Management and rehabilitation of ligamentous injuries to the ankle

Abstract

The management of ligamentous injuries to the ankle is controversial. Neither the methods for classification and diagnosis, or the procedures for treatment are clear cut. Ankle sprains are a common occurrence, with the majority involving the lateral ligament complex. Within this complex, the anterior talofibular ligament is injured most frequently, usually while the foot is in the plantar flexed position. Ankle injuries can be diagnosed through physical exam, including the anterior drawer test and/or a stress exam, or through roentgenographic evaluation. The purpose of the stress roentgenogram is to measure the degree of talar tilt. However, it does not always yield consistent, reliable results. This inconsistency has led to the use of arthrography. There is debate over its use as well, however, Ankle sprains can be classified into three groups, according to functional loss. Treatment for first and second degree sprains is usually non-operative. The best approach to Grade III sprains is debatable. The issues in the treatment of Grade III sprains are first, whether treatment should be operative or non-operative, and second, whether non-operative treatment should emphasise immobilisation or mobilisation. Brostrom's work is cited as noteworthy. He recommended adhesive strapping followed by mobilisation as the treatment of choice, and reserves surgery for cases of chronic instability. Results demonstrated that strapping yielded shorter disability periods, while surgery produced less instability. The prevention of functional instability is a major concern in the treatment of ankle injuries. There is no consensus for treating a lateral ligament rupture. The authors suggest immobilisation followed by a rehabilitative programme. Three methods of immobilisation are plaster casting, adhesive strapping, and the air-stirrup. The physiological mechanism of cryotherapy and thermotherapy are discussed briefly and recommendations for their use are provided. Aspiration is also discussed. Loss of motion is designated as a primary cause of chronic pain and reinjury, and exercises intended to restore range of motion are provided. Exercises aimed at restoring strength and proprioception are also presented. This allows for return to activity and serves to prevent reinjury.