ANKLE: LATERAL LIGAMENT INJURIES & RECONSTRUCTION

1. ANKLE: LATERAL LIGAMENT INJURIES & RECONSTRUCTION John W. Cory M.D. OrthoArizona The Foot & Ankle Center

3. LATERAL ANKLE SPRAINSANATOMY Anterior Talo- fibular ligament • ATFL • Calcaneofibular ligament • CFL • Posterior Talo- fibular ligament • PTFL

4. LATERAL ANKLE SPRAINSANATOMY: ATFL • ATFL taut in plantarflexion • Lowest max load to failure(139N) • Greatest strain-deformation before failure • Resists talar internal rotation • In plantarflexion ATFL resists talar adduction • In the loaded ankle bony anatomy is primary stabilizer

5. LATERAL ANKLE SPRAINSANATOMY: CFL • CFL taut in neutral and dorsiflexion(DF) • Resists talar adduction independently in neutral(N) or DF • Resists talar adduction w/ ATFL in PF • 2-3.5X max load to failure of ATFL • 77% increase in talar adduction when sectioned

6. LATERAL ANKLE SPRAINSANATOMY: PTFL • PTFL taut in DF • Prevents internal rotation of talus secondary to ATFL • Prevents adduction in DF • Prevents external rotation of talus in DF secondary to medial ligaments

7. LATERAL ANKLE SPRAINS • 25% of all musculoskeletal injuries (23,000 per day in US alone) • 19% incidence in female college athletes • Soccer > Field hockey or Lacrosse • Tibial varum increases risk • 13% incidence in male college athletes • Talar tilt > 20% increased incidence • *Remember-tarsal coalition or varus heel with lateral overload in recurrent sprains

8. LATERAL ANKLE SPRAINS • 45% of basketball injuries • 31% of soccer injuries • ATFL by far most common injury • ATFL + CFL next most common pattern • PTFL rarely injured in isolation or with CFL

9. LATERAL ANKLE SPRAINSMECHANISM • “Rollover” injury • Inversion of tibiotalar joint • ATFL injured in plantarflexion(PF) • Resists internal rotation of talus and adduction in PF

10. LATERAL ANKLE SPRAINSMECHANISM • CFL injured in neutral or DF • 3.5X stronger than ATFL (345N) • Midsubstance rupture most common • PTFL injured in severe inversions with DF or DF alone

12. LATERAL ANKLE SPRAINSGRADING • Multiple grading scales described • Amount of injury to ligament • Number of ligaments injured • MRI findings • Important for treatment • Predictive of time to return to play • May predict chronic instability

13. LATERAL ANKLE SPRAINSGRADING Mann

14. LATERAL ANKLE SPRAINSGRADING • LIGAMENT INJURY-CLINICAL • Grade I • Ligament stretched w/o any rupture • Grade II • Partial rupture • Grade III • Complete rupture

15. LATERAL ANKLE SPRAINSGRADING • ANATOMIC • Grade I • ATFL • Grade II • ATFL + CFL • Grade III • ATFL + CFL + PTFL

16. LATERAL ANKLE SPRAINSGRADING • MRI FINDINGS • Grade I • Ligaments normal morphology, subQ edema perhaps evidence of stretch • Grade II • Partial rupture, thickening, subQ edema, some edema in ligament • Grade III • Complete disruption

17. LATERAL ANKLE SPRAINSGRADING • MRI FINDINGS • ATFL rupture • Fluid distal to distal fibular epiphysis • CFL rupture • Fluid into peroneal tendon sheath

18. LATERAL ANKLE SPRAINSDIAGNOSIS • History/Observation of injury • Physical examination • Radiographs • MRI • Ultrasound-possible

19. LATERAL ANKLE SPRAINSDIAGNOSIS • OBSERVATION • Rollover injury • Landed on another players foot • Extreme dorsiflexion • Twisting injury

20. LATERAL ANKLE SPRAIN DIAGNOSIS • History • Rollover • Twisting injury • Felt or heard pop • Pain • History of previous injury

22. PHYSICAL EXAMINATION Swelling Tenderness over lateral ligaments Ecchymosis Little or no medial tenderness NO tenderness/crepitation along fibula PHYSICAL EXAMINATION Talar tilt Anterior drawer “Suction sign” Weight bearing ability LATERAL ANKLE SPRAIN DIAGNOSIS

23. LATERAL ANKLE SPRAIN DIAGNOSIS • PHYSICAL EXAMINATION • Ecchymosis can be noted laterally or even medially • Marked swelling

24. LATERAL ANKLE SPRAIN DIAGNOSIS TALAR TILT ANTERIOR DRAWER

25. LATERAL ANKLE SPRAIN DIAGNOSIS • RADIOGRAPHY-STANDARD • AP • Lateral • Mortise • Critcally review for avulsion fractures, OCD, occult fractures

26. LATERAL ANKLE SPRAIN DIAGNOSIS • RADIOGRAPHS-STRESS • Talar Tilt • Seated or supine relaxed knee, DF or PF • Compare uninjured • >10 degrees pathologic-CFL • Anterior Drawer • plantarflexion • >5mm pathologic-ATFL

27. TALAR TILT Ankle: NEUTRAL or slightly PF VARUS STRESS 9-10 Degrees = + Stress Test 3-5 Degrees SIDE to SIDE = + test ANTERIOR DRAWER Ankle - slight PF 9-10 mm = + test 3-5 mm SIDE to SIDE = + test LATERAL ANKLE SPRAIN DIAGNOSIS

28. SUBTALAR INSTABILITY • ST Instability seen in 10% lateral ankle sprains • Test with stress Brodens view • Angle beam 30-45-60 degrees toward head • Normal joint slides- NO angulation • Side to side angular difference is pathologic

29. SUBTALAR INSTABILITY

30. SUBTALAR INSTABILITY Broden’s View Stress Broden’s

31. LATERAL ANKLE SPRAIN DIAGNOSIS • MRI • ATFL-most common • With injury can see edema fluid in SubQ, around tip of fibula, loss of ligament morphology

33. LATERAL ANKLE SPRAIN INITIAL TREATMENT • Diagnosis and Grade guide treatment • R.I.C.E. initial treatment • NSAIDS-tho some believe increase bleeding/hemarthrosis due to platlet inhibition • Protected weight bearing w/brace, splint, tape, or cast—weight bearing ASAP • Casting 2-6 weeks depending on grade( Gr III) • Prolonged casting better pain control but more stiffness-neutral to DF is key

34. LATERAL ANKLE SPRAIN TREATMENT • REHABILITATION • GOAL= 80% of contralateral leg for return to activity • AROM • DF power • PF power • Weight bearing

35. LATERAL ANKLE SPRAIN TREATMENT • Focal compression + cryotherapy tends toward earlier return to function • Early mobilization yields, less swelling, better ROM earlier return compared to casting • Grade I- weight bearing asap, protected return to play w/brace or tape for 3-4 weeks • Grade II- weight bearing asap, PT, protected for remainder of season & possibly indefinitely due to high recurrence

36. Early Functional Rehab w/Protected WB- Grade II Immobilization x 1 week, WB as tolerated Resistance bands X 4 weeks 90% decrease in water displacement ROM improved from -19 to -4 degrees of normal Casting vs Early Functional Rehab- Grade III Functional treatment showed improved function, less joint laxity at 3 months and 6 months No difference at 1 year *Surgery vs Fxnl RX Surgery with higher complication NO decrease in time to return LATERAL ANKLE SPRAIN TREATMENT

37. PREVENTION Proprioceptive Training-Tilt board 12 week protocol- decreased recurrence 3-4 weeks increased stability PREVENTION Bracing,splints, taping Decreased pain Decreased recurrence Elastic bandage has been shown as effective as others LATERAL ANKLE SPRAIN TREATMENT

38. LATERAL ANKLE SPRAIN Prevention/ “RE-Prevention” • The American Journal of Sports Medicine, Vol. 40, No. 1 • ~205 HS BBALL athletes randomized • Injury rate 0.48/1/12 braced/non-braced • Donjoy Brace Am J Sports Med 1999 27: 753 113 studies reviewed Rehab and then bracing for 6 months AFTER sprain

39. LATERAL ANKLE SPRAIN Prevention/ “RE-Prevention” • Journ AT 2004 • To prevent one sprain tape 26 or 143 • To prevent one had to brace 18 or 39(hx of sprain vs none) • Bracing 3X more cost effective • Journal of Trauma-Injury Infection & Critical Care: • September 1998 • 777 volunteers from the U.S. Army Airborne • 0.3% to 1.9% Injuries braced to non-braced

40. SYNDESMOSIS INJURIESANATOMY • Anteriorinferiortibio-fibular ligament • AITFL-35% of stability • Posteriorinferior tibio- fibular ligament • PITFL • Superficial-9% of stability • Deep-22% of stability • Interosseous membrane • IOM • 22% of stability

41. SYNDESMOSIS INJURIES INCIDENCE/MECHANISM • Isolated injuries EXTREMELY rare • NO studies reproduce syndesmosis injury with externally applied force • External rotation AITFL, IOM • Tibiotalar dislocation

42. SYNDESMOSIS INJURIES INJURY PATTERN • Latent-apparent only on stress radiograph • Frank-apparent on routine radiograph • Type I- frank w/lateral subluxation of fibula NO fibula fracture • Type II- type I w/ plastic deformation of fibula prevents reduction • Type III- RARE-posterior rotary subluxation of fibula • Type IV-RARE-diastasis w/ superior dislocation of talus into tibiofibular joint w/o fibular fracture

43. SYNDESMOSIS INJURIES DIAGNOSIS • OBSERVATION/HISTORY • severe injury/external rotation • PHYSICAL EXAMINATION • pain over syndesmosis-well localized, NO tenderness over ATFL, CFL • REMEMBER-palpate ENTIRE fibula and medially for fractures • SEVERE swelling • ”squeeze test”-causes widening/stretch of remaining fibers and pain • abduction/external rotation stress test

44. SYNDESMOSIS INJURIES DIAGNOSIS SQUEEZE TEST ABDUCTION-EXTERNAL ROTATION TEST

45. SYNDESMOSIS INJURIES DIAGNOSIS • RADIOGRAPHS • AP, Lateral, Mortisse-10-50% incidence of associated fracture • Medial clear space: 2-4mm=normal • Tibiofibular clear space: <5mm in F, 6.5mm in M • Tibiofibular overlap at incisura: >2.1mm in F, 5.7 in M • External rotation stress radiograph • Weight bearing radiographs if possible • Negative talar tilt and anterior drawer • MRI is standard of diagnosis

46. SYNDESMOSIS INJURIES TREATMENT • R.I.C.E • Cast or splint non weight bearing • Sprain w/o diastasis(type I) • Latent diastasis(type II)-NO surgery if fibula reduced anatomically per CT/MRI • Cast or brace non-WB for ~4 weeks with progressive WB 2-4 • additional weeks • Weightbearing stress radiographs q/2 weeks to observe reduction • Stable-weightbearing as tolerated • prolonged time to return-avg 43 days • *2X average severe lateral ankle sprain • Frank Diastasis of any type=operative case

47. COMPLETE TEARS, WIDENED SYNDESMOSIS, WIDENED MORTIS TREATED WITH TWO 4.0 4 CORTEX SCREWS WITH ANKLE IN NEUTRAL 3 MONTHS; SCREWS REMOVED AND ANKLE MOBILIZED INJURIES FROM 6 WEEKS TO 3 MONTHS OLD CAN STILL BE SALVAGED WITH SCREW FIXATION AS ABOVE WITH DEBRIDEMENT OF SYNDESMOSIS ADDED TO CREATE SCAR LIGAMENT SYNDESMOSIS INJURIES TREATMENT

48. CHRONIC INSTABILITY When conservative treatment fails…

49. History Dynamic & Static Continued feeling of “giving way” Pain Mechanical Symptoms Recurrent effusions EXAM Tenderness on ligaments Stress test Xray + stress MRI & CT Arthroscopy CHRONIC INSTABILITY

50. CHRONIC INSTABILITY • CT analysis of 14 ankles vs 12 controls • Measured calcaneus and vertical plane • 6.4 deg vs 2.7 deg calcaneal varus in chronic instability • Statistically significant Van Bergeyk AB, et al FAI 2002