eMedicine Specialties > Sports Medicine > Foot and Ankle
Talofibular Ligament Injury: Treatment & Medication
Updated: Aug 19, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Initial treatment of all grades of lateral ankle sprains consists of rest, ice, compression, and elevation (RICE), as well as nonsteroidal anti-inflammatory drugs (NSAIDs). Ice should be applied to the injured ankle for approximately 20 minutes, 3-4 times per day. Compressive dressings should be used to control swelling. Weight bearing should be encouraged as soon as it is tolerated. With grade III injuries, an ankle brace should be worn at all times till the patient can ambulate pain free. Ankle braces can be used for support in all ankle sprains and may help promote earlier ambulation. Studies have found an air stirrup brace and ACE wrap are beneficial in grade 1 ankle sprains and may help in grade II and III sprains as well.
The early phase of rehabilitation is begun approximately 48 hours postinjury. Icing is continued and range of motion exercises are initiated. Writing the alphabet with the great toe moves the ankle through full range of motion in all planes. Stationary biking and stretching of the Achilles tendon are also beneficial.
As strength and mobility improve, isometric exercises for ankle dorsiflexion, plantar flexion, inversion, and eversion are initiated. The isometric exercises are followed by resistance exercises (initially using a Thera-Band strap) and then heel and toe raises. Agility training also aids in returning the athlete to sports. Proprioceptive and balance training are also extremely important to help the patient heal fully, especially in jumping athletes. Proprioceptive training should be incorporated into all rehabilitation protocols.
In grade III ankle sprains, some studies have shown that early mobilization and rehabilitation may provide earlier functional recovery relative to surgery, and there is general agreement to try a 6-week period of conservative management, including early, controlled mobilization and rehabilitation before considering surgery.
Also, no difference is found in long-term outcome when comparing early surgical repair with delayed surgical repair following failed conservative therapy. Therefore, there is no indication for routine early surgical repair.
Related eMedicine topics:
Achilles Tendon Pathology
Achilles Tendon Rupture
Achilles Tendonitis
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Specialty Site Surgery
Surgical Intervention
Primary repair of acute lateral ligament tears is rarely indicated. Open repair seems to offer no advantage over closed management at the time of the initial injury. Delayed repair may be necessary in patients with chronic mechanical instability on clinical examination and functional instability; however, surgical intervention in these cases should only be considered after an aggressive rehabilitation program has been unsuccessful.
Consultations
- An emergent consultation is rarely required.
- Consultation with an orthopedic surgeon should be obtained for patients with unstable ankles, dislocations, or associated fractures.
Recovery Phase
Rehabilitation Program
Physical Therapy
When the early phase rehabilitation goals of decreased swelling, full weight bearing, and no tenderness to palpation are met, more aggressive strengthening and proprioceptive training are added. Increased stretching of the Achilles tendon, as well as the gastrocnemius and soleus muscles, is performed using an incline board. Thera-Band exercises are continued for strengthening. Exercises such as one-leg stands and wobble board training are added for proprioception. This training continues until the ankle is at 80-90% of full strength and there are no deficits in proprioception. When these goals are met, the patient may be discharged from therapy.
Surgical Intervention
Maximum benefit from conservative therapy is reached after approximately 10 weeks of active rehabilitation. At this time, 20% of athletes continue to have symptoms secondary to either a functional or mechanical instability. If the patient has reached his or her maximal benefit from functional rehabilitation and has a persistent deficit, then surgical reconstruction should be considered.
Maintenance Phase
Rehabilitation Program
Physical Therapy
The patient should be independent with a home exercise program with sport-specific activities and gradually return to play when the functional goals are met. The physician and/or physical therapist may recommend taping or bracing the ankle upon returning to activity. Taping or bracing a previously injured ankle during athletic activity has been shown to reduce the incidence of recurrent injury.
Medication
The goal of medical therapy is to reduce pain during the acute phase of recovery.
Related eMedicine topics:
Toxicity, Acetaminophen
Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Opioids: A Guide to State Opioid Prescribing Policies
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Nonsteroidal Anti-inflammatory Drugs
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities, which make these ideal agents for treating ankle injuries. The mechanism of action of NSAIDs is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. Many NSAIDs are currently on the market. In general, the mechanism of action of these agents is the same. No evidence exists that one NSAID is more efficacious than another; however, individual response may differ.
Acetaminophen, with or without an opiate analgesic, may be added to NSAID therapy (or used as a substitute).
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or 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; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
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, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.
Acetaminophen (Tempra, Tylenol, Feverall)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity; known G-6-P deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity is possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses that exceed the recommended maximum dose.
Hydrocodone and acetaminophen (Vicodin, Lorcet-HD, Lortab)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants.
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction
Acetaminophen and codeine (Tylenol with codeine)
Indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 4 g/d of acetaminophen
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction
More on Talofibular Ligament Injury |
| Overview: Talofibular Ligament Injury |
| Differential Diagnoses & Workup: Talofibular Ligament Injury |
 Treatment & Medication: Talofibular Ligament Injury |
| Follow-up: Talofibular Ligament Injury |
| References |
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Further Reading
Keywords
talofibular ligament injury, ankle sprain, inversion ankle injury, lateral ligament ankle sprain, anterior talofibular ligament injury, ATFL sprain, posterior talofibular ligament injury, PTFL sprain, recurrent ankle sprain
