LAS VEGAS, NV--(Marketwire - March 12, 2009) - A panel of foot and ankle orthopaedic
surgeons at the recent American Orthopaedic Foot & Ankle Society Specialty
Day, held as part of the 2009 American Academy of Orthopaedic Surgeons'
Annual Meeting in Las Vegas, discussed different types and methods of
treatment of ankle sprains. The panel, including Moderator Mark E. Easley,
MD, D. Rod Walters II, PhD, Richard M. Marks, MD, Florian Nickisch, MD,
John G. Kennedy, MD and Jeffrey E. Johnson, MD, used a case-based approach
to describe their experiences with diagnosing and treating many of the
conditions that are responsible for persistent pain and loss of function
after ankle sprains.
In addition to a review of conventional treatment methods, the panelists
highlighted state-of-the-art techniques of rehabilitation, minimally
invasive surgery, and arthroscopy. According to Dr. Easley of the Duke
University Medical Center, "In the United States, the incidence of ankle
sprains is roughly 2,300 a day, almost 100 every hour. Although the
majority of acute ankle sprains heal without surgery, approximately 15-20%
of patients have persistent ankle symptoms. Failure of the ankle to heal
may be due to cartilage injuries, subtle ankle fractures, tendon tears,
development of scar tissue, or abnormalities unmasked by an ankle
sprain."
Anterior lateral soft tissue impingement
Richard M. Marks, MD, from the Medical College of Wisconsin, said that
chronic ankle pain following a sprain may be caused by differing factors.
"A frequently overlooked cause is anterolateral corner impingement (ALCI),
which is caused by fibrous scar tissue from torn fibers of the anterior
inferior tibial-fibular ligament (AITFL) or fibers from the anterior
talo-fibular ligament (ATFL). These ligaments help to stabilize the lateral
ankle. Symptoms vary from either dull, achy discomfort in the anterolateral
corner of the joint, or a sensation of ankle instability as a result of
pinching of the scar tissue with activity. Often MRIs fail to recognize
these instances. An injection of the anterolateral corner with a local
anesthetic can help with the diagnosis."
He went on to say that the best treatment is, "An initial course of
immobilization in a stirrup splint or boot combined with physical therapy.
Failure to respond after several months of treatment necessitates surgery,
which is either performed arthroscopically to remove the scar tissue in the
corner of the ankle or in combination with a lateral ligamentous
reconstruction."
Occult fractures
Occult fractures of the ankle and hind foot are rare and often misdiagnosed
as ankle sprains, especially since they can be difficult to diagnose on a
plain x-ray. Florian Nickisch, MD, from the University of Utah, Department
of Orthopaedic Surgery, discussed in his presentation, "They are a major
source of prolonged disability, however, and in some instances delaying
treatment can result in significant long-term disability for the patient.
When evaluating a patient with a presumed acute ankle sprain or residual
pain, it is therefore important to be aware of the many occult fractures
around the ankle and hind foot and their appropriate management."
He added, "Most of these occult fractures involve relatively small
fragments of the talus, the central bone in the ankle joint or the
calcaneus, the heel bone. Many extend into the joint surface of the ankle
or the subtalar joint (the joint below the ankle joint that allows the foot
to accommodate to uneven ground). Because of their small size and their
often obscure anatomic location, these fractures can be hard to see on
regular ankle or foot x-rays. A thorough history, including the mechanism
of injury, a detailed physical examination, and awareness of these injuries
with a high level of suspicion are necessary to make the correct diagnosis.
Often advanced imaging modalities like a CT or MRI are required to
determine the best treatment. Depending on the size, number of fracture
fragments and their displacement, they may require surgery in order to
achieve an optimal outcome and prevent long-term disability."
Talar chondral lesions - acute
Chondral cartilage injuries of the ankle are becoming an increasingly
recognized cause of post-residual sprain dysfunction and pain. According
to John G. Kennedy, MD, of the Hospital for Special Surgery in New York,
"This is, in part, due to increasingly sophisticated imaging and an
increased index of suspicion on behalf of the treating physician. Several
recent studies have demonstrated an incidence of up to 50% of chondral
injuries following high-grade ankle sprains. These are typically shear
injuries of the medial and central aspect of the ankle:
-- Most lesions are best identified with an MRI.
-- Pure cartilage injuries will not typically be picked up by a routine x-
ray.
-- Patients often complain of clicking, or locking of the ankle joint
from the loose piece of cartilage."
Fibrous tarsal coalitions
A fibrous tarsal coalition is an abnormal connection between two bones in
the foot which is present since birth. This connection limits the motion of
the two connected bones and causes stiffness of the foot, especially the
side-to-side motion of the heel. Jeffrey E. Johnson, MD, of Washington
University Department of Orthopedic Surgery said, "Although this is a
relatively uncommon cause of persistent pain following an 'ankle sprain,'
it is often overlooked and the diagnosis may be delayed. The two common
scenarios in which a tarsal coalition present are: 1) the active adolescent
with a complaint of recurrent sprains and a stiff painful hind foot (the
patient may not remember a significant ankle injury); and 2) the adult with
lingering pain over the outside of the hind foot after a sprain due to a
previously painless tarsal coalition that becomes painful after an injury."
Dr. Johnson continued, "The key to making the diagnosis of this condition
after a sprain is to perform a careful examination of the ankle to
determine if the location of tenderness is over the ankle ligaments (as in
a sprain) or over the typical locations for a tarsal coalition, which are
slightly lower on the side of the hind foot. In addition, the physical
exam will demonstrate limited side-to-side range of motion of the foot.
Careful scrutiny of the x-ray will often identify the abnormal bone
formation indicating a tarsal coalition; however, a CT scan is often
obtained to confirm the diagnosis. If the pain does not resolve with ankle
rehabilitation and immobilization, surgical excision of the painful
connection between the calcaneus and navicular bones is recommended. This
will not significantly improve the range of motion of the foot, but it will
relieve pain."
Ankle rehabilitation
D. Rod Walters, PhD, a consultant in sports medicine, said his approach to
ankle rehabilitation includes restoration of range of motion, strength,
ankle function, and sport specific conditioning. "Failure to do these
things results in chronic ankle dysfunction, an anomaly affecting some
20-50% of lateral ankle sprain patients. Ankle dysfunction is characterized
by pain, inflammation, and loss of motion and may produce long-term
disability and function, leading to increased treatment costs and time loss
for patients."
He continued, "For injury prevention, strengthening of the muscles of the
ankle should include all appropriate motions -- and include exercise of
concentric (shortening) and eccentric (lengthening) contractions. The
eccentric mode is so important, especially in sport activity, and is often
overlooked due to the difficulty associated with determining the actual
deficit. When approaching bracing and /or taping options for the ankle,
the focus needs to be on control of the calcaneous (heel bone) to minimize
motions associated with the subtalar joint (true ankle motion of inversion
and eversion) while syndesmosis (high ankle sprain) injuries indicate
attention to the first ray (great toe and the area it articulates within
the foot) and the corresponding motions of pronation and supination. Brace
options for these two injuries should address these needs."
This symposium makes it easy to understand the various types of conditions
that comprise the term "ankle sprain." From the simple to the complex, from
the short-term injury to long-lasting condition, this seminar illustrates
the many different aspects to what otherwise might be thought of as a
simple ankle sprain.
About AOFAS
The AOFAS promotes quality, ethical and cost-effective patient care through
education, research and training of orthopaedic surgeons and other health
care providers. It creates public awareness for the prevention and
treatment of foot and ankle disorders, provides leadership, and serves as a
resource for government, industry and the national and international health
care community.
About Orthopaedic Foot and Ankle Surgeons
Orthopaedic foot and ankle surgeons are medical doctors (MD and DO) who
specialize in the diagnosis, care, and treatment of patients with disorders
of the musculoskeletal system of the foot and ankle. This includes the
bones, joints, ligaments, muscles tendons, nerves, and skin. Orthopaedic
foot and ankle surgeons use medical, physical, and rehabilitative methods
as well as surgery to treat patients of all ages. They perform
reconstructive procedures, treat sports injuries, and manage and treat
trauma of the foot and ankle.
Orthopaedic foot and ankle surgeons work with physicians of many other
specialties, including internal medicine, pediatrics, vascular surgery,
endocrinology, radiology, anesthesiology, and others. Medical school
curriculum and post-graduate training provides the solid clinical
background necessary to recognize medical problems, admit patients to a
hospital when necessary, and contribute significantly to the coordination
of care appropriate for each patient.
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