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Calcaneofibular Ligament Injury: Treatment & Medication
Updated: Jan 2, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Rest, ice, compression, and elevation (RICE) are vital components to a fast recovery.12,17 Nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate for the presence of pain and swelling.18 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.17,19 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.20,21,22
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, 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.
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.
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.
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.
Medical Issues/Complications
See Complications, below.
Medication
The goal of pharmacotherapy is to decrease the patient's pain and inflammation.
Nonsteroidal anti-inflammatory drugs
NSAIDs are most commonly used for the relief of mild to moderate pain. Although the effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include naproxen and ketoprofen.
Ibuprofen (Motrin, Advil, Ibuprin, Nuprin)
DOC for the treatment of mild to moderate pain if no contraindications are present. Inhibits inflammatory reactions and pain, probably by decreasing the activity of the enzyme cyclooxygenase, which results in the inhibition of prostaglandin synthesis.
Adult
400 mg PO q4-6h, 600 mg PO q6h, or 800 mg PO q8h, while symptoms persist; not to exceed 3.2 g/d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of loop diuretics when administered concurrently; PT duration may increase when administered concurrently with anticoagulants; instruct patients to watch for the signs and symptoms of bleeding; ibuprofen and other NSAIDs may increase serum lithium levels and the risk of methotrexate toxicity
Documented hypersensitivity; avoid in patients in whom aspirin, iodides, or other NSAIDs induce hypersensitivity because of potential cross-sensitivity to other NSAIDs; contraindicated in the presence of diagnosed peptic ulcer disease, recent GI bleed or perforation, renal insufficiency, and in those at high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function
Naproxen (Naprosyn, Aleve)
Used for the relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of the enzyme cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
200-250 mg PO q6-8h or 500 PO mg bid; not to exceed 1.25 g/d; may increase to 1.5 g/d for limited periods
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Probenecid and lithium may increase the concentrations and, possibly, the toxicity of NSAIDs; the effect of loop diuretics may decrease when administered concurrently; PT duration may increase when administered concurrently with anticoagulants; instruct patients to watch for the signs and symptoms of bleeding; concurrent administration with phenytoin may increase serum phenytoin levels, resulting in an increase in the pharmacologic and toxic effects of phenytoin
Documented hypersensitivity; contraindicated in those with diagnosed peptic ulcer disease, recent GI bleed or perforation, renal insufficiency, and those at high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely and usually return to normal in ongoing therapy; discontinuation may be necessary if leukopenia, granulocytopenia, or thrombocytopenia persists
Ketoprofen (Orudis, Actron, Oruvail)
Initially administer small doses to patients with a small body size, elderly patients, and patients with renal or liver disease. Doses >75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for a response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Probenecid and lithium may increase the concentrations and, possibly, the toxicity of NSAIDs; the effect of loop diuretics may decrease when administered concurrently; PT duration may increase when administered concurrently with anticoagulants; concurrent administration with phenytoin may increase serum phenytoin levels, resulting in an increase in the pharmacologic and toxic effects of phenytoin.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Avoid use in patients diagnosed with GI disease, cardiovascular disease, renal or hepatic impairment, and patients receiving anticoagulants.
Celecoxib (Celebrex)
Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme and is induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus the incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared with nonselective NSAIDs. Seek the lowest dose for each patient.
Neutralizes circulating myelin antibodies through anti-idiotypic antibodies; downregulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).
Has a sulfonamide chain and is primarily dependent upon cytochrome P450 enzymes (a hepatic enzyme) for metabolism.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may cause an increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations.
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause fluid retention and peripheral edema; caution in patients with compromised cardiac function, hypertension, conditions predisposing to fluid retention; caution in the presence of severe heart failure and hyponatremia because circulatory hemodynamics may deteriorate; NSAIDs may mask the usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction
More on Calcaneofibular Ligament Injury |
| Overview: Calcaneofibular Ligament Injury |
| Differential Diagnoses & Workup: Calcaneofibular Ligament Injury |
 Treatment & Medication: Calcaneofibular Ligament Injury |
| Follow-up: Calcaneofibular Ligament Injury |
| Multimedia: Calcaneofibular Ligament Injury |
| References |
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Further Reading
Keywords
ankle ligament injury, ankle injury, ligament injury, lateral ankle injury, sprain, ankle sprain, lateral ankle sprain, CFL injury
