Increased Ligament Thickness in Previously Sprained Ankles as Measured by Musculoskeletal Ultrasound

Context:Lateral ankle sprains are among the most common injuries in sport, with the anterior talofibular ligament (ATFL) most susceptible to damage. Although we understand that after a sprain, scar tissue forms within the ligament, little is known about the morphologic changes in a ligament after injury.Objective:To examine whether morphologic differences exist in the thickness of the ATFL in healthy, coper, and unstable-ankle groups.Design:Cross-sectional study.Setting:Laboratory.Results:A group-by-limb interaction was evident (P = .038). The ATFLs of the injured limb for the coper group (2.20 ± 0.47 mm) and the injured limb for the unstable group (2.28 ± 0.53 mm) were thicker than the ATFL of the “injured” limb of the healthy group (1.95 ± 0.29 mm) at P = .015 and P = .015, respectively. No differences were seen in the uninjured limbs among groups.Conclusions:Because ATFL thicknesses of the healthy group''s uninjured ankles were similar, we contend that lasting morphologic changes occurred in those with a previous injury to the ankle. Similar differences were seen between the injured limbs of the coper and unstable groups, so there must be another explanation for the sensations of instability and the reinjuries in the unstable group.Key Words: ankle instability, anterior talofibular ligament, morphology

Key Points

• The anterior talofibular ligament can be viewed using musculoskeletal ultrasound imaging.
• The anterior talofibular ligaments of previously sprained ankles were thicker than those of uninjured ankles.
• Although coper ankles were more functionally similar to healthy ankles than to unstable ankles, they were structurally different. Only further research can determine the relationship between ligament damage and functional stability of the ankle.

Musculoskeletal ultrasound (MSUS) imaging is a new technique being used in the sports medicine setting. Compared with other imaging techniques, such as radiographic or magnetic resonance imaging (MRI), MSUS offers a safer, more time-efficient, and more cost-effective alternative. A real-time image can be captured via MSUS by using a transducer to send high-frequency sound waves into the body and recording the echo of the sound waves reflecting back, providing an image of the internal structure.^1,2 This method has been found to be effective in imaging upper extremity, lower extremity, and joint injuries.^1,3,4Oae et al³ reported greater than 90% accuracy for both MSUS and MRI in identifying injuries to the ankle. Lateral ankle sprains (LASs) are among the most common injuries in sport.⁵ An estimated 850 000 new ankle sprains occur each year in the United States,⁷ which does not include a 70% reinjury rate at the ankle.⁶ Ankle stability plays an important role in injury prevention. Passive stability of the ankle is predominantly the responsibility of ligaments supporting the bony structure of the talocrural joint because there are no musculotendinous insertions on the talus. Ligaments supporting the lateral complex of the ankle include the anterior talofibular ligament (ATFL), calcaneofibular ligament, and posterior talofibular ligament. The ATFL is a flat ligament that attaches from the anterior border of the lateral malleolus to the talus, just anterior to the lateral malleolus articular surface.⁸ The ATFL limits plantar flexion and inversion, motions that coincide with the most common mechanism of injury.⁸ As a result, the ATFL becomes vulnerable in a plantar-flexed and inverted position and is most susceptible to damage during an LAS.^5,6,9 An isolated tear of the ATFL occurs in about 80% of LASs.^10,11After an LAS, the fibrous structure of an ankle ligament is often disrupted by severe damage. Using MRI, Takao et al¹² reported visible scarring of the ATFL after injury. Using MSUS, McCarthy et al¹³ described a thickened ATFL, osseous spurs, and synovitic lesions after injury. Thickness values for the ATFL have been derived primarily from cadaveric studies^14,15; however, MRI-based in vivo studies demonstrated thickness of the ATFL to be in the range of 2 to 3 mm.^16,17 An abnormal ligament could affect the stabilizing properties of the ligament. In animal studies, although scar tissue formed within a ligament after injury, the newly scarred ligament allowed normal movement; however, the load capacity of that ligament was decreased by 60%.^18–20 Therefore, the strength of a ligament can be sufficient for active movement and injury rehabilitation soon after injury, but the decrease in load capacity of the scarred ligament may affect its stabilizing properties.Despite medical treatment and postinjury rehabilitation, more than 50% of individuals who sustain a moderate or severe ankle sprain experience some degree of residual disability and impairment due to symptoms such as pain, instability, loss of range of motion, and edema.^6,21 Those who do not fully recover from their ankle sprain often develop chronic ankle instability (CAI), which limits function not only in sport but also in activities of daily living. Patients with CAI typically complain of the ankle “giving way” or of repeated ankle sprains under seemingly low-risk conditions.²²Typically, CAI researchers have categorized participants into 2 groups: those with ankle instability (unstable) and those without ankle instability (healthy). The unstable group consists of individuals who experience recurrent sprains, sensations of instability, or both. Unfortunately, this method of grouping ignores those who sustained an ankle sprain but did not experience recurrent sprains or sensations of instability. In general, an ankle “coper” refers to an individual who has experienced an initial ankle sprain but not a subsequent sprain.²³ Only recently have copers been addressed in ankle-instability research.^24–29 Because copers are still a new cohort in this research, the classification of ankle copers differs somewhat among researchers.^25,28Although we understand that the fibrous nature of a ligament is disrupted after an LAS, little is known about the actual morphologic changes in a ligament. Therefore, the purpose of our study, using a mixed-model analysis, was to determine whether MSUS can be used to see differences in ligament thickness between the uninjured limb and the injured limb among the healthy, coper, and unstable groups. We hypothesized that the ligaments of the previously injured ankles would be thicker than the uninjured ankles.     

HIV Prevention and Treatment Behavior Change and the Situated Information Motivation Behavioral Skills (sIMB) Model: A Qualitative Evaluation of a Community Health Worker Intervention in Rakai,Uganda

AIDS and Behavior - A community health worker (CHW) model can promote HIV prevention and treatment behaviors, especially in highly mobile populations. In a fishing community in Rakai, Uganda, the...     

Monoclonal autoantibody from a (New Zealand black x New Zealand white)F1 mouse and some human scleroderma sera target an Mr 34,000 nucleolar protein of the U3 RNP particle

A monoclonal IgG2a antinucleolar autoantibody (72B9) was obtained by fusion of spleen cells from a (New Zealand black x New Zealand white)F1 mouse with myeloma cells (P3x63Ag8.653). Antibody 72B9 recognized a highly conserved nucleolar antigen present in both animal and plant cells. The staining pattern produced by antibody 72B9 in different cell substrates was identical with those obtained by scleroderma antibodies reactive with a basic (pI 8.5) nucleolar protein of Mr 34,000, which is associated with the U3 RNP particle. Western blotting further confirmed its reactivity with this scleroderma-related U3 RNP protein.     

Antiphospholipid antibodies in systemic lupus erythematosus: Clinical and laboratory associations in 111 patients

Summary An enzyme linked immunosorbent assay (ELISA) was used to evaluate the prevalence and disease associations of antibodies to a range of negatively charged phospholipids in 111 patients with systemic lupus erythematosus (SLE). The frequency of one or more isotypes of different antiphospholipid antibodies (APLs) was similar (range 33%–45%). When individual isotypes were considered alone there was considerable variation (range 5%–32%). There were significant associations between thrombosis, thrombocytopenia, and central nervous system (CNS) disease but not abortion with elevated APL. Strong associations were found between raised anti-ds-DNA (Farr assay) and a positive direct Coomb's test with raised APL. Thus, APLs are common in SLE and are associated with discrete clinical and laboratory features. However, detection of antibodies to a range of negatively charged phospholipids added little clinically useful information to that obtained by measuring anticardiolipin antibody (ACL) alone. We cannot recommend the use of APLs other than ACL for routine testing.     

Functional tricuspid regurgitation secondary to aortic annular abscess: An unusual presentation of infective endocarditis

An unusual case of aortic annular abscess is presented, in which the patient presented with features of gross tricuspid regurgitation. There was no direct involvement of the tricuspid valve. Tricuspid regurgitation disappeared following surgical repair of the annular abscess. The present case also illustrates the utility of trans-oesophageal echocardiography in establishing the diagnosis and planning surgical intervention.     

Disseminated herpes zoster in the immunocompromised host: a comparative trial of acyclovir and vidarabine. The NIAID Collaborative Antiviral Study Group.

Seventy-three immunocompromised patients with disseminated herpes zoster were evaluated in a double-blind controlled trial of acyclovir (n = 37) versus vidarabine (n = 36) therapy. Acyclovir was administered at 30 mg/kg/day at 8-h intervals and vidarabine was given as a continuous 12-h infusion at 10 mg/kg/day for 7 days (longer if resolution of cutaneous or visceral disease was incomplete). No demographic differences existed between treatment groups. No deaths attributable to varicella-zoster virus infection occurred within 1 month of treatment. Neither rates of cutaneous healing, resolution of acute neuritis, and frequency of postherpetic neuralgia nor adverse clinical and laboratory events differed between treatment groups. Acyclovir recipients were discharged from the hospital more promptly than vidarabine recipients (P = .04, log rank test). These data indicate that disseminated herpes zoster is amenable to therapy with either acyclovir or vidarabine; resultant mortality is low.