Physiotherapeutic Intervention Following Lateral ...



Physiotherapeutic Intervention Following Lateral Collateral Ligament Sprain of Ankle in Athletes

The ankle is one of the most common sites for acute musculoskeletal injuries, and sprains account for 75 percent of ankle injuries (Barker 1997).

The severity of the sprain is so frequently unorganized that the statement of Watson-Jones must be needed, “it is worse to sprain an ankle than break it”. This statement implies that fracture receive adequate treatment while sprain is neglected on given inappropriate care (Cailiet, 1992).

The three main components of lateral ligament complex are the anterior talo-fibular ligament (ATFL), the calcaneo-fibular ligament (CFL), and the posterior talo-fibular ligament (PTFL) (Magee 2000).

The most common ankle injury involves an isolated tear of the ATFL, followed by a combine tear of ATFL and the CFL. The mechanism of injury is usually inversion of the planter flexed foot (Brotzman et al 1996).

Classification of Lateral Ankle Sprains

|Severity |Signs and Symptoms |Disability |

|Grade 1 (mild) |No hemorrhage |No or little limp |

|Stable |Minimal swelling |Minimal function loss |

| |Point tenderness |Difficulty hopping |

| |No varus laxity |Recovery 8 days (range, 2-10) |

|Grade 2 (moderate) |Some hemorrhage |Limp with walking |

|stable |Localized swelling (margin of |Unable to toe raise |

| |Achilles tendon less defined) |Unable to hop |

| |Anterior drawer sign may be |Unable to run |

| |present. |Recovery 20 days (range, 10-30) |

| |No varus laxity | |

|Grade 3 (severe) |Diffuse swelling on both sides of|Unable to bear weight |

|unstable |Achilles tendon, early hemorrhage|Fully significant pain inhibition |

| |Possible tenderness medially and |Initially almost complete loss of range of motion |

| |laterally |Recovery 40 days (range, 30-90) |

| |Positive varus laxity | |

From Reid, D.C: Sports injury assessment and rehabilitation, New York, Churchill Livingstone, 1992, p-226.

The diagnosis of lateral collateral ligament trauma is based on patient history, clinical examination and clinical stress test, stress radiography (Breitenseher 2007).

Most acute ankle sprains can be treated non-operatively. Those treated non-operatively generally have fewer complications and more rapid recovery (Brotzman et al 1996).

Initial non-operative, functional treatment is also supported by the very high success rate of reconstructive procedures for chronic ankle instability, such as those described by Brostorm and Watson-Jones. Failure of initial non-operative functional treatment still leaves the option of reconstructive surgery with a high success rate (Brotzman et al 1996).

Treatment consists of ice, compression, elevation and possibly immobilization and crutches. When working with a trained professional other forms of therapy can be added such as: joint mobilization, contrast baths, iontophoresis, phonophoresis, orthotic correction etc. Ultrasound therapy is no better than placebo in the management of lateral ligament injuries. (Nyanzi et al 1999)

Rehabilitation consists of balancing and postural control issues. It is not enough to strengthen the structures around the joint. An approach through human anatomy, kinesiology and neurophysiology must be taken. The athlete must be put in weight bearing positions with movement at more than one joint and plane. Balance board, wobble board, theraband, sissel pad, speed, agility and core strength must all be part of the rehab process. To do this properly it is integral to be evaluated by a sports medicine orthopedically trained physician. The doctor will then refer you to a trained professional for your physical therapy.

It may be concluded that the prolonged immobilization though a common practice is a treatment error (Weinstein, 1993, Karlson et al 1999 and Dettori et al, 1999). Early functional rehabilitation has more advantage in restoration of normal activity and should be incorporated as soon as possible for speeding return to activity and preventing chronic instability in athletes. This is supported by the work of Bahr et al 1997, Mattacola et al 1997 and Wolfe et al 2001.

Reference

➢ Barker HB, Beynnon BD, Renstron PA. Ankle injury risk factors in sports. Sports Med 1997; 23:69-74.

➢ Brotzman S B, Wilk K E, 1996, Clinical Orthopaedic Rehabilitation, Stephenson K, Charles S L, Brotzman S B, Foot and Ankle Injury, 2nd Edition, Mosby, Philadelphia, Pennsylvania, p 371-390.

➢ Perlman M, Leveille D, DeLeonibus J, Hartman R, Klein J, Handelman R, et al. Inversion lateral ankle trauma: differential diagnosis, review of the literature, and prospective study. J Foot Surg 1987; 26: 95-135.

➢ Bennett WF. Lateral ankle sprains. Part II: acute and chronic treatment. Orthop Rev 1994; 23:504-10.

➢ Cailliet R, 1992.Soft tissue pain and disability. 2nd edition, Jaypee, Daryaganj, New Delhi.

➢ Magee D J, 2000, Orthopedic Physical Assessment, Foot and Ankle Injury, 4th edition, Jaypee, Daryaganj, New Delhi.

➢ Wolfe MW, Uhl TL, Mattacola CG. Management of ankle sprains, 2001;1-14

➢ Reid, D.C: Sports injury assessment and rehabilitation, New York, Churchill Livingstone, 1992, p-226.

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