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Calcaneofibular Ligament Injury Treatment & Management

  • Author: Bryan L Reuss, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Oct 20, 2015
 

Acute Phase

Rehabilitation Program

Physical Therapy

Rest, ice, compression, and elevation (RICE) are vital components to a fast recovery.[13, 20] Nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate for the presence of pain and swelling.[21] Crutches are also acceptable for a short time after the injury occurs until ambulation is pain free. A widely agreed upon finding is that grade I and grade II ligamentous sprains should be treated nonsurgically, and these injuries have good to excellent prognosis with such treatment.[20, 22] Occasionally, in grade II sprains, a plaster splint may be necessary for 48-72 hours. Reevaluate the injury at this time, and a cast may be applied if the patient continues to have severe pain. Ultimately, it is accepted that grade I and grade II sprains are treated conservatively, whereas the decision to treat grade III lateral ankle sprains (often associated with a complete tear of the ATFL and CFL) is approached on an individual basis.[23, 24, 25]

Medical Issues/Complications

Proper assessment and treatment ensure a decreased complication rate for ankle injuries (see Complications, below).

Surgical Intervention

In grade III sprains, many authors support the decision that younger athletes and patients should be treated surgically,[26] whereas older patients should be casted, with the option of a secondary repair at a later time. Other investigators have shown that functional treatment (early controlled movement) is superior to surgical treatment for grade I, II, and III lateral ankle sprains. If acute surgical treatment is chosen, the operation consists of reapproximating the torn ligament with the ankle in a neutral dorsiflexed and slightly everted position.

The image below depicts surgical intervention of the right ankle.

Surgical dissection/ankle procedure in a right ank Surgical dissection/ankle procedure in a right ankle. The superior blue vessel loop (at 2 o'clock meridian) is around the anterior talofibular ligament, and the inferior blue vessel loop (at 6-o'clock meridian) is around the calcaneofibular ligament. The fibula is seen on the left side of surgical wound.

Consultations

In patients with grade III ankle sprains who present to the ED or a physician's office, a posterior plaster splint and an orthopedic evaluation within 1-2 weeks of the injury is warranted because surgery may be necessary.

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Recovery Phase

Rehabilitation Program

Physical Therapy

Whether the immediate treatment is surgical or conservative, rehabilitation of the weakened and often unstable ankle joint is paramount. Once the initial period of immobilization is over, it is important for the patient to begin a thorough rehabilitation program that focuses on muscle strengthening and proprioception. Implementation of ROM and ankle-strengthening exercises when the patient is pain free is important. Because immobilization and early mobilization with ankle rehabilitation provide equal long-term stability to the ankle, early mobilization should be the goal when possible; this therapy allows for an earlier return to work and activities and is more comfortable to the patient. The maximum therapy benefit is gained with at least 10 weeks of rigorous rehabilitation. Dedication of the patient to his/her rehabilitation reduces the chance of further injury to the ankle joint.

Medical Issues/Complications

See Complications, below.

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Maintenance Phase

Rehabilitation Program

Physical Therapy

Prevention is the foundation of a good maintenance phase therapy. Stretching of the ankle, continuous strengthening exercises, and ankle stabilizers are important in preventing further injury. The patient should also apply common sense when encountering situations that may place the ankle at risk for another inversion injury. If chronic instability occurs in day-to-day situations in which a brace is impractical, surgical reapproximation of the torn ligament or ligamentous reconstruction is indicated to increase stability. An alternative treatment that claims to have achieved good-to-excellent long-term results in 28 of 30 patients is the modified Bostrom procedure, which does not involve calcaneofibular ligament reconstruction.[27]

Medical Issues/Complications

See Complications, below.

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Contributor Information and Disclosures
Author

Bryan L Reuss, MD Orthopedic Surgeon, Orlando Orthopedic Center

Disclosure: Nothing to disclose.

Coauthor(s)

Michael C Wadman, MD Associate Professor, Department of Emergency Medicine, University of Nebraska College of Medicine

Michael C Wadman, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Randy Schwartzberg, MD Director of Sports Medicine Education, Department of Orthopedic Surgery, Orlando Regional Healthcare System

Randy Schwartzberg, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Florida Medical Association, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

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Surgical dissection/ankle procedure in a right ankle. The superior blue vessel loop (at 2 o'clock meridian) is around the anterior talofibular ligament, and the inferior blue vessel loop (at 6-o'clock meridian) is around the calcaneofibular ligament. The fibula is seen on the left side of surgical wound.
Anterior drawer test for the evaluation of anterior talofibular ligament sufficiency.
Aircast providing rigid lateral ankle support.
 
 
 
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