Photograph of passive range of motion exercise using a band.
Photographs of isometric peroneal strengthening exercise using a ball (A) and Achilles strengthening exercise against a wall (B).
(A, B) Photographs of isotonic peroneal strengthening exercise using a band.
Photograph of single leg balance exercise.
Clinical Classification of Lateral Ankle Ligaments Injury14)
| Grade | Injured ligament | Clinical symptoms | Stress test |
|---|---|---|---|
| I | ATFL stretched | Mild swelling and tenderness | Anterior drawer test (―) |
| Minimal difficulty with ROM and weightbearing | Varus tilt test (―) | ||
| II | ATFL torn and/or CFL tear | Moderate swelling and ecchymosis | Anterior drawer test (+) |
| Anterolateral ankle tenderness | Varus tilt test (―) | ||
| Restricted ROM, increasing difficulty to bear weight | |||
| III | ATFL, CFL torn and/or PTFL tear | Diffuse swelling and ecchymosis | Anterior drawer test (+) |
| Tenderness over anterolateral capsule, ATFL, CFL | Varus tilt test (+) | ||
| Inability to bear weight |
Data from the article of Jackson et al. (Clin Orthop Relat Res. 1974;101:201-15).14) ATFL: anterior talofibular ligament, CFL: calcaneofibular ligament, PTFL: posterior talofibular ligament, ROM: range of motion.
Classification of Lateral Ankle Ligament Injury and Treatment Recommendations15)
| Classification | Criteria | Recommendation |
|---|---|---|
| Type I | Stable ankle to clinical testing (with anesthesia, if necessary) | Symptomatic treatment |
| Type II | Unstable ankle with positive anterior drawer test or positive talar tilt test or both | |
| Group 1 | Nonathlete or older patient | Functional treatment |
| Group 2 | Athlete or high-demand patient | |
| Type A | Negative radiographic stress test | Functional treatment |
| Type B | Positive radiographic stress test (talar tilt angle >15。, anterior talar translation >10 mm) | Surgical repair |
| Type C | Subtalar instability (+) | Functional treatment |
Data from the book of Coughlin and Mann (Surgery of the foot and ankle. 7th ed. St. Louis: Mosby; 1999).15)
Functional Rehabilitation Program after Acute Lateral Ankle Sprain
| Goal | Suggested exercises | Frequency and duration |
|---|---|---|
| Restoration of motion | ||
| Active ROM exercise | Circle exercise or alphabet exercise | 10 times at a time |
| Passive ROM exercise | Stretching using band or towel (refer to Fig. 1) Stationary bicycle | Repetition (5 times a day) |
| Strengthening exercise | ||
| Isometric exercise | Push against a wall or fixed object (refer to Fig. 2) | Maintenance for 10 seconds |
| Isotonic exercise | Resistive exercise using band (refer to Fig. 3) | 10 times at a time |
| Plantarflexion | Repetition (5 times a day) | |
| Dorsiflexion | ||
| Inversion | ||
| Eversion | Peroneal strengthening exercise | |
| Proprioceptive training | Balance exercise on wobble or tilt board | 5 times at a time |
| One-leg standing with eyes open | Repetition (3 times a day) | |
| One-leg standing with eyes closed (refer to Fig. 4) | ||
| Progress from static to dynamic balance | ||
| Walking & jogging | Gait training with straight plane | Distance gradually increase |
| Zigzag walking | ||
| Forward and backward jogging | ||
| Running | Figure-8-running | Distance gradually increase |
| Cutting & jumping |
Running Figure-8-running Distance gradually increase Cutting & jumping
Clinical Outcomes after Surgical Treatment for Acute Lateral Ankle Ligament Injury
| Study | Journal | Key result |
|---|---|---|
| Povacz et al. (1998)47) | Nonoperative treatment of an injury of the fibular collateral ligaments of the ankle yields results that are comparable with those of operative repair and is associated with a shorter period of recovery. | |
| Pijnenburg et al. (2000)46) | Operative treatment for ruptures of the lateral ankle ligaments leads to better results than functional treatment, and functional treatment leads to better results than cast immobilization for six weeks. | |
| Specchiulli and Cofano (2001)40) | No significant differences were found between the primary repair and conservative management groups with regard to objective or subjective stability, functional scores, or the overall result. | |
| Pijnenburg et al. (2003)45) | Compared with functional treatment, operative treatment gives a better long-term outcome in terms of residual pain, recurrent sprains and stability. | |
| Pihlajamäki et al. (2010)44) | The long-term results of surgical treatment of acute lateral ligament rupture of the ankle correspond with those of functional treatment. Although surgery appeared to decrease the prevalence of reinjury of the lateral ligaments, there may be an increased risk for the subsequent development of osteoarthritis. | |
| Takao et al. (2012)48) | Functional treatment alone and functional treatment after primary surgical repair showed similar overall results after acute lateral ankle sprain. But, functional treatment alone had an approximately 10% failure rate and a slower return to full athletic activity. | |
| White et al. (2016)49) | Acute repair of grade III injuries in professional high-demand athlete leads to a predictable return to sport (approximately 10 weeks) and may reduce the incidence of repeat sprains and intra-articular damage. |
Recent Systemic Reviews regarding the Conservative and Surgical Treatments for Acute Lateral Ankle Sprain
| Study | Conclusion |
|---|---|
| Kerkhoffs et al. (2007)3) | There are insufficient high-quality randomized controlled trials available to give a final judgement on the effectiveness of surgery compared with conservative treatment. |
| Chan et al. (2011)16) | Given that the results of secondary repair are similar to primary repair and that functional treatment has yielded similar outcomes, surgery is rarely indicated in the acute setting. |
| Kerkhoffs et al. (2012)23) | There was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications after surgical treatment. Functional treatment is preferred over surgical therapy. |
| van den Bekerom et al. (2013)4) | Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, nonoperative measures. Acute repair of the lateral ankle ligaments in grade III injuries in professional athletes may give better results. |
| Petersen et al. (2013)22) | The majority of grades I, II, and III lateral ankle ligament ruptures can be managed without surgery. The indication for surgical repair should be always made on an individual basis. |
| Chaudhry et al. (2015)50) | Cochrane review failed to demonstrate a benefit of surgery compared with conservative management for acute lateral ligament complex injuries. Surgery for acute lateral ligament complex injuries is not recommended, regardless of severity. |
| Al-Mohrej and Al-Kenani (2016)24) | Regardless of severity, surgery for acute ankle sprain is not recommended anymore. |