Calcaneofibular Ligament Injury Treatment & Management
- Author: Bryan L Reuss, MD; Chief Editor: Sherwin SW Ho, MD more...
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. 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]
Proper assessment and treatment ensure a decreased complication rate for ankle injuries (see Complications, below).
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.
The image below depicts surgical intervention of the right ankle.
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.
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.
See Complications, below.
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.
See Complications, below.
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