This can be provided either with taping or bracing. As both seem equally effective, the choice of taping or bracing should be made on the grounds of patient preference, cost, availability and expertise in tape application. Any athlete who has had a significant lateral ligament injury should have protective taping or bracing for all future sporting activities.
There are a number of methods to protect against inversion injuries. The three main methods of tape application are stirrups, heel lock and the figure-of-six. Usually at least two of these methods are used. Braces have the advantage of ease of fitting and adjustment, lack of skin irritation and reduced cost compared to taping over a lengthy period. There are a number of different ankle braces available. The lace-up brace is an effective ankle brace. Treatment of grade III ankle injuries requires initial conservative management over a 6 week period.
If the patient continues to make good progress and is able to perform sporting activity with the aid of taping or bracing and without persistent problems during or following activity, surgery may not be required.
If however, despite appropriate rehabilitation and protection, the patient complains of recurrent episodes of instability or persistent pain, then surgical reconstruction of the lateral ligament, using one of the peroneal tendons or a fibular periosteal flap, is recommended. Following surgery, it is extremely important to undertake a comprehensive rehabilitation programme to restore full joint range of motion, strength and proprioception.
The indications for use of nonsteroidal anti-inflammatory drugs in ankle injuries is unclear. The majority of practitioners tend to prescribe these drugs in all cases of lateral ligament sprains although evidence of their efficacy in this condition is not convincing. However, it may be appropriate to commence medication days following injury because of the risk of developing synovitis on resumption of weight bearing.
Medial ligament injuries do not occur as frequently as lateral ligament injuries because the deltoid ligament requires considerable force to be damaged. Occasionally they may be seen in conjunction with a lateral ligament injury.
Medial ligament injuries may occur with fracture of the medial malleolus, talar dome or damage to articular surfaces. Medial ligament sprains should be treated in the same manner as lateral ligament sprains, although return to activity may be prolonged.
A fracture affecting one or more of the malleoli lateral, medial, posterior is known as a Pott's fracture. It can be difficult to distinguish clinically between a fracture and a moderate to severe ligament sprain. Both conditions may result from inversion injuries, with severe pain and varying degrees of swelling and disability. The management of these fractures involves restoration of the normal relationship between the superior surface of the talus and the ankle mortise inferior margins of tibia and fibula.
If this relationship has been disrupted, internal fixation is required. These fractures can be treated symptomatically with immobilization and crutches in the early stages for pain relief only. Lateral malleolar fractures associated with medial instability, hairline medial malleolar fractures or larger undisplaced posterior malleolar fractures are potentially unstable, but may be treated conservatively.
This involves a below knee cast extending to include the metatarsal heads. A walking heel may be applied after swelling has subsided days. The cast should be worn for 6 weeks. Displaced medial malleolar, large posterior malleolar, bimalleolar or trimalleolar fractures, or any displaced fracture which involves the ankle mortise, should be internally fixed. A comprehensive rehabilitation program should be undertaken following surgical fixation or removal of cast. The aims of the rehabilitation program are to restore full range of motion, strengthen the surrounding muscles and improve proprioception.
In most cases of ligament sprain, the patient progresses satisfactorily through the rehabilitation process with reduction in pain and swelling and improvement in function. However, there is a significant group of patients who do not progress well and complain of persistent pain, swelling and impaired function without any indication of improvement weeks after their injury.
In these cases, it is important to consider the presence of one of the conditions listed in Table 2. Table 2: Causes of persistent ankle pain following acute injury. An ankle ligament injury which is inadequately rehabilitated may present with persistent pain and loss of function. This usually occurs with increased activity levels. The common problems associated with inadequate rehabilitation are a loss of range of motion in the ankle joint especially dorsiflexion , weakness of the peroneal muscles and impaired proprioception.
Management involves restoration of full dorsiflexion by mobilization of the ankle joint, a programme of strengthening exercises for the peroneal muscles and proprioceptive exercises. If rehabilitation has been appropriate and symptoms persist, it is necessary to consider the presence of other pathology. Symptoms of intra-articular pathology include clicking, locking and joint swelling. Examination may reveal effusion, bony tenderness or swelling at the sinus tarsi or peroneal tendons.
The ankle should be re-assessed for evidence of chronic ligamentous instability. Osteochondral Fractures of the Talar Dome. Osteochondral fractures of the dome of the talus which occur in association with ankle sprains are commonly overlooked. These fractures may occur when there is a compressive component to the inversion injury, especially with landing from a jump. The dome of the talus is compressed by the tibial plafond causing damage of the osteochondral surface.
The fractures occur most commonly in the superomedial and the superolateral corners of the talus. If large, these fractures may be recognized at the time of injury.
The fracture site will be tender and may be evident on X-ray. One of the primary reasons for the delay is the period of non-weight bearing that is required for the acute injury to begin to heal. Non-weight bearing is detrimental to the other structures throughout the involved lower extremity. The muscle mass is greatly affected by atrophy and weakness occurring throughout leg.
Treatment of a high ankle sprain can begin immediately, and the Physical Therapy rehabilitation will focus on reducing the swelling and pain while the patient remains non-weight bearing.
Regaining motion and exercising the core and lower extremity muscles without putting weight on the involved foot will help to prevent gross muscle strength loss and atrophy. When the patient is given the ok to weight bear, the rehabilitation program can be progressed to include various weight bearing or closed chain exercises. There is an increased rate of re-occurrence of this type of ankle sprain.
Unfortunately, many people that have experienced this type of sprain develop arthritic changes in the mortise later in life. Fully rehabilitating the involved ankle will lessen the chance of developing arthritic changes. Healthcare providers suggest that athletes and especially those that play contact sports should incorporate balance and proprioception exercises and drills into their regular routine in hope of preventing the high ankle sprain from occurring.
Some suggest that proper bracing might limit the amount of dorsiflexion that can occur in an ankle which would limit the severity of the injury should it occur. Unfortunately, many athletes report that this type of brace limits their function and performance. High ankle sprains occur infrequently when compared to medial and lateral ankle sprains. An inability to bear weight or tenderness in the bone including the medial and lateral malleoli as well as the 5th metatarsal and navicular signify a need for radiographs as per the Ottawa Ankle Rules.
The initial treatment of an ankle sprain is known by the mnemonic RICE. RICE is used to limit swelling, as too much swelling can significantly increase the patient's pain and ultimate recovery time. However, there is some evidence that suggest that anti-inflammatories may have an adverse effect on ligament healing. Once the symptoms associated with the initial ankle sprain have started to improve, patients will benefit from physical therapy exercises designed to improve their range of motion, strength and proprioception.
Proprioception is the ability of the brain to sense the position of a joint ex. Note that nerves within the ligament mediate proprioception and therefore this sense can be out of kilter following a ligament injury.
As the acuity of the injury resolves, patients with seemingly normal ankles on examination no swelling, no tenderness, no laxity may still feel unstable if proprioception has not returned to normal.
It is important that the motion follow a deliberate pattern — and not random waving of the foot — as deliberate motion helps improve proprioception as well. Proprioception can also be improved by having the patient stand on one foot with eyes closed. Once this is mastered, standing on one foot on a soft surface such as a pillow or bed with eyes closed and head moving side to side can further improve proprioception.
Rehabilitation after an ankle sprain can often be completed with a home program, though trained physical therapists may be beneficial in providing initial instruction defining the program. Surgery is rarely indicated for the treatment of acute ankle sprains. However, patients who have recurrent ankle sprains may be candidates for an ankle ligament stabilization procedure to treat their anatomic instability and restore functional stability.
Most people with sprained ankles fully recover. Even if the ligaments are permanently deformed, the muscles crossing the ankle joint can provide sufficient dynamic stability. However, because ankle sprains are such a common injuries, even a low rate of complications coupled with a high incidence may produce a significant number of people with poor outcomes. Ankle injuries associated with chronic anatomic instability may lead to the development of traumatic arthritis. Risk factors for ankle sprains include a high arched foot cavus foot , ligamentous laxity leading to increased inversion, participating in high risk activities ex.
Rovere et al PMID: studied the effectiveness of taping, wearing a laced stabilizer and high-top or low-top shoes among collegiate football for 6 seasons. They reported that the combination associated with the fewest injuries overall was low-top shoes and laced ankle stabilizers.
Football and soccer are the next most implicated sports causing ankle sprains during athletics. Ankle sprain, syndesmosis, mortise, talo-fibular ligament, calcaneo-fibular ligament, deltoid ligament, proprioception. Recognize an ankle sprain and differentiate between it and other ankle and hindfoot injuries. Apply the Ottawa ankle rules to recognize need for x-rays. Table of Contents. Toggle navigation. Ankle Sprains Description Ankle sprains are among the most common musculoskeletal injuries.
Figure 1: Ankle Inversion, the typical mechanism of injury of an ankle sprain. Figure 2: The Ankle Mortise. The talus T sits in an inverted U known as the mortise. The joint between the tibia Tib and fibula Fib , the distal tibiofibular syndesosis. This relationship is vital to ankle function and is regulated by the anterior and posterior tibiofibular ligaments also referred to as the syndesmotic ligaments shown in red.
Image courtesy of Joseph Bernstein MD. Figure 3: The Lateral Ligaments of the Ankle.
0コメント