Syndesmotic ankle sprains in athletes

Ankle sprains are among the most common athletic injuries and represent a significant source of persistent pain and disability. Despite the high incidence of ankle sprains in athletes, syndesmosis injuries have historically been underdiagnosed, and assessment in terms of severity and optimal treatment has not been determined. More recently, a heightened awareness in sports medicine has resulted in more frequent diagnoses of syndesmosis injuries. However, there is a low level of evidence and a paucity of literature on this topic compared with lateral ankle sprains. As a result, no clear guidelines are available to help the clinician assess the severity of injury, choose an imaging modality to visualize the injury, make a decision in terms of operative versus nonoperative treatment, or decide when the athlete may return to play. Increased knowledge and understanding of these injuries by clinicians and researchers are essential to improve the prevention, diagnosis, and treatment of this significant condition. This review will discuss the anatomy, mechanism of injury, diagnosis, and treatment of syndesmosis sprains of the ankle while identifying controversies in management and topics for future research.     

Treatment of ankle sprains in young athletes

To study the incidence of fibulocollateral ligament ankle sprains in the young male athlete, a survey of 84 varsity basketball players was done. Seventy percent of the players had a history of an ankle sprain. Eighty percent of those with a positive history had multiple sprains. Most of the injuries were mild, but in 32% of the injuries, the athlete missed more than 2 weeks of play. No medical attention was sought in 55% of the cases. About 50% of the athletes with a sprain had residual symptoms from their injuries; 15% of the injured athletes felt that their residual symptoms compromised their playing performance. This article emphasizes the potential seriousness of the ankle sprain in the young athlete and presents a recommended method of management, including assessment of severity, treatment, and rehabilitation.     

Cryotherapy in ankle sprains

This study assesses recovery from ankle sprains. Thirty-seven final participants were categorized according to the severity of their injury and the use of cryotherapy (15 minutes, one to three times per day) versus heat therapy (15 minutes, one to three times per day) for a minimum of three days. Therapy commenced either less than one hour, from one to 36 hours, or greater than 36 hours after traumatic event. Sprains were graded into five categories based on severity of the injury, but only two categories, subject to conservative treatment, are considered in this study. The study showed that cryotherapy started within 36 hours after the injury was statistically more effective than heat therapy for complete and rapid recovery. Patients in a group with Grade four sprains (unable to bear weight because of pain) reached full activity in 13.2 days compared to 30.4 days in a group using cryotherapy initiated 36 hours after injury or to 33.3 days in a group using heat therapy. Therefore, early use of cryotherapy, continued with adhesive compression, is an effective treatment of ankle sprains yielding earlier complete recovery than late cryotherapy or heat therapy.     

Rehabilitation of ankle sprains

Ankle sprains occur as a result of many factors. The initial treatment of all sprains, controlling further damage and edema, is the same. Recovery rates vary depending on the severity of injury and chronicity of the problem. Because there are no established criteria correlating objective measures (for example, torque production, range of motion, swelling) and function, the clinician should not allow the athlete to participate in their respective activity until the ankle feels stable when stressed.     

Sensorimotor deficits with ankle sprains and chronic ankle instability

The presence of sensorimotor deficits in patients who have suffered ankle sprains or who have chronic ankle instability has been recognized for several decades; however, a body of research literature has developed that elucidates potential physiologic explanations for these deficits. Alterations in a spectrum of sensorimotor measures make it apparent that conscious perception of afferent somatosensory information, reflex responses, and efferent motor control deficits are present with ankle instability. The specific origin of these deficits local to the ankle ligaments or at the spinal or supraspinal levels of motor control have yet to be fully elucidated. It is clear, however, that both feedback and feedforward mechanisms of motor control are altered with ankle instability.     

Prevention of ankle sprains

Two different methods for the prevention of ankle joint injuries in soccer were tested. Coordination training on an ankle disk improves functional stability and postural control, whereas an orthosis provides mechanical support. Both techniques reduce the frequency of ankle sprains in soccer players with previous ankle problems. The orthosis is an alternative to taping, and can be used during the rehabilitation period after injury or when playing on uneven ground. Coordination training on an ankle disk ought to be included in the rehabilitation of ankle injuries to prevent functional instability. It may also be done prophylactically by players with previous ankle problems in order to break the vicious circle of recurrent sprains and feeling of giving way.     

The effect of a balance training program on the risk of ankle sprains in high school athletes

BACKGROUND: Ankle sprains are the most common musculoskeletal injuries that occur in athletes, and they have a profound impact on health care costs and resources. HYPOTHESIS: A balance training program can reduce the risk of ankle sprains in high school athletes. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Seven hundred and sixty-five high school soccer and basketball players (523 girls and 242 boys) were randomly assigned to either an intervention group (27 teams, 373 subjects) that participated in a balance training program or to a control group (28 teams, 392 subjects) that performed only standard conditioning exercises. On-site athletic trainers recorded athlete exposures and sprains. RESULTS: The rate of ankle sprains was significantly lower for subjects in the intervention group (6.1%, 1.13 of 1000 exposures vs 9.9%, 1.87 of 1000 exposures; P = .04). Athletes with a history of an ankle sprain had a 2-fold increased risk of sustaining a sprain (risk ratio, 2.14), whereas athletes who performed the intervention program decreased their risk of a sprain by one half (risk ratio, 0.56). The ankle sprain rate for athletes without previous sprains was 4.3% in the intervention group and 7.7% in the control group, but this difference was not significant (P = .059). CONCLUSION: A balance training program will significantly reduce the risk of ankle sprains in high school soccer and basketball players.     

The effects of ankle compliance and flexibility on ankle sprains

PURPOSE: The goal of this study was to examine the influence of changes in subtalar joint flexibility and compliance on ankle sprain occurrence. METHODS: Muscle model driven simulations of 10 subjects performing the landing phase of a side-shuffle movement were performed. The passive flexibility or compliance of the subtalar joint was varied, and each subject-specific simulation was exposed to a set of perturbed floor conditions. RESULTS: Increases in flexibility and compliance both led to an increase in the occurrence of excessive supination, while changes in flexibility had a greater influence. Changes in flexibility or compliance caused only small changes in the occurrence of excessive supination torques. CONCLUSION: These results suggest that increased mechanical laxity does not directly cause an increase in sprain occurrence during side-shuffle movements.     

Risk factors for noncontact ankle sprains in high school athletes: the role of hip strength and balance ability

BACKGROUND: Ankle sprains are among the most common sports injuries. HYPOTHESIS: Poor balance as measured on a balance board and weakness in hip abduction strength are associated with an increased risk of noncontact ankle sprains in high school athletes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: One hundred sixty-nine high school athletes (101 male athletes, 68 female athletes) from football, men's basketball, men's soccer, women's gymnastics, women's basketball, and women's soccer were observed for 2 years. Balance in single-limb stance on an instrumented tilt board and hip flexion, abduction, and adduction strength (handheld dynamometer) were assessed in the preseason. Body mass, height, generalized ligamentous laxity, previous ankle sprains, and ankle tape or brace use were also documented. RESULTS: There were 20 noncontact inversion ankle sprains. Balance ability (P = .72), hip abduction strength (P = .66), hip adduction strength (P = .41), and hip flexion strength (P = .87) were not significant risk factors for ankle sprains. The incidence of grade II and grade III sprains was higher in athletes with a history of a previous ankle sprain (1.12 vs 0.26 per 1000 exposures, P < .05). A higher body mass index in male athletes was associated with increased risk (P < .05). The combination of a previous injury and being overweight further increased risk (P < .01). CONCLUSION: Balance as measured on a balance board and hip strength were not significant indicators for noncontact ankle sprains. The apparent high injury risk associated with the combination of a history of a previous ankle sprain and being overweight in male athletes warrants further examination.     

Periosteal stripping in high ankle sprains: An association with osteonecrosis

ObjectiveWe present a series of 20 cases of a sleeve-type injury of the distal tibia characterized by traumatic periosteal stripping caused by a high ankle sprain. We characterize the magnetic resonance imaging findings associated with this injury and highlight its association with distal tibial osteonecrosis.Materials and methodsWe collected 20 cases of high ankle sprains with periosteal stripping of the distal tibia through teaching files and a search through our PACS database. We recorded the presence and pattern of syndesmotic ligamentous injury and the presence or absence of syndesmotic widening in patients with periosteal stripping. The presence or absence of associated fractures and osteonecrosis was noted and characterized by location.ResultsThe most commonly torn ligament was the anterior inferior tibiofibular ligament. 25% (5/20) of the patients in our series developed osteonecrosis. Osteonecrosis developed as early as 3–4 weeks following the initial injury. Of the patients with osteonecrosis, 40% (2/5) had fractures of the posterior malleolus. All patients with osteonecrosis had widening of the syndesmosis. Two of the five patients with osteonecrosis were in the pediatric age group.ConclusionIn contrast to conventional syndesmotic and interosseous ligamentous tearing, high ankle injuries with tibial periosteal stripping may result in avulsion of the extra-osseous vasculature supplied by the periosteum, leading to osteonecrosis. This pattern of injury has not been emphasized in the literature. Our findings underscore the importance of the integrity of the periosteum for maintaining adequate vascularity of the distal tibia.     

Variable schedules of ibuprofen for ankle sprains.

In a study of 144 patients, with Grade 1 and 2 inversion injuries to the ankle sustained in sport, treatment with a non-steroidal anti-inflammatory was considerably superior to placebo with respect to joint tenderness, level of training and injury severity. No difference in efficacy could be determined between ibuprofen 2400 mg given in two or four equally divided daily doses. Ten patients withdrew from the study because of side effects, five from ibuprofen twice daily, three from ibuprofen four times daily and two from the placebo group. This study confirms the efficacy, flexibility and tolerability of high dose ibuprofen.     

Prospective evaluation of syndesmotic ankle sprains without diastasis

Sixty consecutive collegiate athletes with "high" ankle symptoms were prospectively evaluated over a 3-year period in an effort to better define this debilitating ankle injury. All athletes included in this study had tenderness over the distal anterior tibiofibular ligament, tenderness proximally along the interosseous membrane, and functional disability. No study subject had a fracture or frank tibia-fibula diastasis. The severity of the sprain was quantified using the interosseous "tenderness length." A standard rehabilitation protocol was followed by all patients. Athletes returned to competition when they could perform all functional testing without difficulty. Time to return to full competitive activity averaged 13.4 days. The number of days missed from competition was statistically related to the interosseous tenderness length (P = 0.0001) and to positive results on the squeeze test (P = 0.03). Fifty-three of the 60 injured athletes were evaluated at least 6 months after injury. Patients rated their outcomes as good or excellent. Six of the patients experienced occasional ankle pain and stiffness, four patients reported recurrent ankle sprains, and one patient had heterotopic ossification formation.     

Risk factors for noncontact ankle sprains in high school football players: the role of previous ankle sprains and body mass index

BACKGROUND: In a previous study, we noted a possible connection between an athlete's weight and risk of ankle sprain. HYPOTHESIS: A high body mass index and a history of a previous ankle sprain increase the risk of a subsequent noncontact sprain. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: One hundred fifty-two athletes from 4 football teams were observed (2 varsity and 2 junior varsity). Two teams were observed for 3 seasons, and 2 teams were observed for 1 season. Before each season, body mass, height, history of previous ankle sprains, and ankle tape or brace use were recorded. RESULTS: There were 24 ankle sprains, of which 15 were noncontact inversion sprains (11 grade I, 3 grade II, 1 grade III; incidence, 1.08 per 1000 athlete-exposures). Injury incidence was higher in athletes with previous ankle injuries (2.60 vs 0.39; P < .001). Body mass index was also a risk factor (P < .05): injury incidence was 0.52 for players with a normal body mass index, 1.05 for players at risk of overweight, and 2.03 for overweight players. Injury incidence was 0.22 for normal-weight players with no previous ankle sprain compared with 4.27 for overweight players who had a previous sprain. CONCLUSION: An overweight player who had a previous ankle sprain was 19 times more likely to sustain a noncontact ankle sprain than was a normal-weight player with no previous ankle sprain. CLINICAL RELEVANCE: Ankle sprain prevention strategies should be targeted at football players with a high body mass index and a history of previous ankle sprains.