Identifying And Treating Stress Fractures And Lateral Ankle Sprains In Athletes

Ron Raducanu, DPM, FACFAS

What You Should Know About Lateral Ankle Sprains

   The other very common injury is a lateral ankle sprain. These injuries tend to be much more easily identifiable as the patient generally presents with edema, ecchymosis and pain in the lateral ankle. These injuries also tend to be more dynamic acute injuries. With these injuries, patients can usually describe the incident of injury or impact, and give a much more defined time of injury.

   One of the most important and often overlooked aspects of the diagnosis of acute ankle sprains is the evaluation of both the peroneal tendons and checking for a potential fracture at the base of the fifth metatarsal. It is generally for this reason that in-office radiographs are indicated for these injuries. It is necessary to include the ankle in the radiographic studies as the same mechanism of injury is present in acute ankle fractures as well.

   One of the important questions to ask these patients during the initial evaluation is whether they heard anything during the injury like a “pop” or “snap.” Physicians should also ascertain whether the patient was able to ambulate immediately after the injury. Also ask whether the patient noticed ecchymosis and edema immediately, or if there was a lag in time between the injury and when he or she noticed these hallmarks.

Keys To Managing Anterior Talofibular Ligament Injuries

   Interestingly, some patients who present with a chronic injury of the lateral ankle describe a type of transient swelling of the lateral ankle as the day progresses. It is important to explain to these patients that if they sustained an injury to the anterior talofibular ligament (ATFL) — which is the most common ligament affected — since it is an intracapsular ligament, they may have now compromised their ankle joint capsule. This can cause joint fluid to exude through the injury and cause this transient edema. This may also increase their chances for arthritic changes within the ankle joint due to ineffective retention of this important fluid within the joint.

   If one identifies an acute injury to either the ATFL or the peroneal tendons, immediate non-weightbearing in a cast boot for several weeks is indicated. If you diagnose a fracture to either the ankle or the fifth metatarsal, proceed to determine the severity of the fracture. Then the physician must choose between long-term non-weightbearing cast immobilization or open reduction with internal fixation.

   After one has identified a ligamentous or tendinous injury and conservative management has failed, the physician should obtain MRI to further rule out the location of the injury within the tendon or ligamentous structure. Also determine the injury’s severity, specifically whether it is a through and through injury, a rupture or only a partial rupture. Generally, if immobilization is unsuccessful in relieving the patient’s symptoms, surgical intervention is required to restore the structure to a functional state.

   Another injury that MRI can help identify is an osteochondral lesion within the dome of the talus. An acute injury of this nature rarely shows up on an initial radiograph. This can lead to long-term complications if it is not addressed.

   One of the more recent advances in the surgical management of the acute partial ATFL rupture is the use of thermal capsular shrinkage of this ligament in an attempt to limit the morbidity associated with using tendonous grafting to repair the ligament. The postoperative recovery is quicker and the return to activity is also on a much shorter timeline.

   Whether one selects a surgical approach or has success with conservative management, many of these patients with lateral ankle sprains do require some form of physical therapy and bracing support of the affected ankle.

   One of the challenges in treating a lateral ankle sprain is the re-education of the mechanoreceptors within the ATFL. Once the ATFL is injured, it hampers the effectiveness of the mechanoreceptors within the ligament itself to provide the nervous system with important proprioceptive information.

   It is vital to re-establish this function as quickly as possible as this loss of proprioception has been associated with chronic injuries to this ligament, which ultimately can cause more severe injury and chronic ankle instability.

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