SLR - March 2012 - Vikram V. Thakar

Functional Treatment After Surgical Repair for Acute Lateral Ligament Disruption of the Ankle in Athletes

Reference: Takao, M, Miyamoto, W, Matsui, K, Sasahara, J, Matsushita, T. (2011). Functional Treatment After Surgical Repair for Acute Lateral Ligament Disruption of the Ankle in Athletes. The American Journal of Sports Medicine, Vol. 40, No. 2.

 Scientific Literature Review

Reviewed by: Vikram V. Thakar, DPM
Residency Program: Massachusetts General Hospital, Boston, MA

Podiatric Relevance:
Acute lateral ankle ligament injuries, especially sports-related, are frequently seen by podiatrist in clinical practice. Although treatment selection remains controversial, initial functional (conservative) treatment is commonly prescribed, usually consisting of immediate RICE (rest, ice, compression, and elevation) and a short period of immobilization followed by early AROM (active range-of-motion) exercises. Several studies report a 20-40 percent failure rate following non-operative functional treatment for complete rupture of the lateral ankle ligaments, resulting in recurrent lateral ankle instability. The purpose of this study was to investigate and compare clinical outcomes between functional treatment alone and functional treatment after surgical repair, and clarify the efficacy of this sequential treatment approach.

Methods:
Between April 2005 and December 2008, 191 patients who had sustained an ankle injury were seen in the authors’ clinic. The primary complaint was lateral ankle pain, with ecchymosis and tenderness around the distal fibula. Inclusion criteria were radiographic lateral instability with 5 degrees or more talar tilt angle in inversion stress compared to the contralateral side, and/or 6 mm or more anterior talar displacement to the anterior drawer test. Patients without radiographic instability of the talocrural and subtalar joints were excluded from this study, ultimately including 132 patients (132 feet), divided into two groups. No patients had previous ankle surgery.

Seventy-eight patients received functional treatment alone (group F = 43 male & 35 female), and fifty-four patients received functional treatment after primary surgical repair (group RF = 31 male & 23 female). Clinical results were evaluated using the Japanese Society for Surgery of the Foot Ankle-Hindfoot scale (JSSF) score, measuring talar tilt angle and anterior displacement of the talus via stress radiography, and also noting elapsed time between the initial injury and return to full athletic activity with and without external supports. All of the study patients had sports-related injuries, and all were treated with PRICE (protection, rest, ice, compression, and elevation) by an athletic trainer within 24 hours of injury. In group F, all patients had surgery performed within seven days (mean 3.5) after injury. No patients were lost to follow-up.

Results:
All patients returned to their previous athletic activities. The mean JSSF scores at 2 years after injury were 95.6 +/- 5.0 points in group F and 97.5 +/- 2.6 points in group RF (P =.0669). The differences of the talar tilt angles compared with the contralateral side and displacement of the talus on stress radiography at 2 years after injury were 1.1 -/+1.5 degrees and 3.6 -/+ 1.6 mm in group F, and 0.8 -/+  0.9 degrees and 3.2 -/+ 0.8 mm in group RF, respectively (P = .4093, .1883). In group F, 8 cases showed fair to poor results, with JSSF scores below 80 points and instability at 2 years after injury. In group RF, 9 cases (9.4%) showed dorsum foot pain along the superficial peroneal nerve, which disappeared within a month. The mean time elapsed between the injury and the patient’s return to full athletic activity with external supports was 6.3 +/ 1.3 weeks in group F and 5.7 +/- 1.3 weeks in group RF (P = .0498). The mean time elapsed between the injury and the patient’s return to full athletic activity with no external supports was 16.0 -/+ 5.6 weeks in group F and 10.1 -/+ 1.8 weeks in group RF (P < .0001).

Conclusions:
Non-operative functional treatment alone and functional treatment after primary surgical repair for acute lateral ankle disruption showed similar overall results, but functional treatment alone had an approximately 10 percent failure rate and a slower return to full athletic activity. As a definitive conclusion could not be reached, the authors recommend that treatment be tailored to suit each individual patient athlete’s needs.

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