avulsion fracture of the lateral ankle, and to investigate how the anterior talofibular ligament (ATFL) view or the calcaneofibular ligament (CFL) view affects the diagnosis of the avulsion fracture and outcome of functional treatment of the ankle inversion injury.     

Complications of lateral ankle ligament reconstruction

Complications after ankle ligament reconstruction are infrequent, but present significant challenges to the treating orthopaedist. Local wound problems and nerve injuries may cause difficulty in the early postoperative period. Recurrent instability may be attributable to failure of the operation, poor rehabilitation, reinjury, or unrecognized predisposing factors. Postoperative stiffness of the subtalar and ankle joints frequently is reported after anatomic and nonanatomic tenodesis procedures and may cause significant morbidity. The current author reviews reported complications and treatment options in failed lateral ankle ligament surgery.     

Ankle sprain complications: MRI evaluation

Sprains are disruptions of the ligamentous anatomy about a joint. The ankle sprain is one of the most common injuries seen in podiatric and orthopedic practice. It usually is incurred from an inversion force on the ankle, but eversion forces also can traumatize the ankle. Many times, this injury is taken for granted because of the frequency of its presentation. The patient usually is given appropriate initial care, but the patient can experience continued or residual pain. Podiatrists have found this problem is common and have come to recognize that secondary or accessory injuries occur that slow the natural recovery of this injury.