Ankle Sprains
Some interesting statistics about ankle sprains from a foot ankle in Singapore:
- 1/10,000 persons/day
- 23,000 ankle sprains in the U.S. each day
- 40-45% of sports injuries are ankle injuries
- 85% of ankle injuries are sprains
- 85% of sprains are due to inversion with injury to the lateral ligaments
Inversion sprains (where the foot turns inwards) are the most common form of ankle sprain.
It damages the lateral ligaments of the ankle joint.
Lateral Ankle Ligaments
•ATFL
–anterior talo-fibular ligament
– this is the most important ligament that is injured in an inversion ankle sprain.
•CFL – calcaneo-fibular ligament
•PTFL – Posterior talo-fibular ligament
The Anterior Talofibular Ligament (ATFL) is the main determinant of whether one will get recurrent inversion sprains in the future. The Calcaneofibular Ligament (CFL) is the 2nd important structure that provides ankle stability.
A grade I sprain is when the ATFL and CFL are stretched but not torn. This type of sprain is usually not seen in the clinic.
A grade II sprain is when the ATFL and CFL are partially torn. This is a common problem which presents in our clinic.
A grade III sprain is when the ATFL and CFL are completely ruptured.
Severity of Ankle Inversion Sprains
Treatment of Acute Ankle Sprains
•PRICEM
•Protection: (orthosis or brace)
•Rest: limit weight bearing until not painful
•Ice, Compression, and Elevation
–Most important component acutely
–Limiting inflammation and swelling has been shown to speed recovery
•Mobilize
–early range of motion has also been shown to speed recovery
Prognosis is Related to the Grade of the Ankle Sprain
•Grade I
–Require an average 11.7 days before full resumption of athletic activity
•Grade II
–Require approximately 2-6 weeks
•Grade III
–Average duration of disability ranges 4.5-26 wks
–Only 25-60% being symptom free 1-4 yrs after injury
Chronic Ankle Instability
A condition characterized by a recurring “giving way” of the outer (lateral) side of the ankle
–Repeated turning of the ankle, especially on uneven surfaces or when participating in sports
–Persistent discomfort and swelling
– Pain
These patients have ligaments that were torn and have not healed properly, leaving the ankle joint too loose.
Treatment
•Physiotherapy
–Re-train nerves to respond to movements of the ankle
–Strengthen the muscles around the ankle
–Stretch out stiff ankle or stiff Achilles tendon
•Bracing
•Surgery
Surgery for Chronic Ankle Instability
I prefer the Bostrum-Gould Procedure.
Surgery involves repairing the torn and stretched ligaments back to the original tension.
In order to allow immediate weight bearing after the surgery, an internal brace is used to protect the ligament repair.
Scientific Basis for Internal Brace After Bostrum Repair
Publications are now highlighting that the Broström repair can be improved with the Internal Brace ligament augmentation.
In addition to biomechanical evidence showing time zero strength at the ATFL of ~250 N (Native ~150 N) there is now peer-reviewed clinical evidence showing faster rehabilitation and better outcomes with the Internal Brace ligament augmentation.
Internal Brace ligament augmentation has been used successfully in both high-level athletes and normal active patients for 5+ years with documented clinical and biomechanical evidence of early return to activity and everyday life.
Top articles highlighting InternalBrace ligament augmentation:
Functional results of open Broström ankle ligament repair augmented with a suture tape [published online
February 8, 2018]. Foot Ankle Int. doi:10.1177/1071100717742363.
February 8, 2018]. Foot Ankle Int. doi:10.1177/1071100717742363.
- Six to 24-month follow-up of 81 patients with a Broström and InternalBrace ligament augmentation
- InternalBrace ligament augmentation shows accelerated rehabilitation and mean return to sport
of 12 weeks (3 months) and average time to full weightbearing of 16 days (range, 1-64 days) - Motivated athletes were able to return to play, some as early as 8 weeks after surgery
- Ankle joint mechanics (dorsiflexion and plantarflexion) comparison between operative and contralateral sides showed no major differences
- Highlights limitations of standard Broström repair where ankle is often immobilized for 6 weeks before rehabilitation starts and usually takes 4-6 months before athlete can return to pla
Isolated anterior talofibular ligament Broström repair for chronic lateral ankle instability: 9-year follow-up.
Am J Sports Med. 2013;41(4):858-864. doi:10.1177/0363546512474967.
- “All my Brostroms do well”… or do they?
- 9-year follow-up of 42 athletes who had ankle ATFL Brostrom repair
– 58% returned to preinjury level of activity, 16% returned to a lower level of activity, 26%
abandoned athletic activity
– In addition to 42% stepping down or abandoning activity, of the patients who had no evidence of
degenerative changes preoperatively, 30% had radiographic signs of degenerative changes of the ankle at 9 years
Anterior talofibular ligament ruptures, part 1: biomechanical comparison of augmented Broström repair
techniques with the intact anterior talofibular ligament. Am J Sports Med. 2014;42(2):405-411.
doi:10.1177/0363546513510141.
- ATFL InternalBrace ligament augmentation cadaveric biomechanical study testing ultimate load
of failure at time 0 - Broström and InternalBrace ligament augmentation = ~250 N
- ATFL InternalBrace ligament augmentation is stronger and as stiff as the native ATFL at time 0
- “Adding strength to Broström is valuable in patients with generalized ligamentous laxity, in large
patients or elite athletes, or when allograft tenodesis reconstruction is not feasible”
ATFL elongation after Brostrom procedure: a biomechanical investigation. Foot Ankle Int. 2008;29(11):1126-1130. doi:10.3113/FAI.2008.1126. Foot & Ankle International, Vol. 29 #11, Nov. 2008
- (Human cadaveric study) Unprotected motion associated with significant lengthening of ligament after ATFL repair
- Conclusion: Need to protect the ATFL and cast during conservative rehab
A review of ligament augmentation with the InternalBrace™: the surgical principle is described for the lateral
ankle ligament and ACL repair in particular, and a comprehensive review of other surgical applications and
techniques is presented. Surg Technol Int. 2015;26:239-255.Supports early mobilization of repaired ligament
with minimal surgical morbidity
- Review of ligament reconstruction techniques and highlight of the application of InternalBrace
ligament augmentation for ATFL Broström and ACL - Highlights change in orthopedics from reconstruction with allograft or autograft to restoration
of normal anatomy with InternalBrace ligament augmentation
Open modified Broström ankle reconstruction with internal brace augmentation: a novel approach.
Orthopedics Today. 2015;35(8):28.
- Novel surgical technique overview of Arthrex InternalBrace ligament augmentation repair
to augment modified Broström - Discusses how “increased construct strength allows the surgeon to consider implementation of an accelerated rehabilitation program, earlier return to activity and decreased recurrent instability”
Stabilizing the lateral ankle via a Brostrom repair with suture tape augmentation. Podiatry Today. 2015;28(5).
- The technique increases the strength of the repair
- Suture tape augmentation serves to protect the repair and allows for earlier rehabilitation.
Effects of immobilization on joints. Clin Orthop Relat Res. 1987;(219):28-37.
Clinical Orthopaedic & Related Research, Volume 219, June 1987
- Direct negative effects on joint mechanics and muscle atrophy
- Diminished proprioception (the ability to sense stimuli arising within the body regarding position, motion, and equilibrium)
- Casting negatively affects ligaments
Arthrex, Inc. LA1-0408-EN_A. Naples, FL; 2014.
- ATFL InternalBrace ligament augmentation with all 4 constructs of 3.5 mm and 4.75 mm
BioComposite SwiveLock® anchors tested - All above 150 N (native strength) and range from 181-352 N
Find out more about other related sport injuries from our foot and ankle specialist in Singapore.
