SOFT-TISSUE MANGEMENT THE ‘DIFFICULT’ANKLE

The immediate treatment of acute ankle ligament injuries has been discussed previously in this journal (Issue 1) and it is well accepted that after initial control of pain and swelling, early functional treatment with weight–bearing and range of motion is the treatment of choice. Cast immobilization is not recommended even for more severe injuries.

This article will focus on the management of those patients who have had an inversion injury to the ankle but now some 4-6 weeks later are not progressing adequately in function or rehabilitation.

Anatomy and biomechanics Although many inversion injuries are mild and self-limiting and the patient does not seek medical advice, these injuries do contribute a major workload to health care providers.

While the majority of

injuries principally involve the lateral lig- ament complex of the ankle, it is not per- haps surprising, with this vast number of injuries, that a significant proportion either fail to resolve or involve other structures.

When considering the other structures that may be involved during such an injury, it is important to consider the functional anatomy and biomechanics of the ankle (Fig.1). The inversion injury of the ankle does not solely involve the talo- crural joint (tibia, fibular and talus) but the talus itself acts as a torque converter as inversion occurs.

The talus has a rotatory motion which ini- tially ‘takes out’ the anterior talo-fibular ligament (ATFL) but also may affect the subtalar ligaments, in particular the cervi- cal ligament and the inter-osseus talocal- caneal ligament (Fig.1).

The ATFL is only 2mm thick and is

FACTS

● It is estimated that approximately 6,500 inversion injuries occur every day in the UK ● In Scandinavia 7-10% of accident and emergency visits are due to sprained ankles ● It is the most commonly occurring injury both within and outside the sporting environment ● 50% of all basketball injuries are due to ankle sprains ● 20-35% of all football injuries are due to ankle sprains

essentially a thickening of the ankle joint capsule. As such, tearing of this ligament may also produce tearing of the capsule with bleeding into the ankle.

The calca-

neo-fibular ligament (CFL) is a sturdier structure but it is intimately associated

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