External ligament rupture of the upper ankle joint

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Classification according to ICD-10
S93.2 Traumatic rupture of ligaments at the level of the upper ankle and foot
ICD-10 online (WHO version 2019)
Foot with swollen ankle and bruises after a torn ligament
The outer ligaments of the ankle

The outer band of the ankle joint is made up of three bands (the "lateral ligament"): ligament talofibular anterior and posterior and fibulocalcaneare ligament . At spraining outward ( supination ) occurs mostly to strain or a tear ( rupture ) of the ligament. Talofibular anterior and / or the ligament. Calcaneofibular , rare is the complete rupture of all three bands.

A rupture of at least one of these three ligaments is also called a fibular ligament rupture .

The anterior fibulotalar ligament is most likely to tear when the foot is both straight ( plantar flexion ) and twisted (inversion). If the foot is angled during a twist (dorsiflexion), this ligament usually remains intact.

In the case of ligament tears, the enormous forces that act simultaneously on the surrounding soft tissues and bones can lead to malleolar fractures or to torn bony ligaments (avulsion fractures ).

First aid

As a first aid measure in the event of a suspected torn ligament, the joint is immobilized, cooled, carefully bandaged and elevated ( PECH rule : “break, ice, compression, elevation”).

The PECH rule is generally accepted as an appropriate treatment measure, although the empirical evidence of its effectiveness is insufficient.

Allegedly “minor” injuries are often underestimated by the person concerned and the treating doctor. If not properly diagnosed and treated, repeated injuries or chronic joint instability can result, which can result in further damage.

According to the guidelines of the DGU , ÖGU and DGOOC , it is estimated that only about half of the patients with acute ligament injuries seek medical help and are therefore adequately treated.

Diagnosis

During the diagnosis, the patient is asked about the history of the injury (mechanism of the accident, fall, height, mechanical force and direction of movement of the foot), previous treatment and previous injuries, the ankle is examined for swellings and hematomas, the gait pattern assessed and an examination carried out by palpation and specific function and pain tests. In addition, there are x-rays and, if necessary, the use of other imaging procedures .

Drawer test

In a breach of the outer bands of the ankle because of choosing the right therapy the main question is important, whether it is a ligament or a torn ligament is. Experienced examiners usually succeed in differentiating between ligament stretching and ligament rupture with the drawer test alone , i.e. without taking X-ray images or using other medical examination methods: for the anterior drawer test, the patient lies on his back. The examiner grasps the heel with one hand from below and the other hand gently presses against the shin from above. If the front outer ligament is only pulled, no drawer movement is possible. In contrast, the foot can be significantly shifted from the joint with respect to the tibia and fibula forward (in a supine patient to the top) at a plan ( " talus feed"). Since the normal drawer movement in the upper ankle joint in a healthy state differs greatly from person to person, it is important to carry out the examination beforehand on the healthy ankle joint of the other leg. In this way it can be found out to what extent the drawer movement in the affected person can still be regarded as not torn.

The stability of the fibular collateral ligaments is also tested by their vertical foldability. Here, the rear foot is pressed inward against the fixed lower leg as much as possible.

Some recommend carrying out the drawer test only within the first 48 hours after the injury if an external ligament tear is suspected, in order not to risk that the ligaments will become loose again in the event of a ligament tear. If more than 48 hours have passed, one should assume a crack instead.

Imaging procedures

In addition, imaging procedures such as X-rays can be useful to rule out a break ( fracture ) of the adjacent bones. In rare cases, magnetic resonance imaging (MRI) can also be useful; this makes the same time any further injury (such as capsule cracks , effusions or bone bruises ) visible. As the German Society for Ultrasound in Medicine emphasizes, sonography can be used in addition to or as an alternative to MRI , which enables the appropriately qualified doctor to reveal instabilities and torn ligaments through a dynamic examination.

The so-called “held X-ray images”, which were common until recently, have come under fire when making a diagnosis. An x-ray shows how far the joint can be opened with a defined force. The degree of injury was then deduced from the opening angle, which can be drawn in the X-ray image. The reason for the criticism is that such recorded images can be used to check the middle outer band in particular, which, however, only rarely tears in isolation, but almost always only in combination with the front outer band. Since the question of whether it is a tear or a strain is important for the selection of the therapy, but not whether one or two ligaments are torn, the drawer test, which checks the anterior outer ligament, is sufficient in most cases as the only one Investigation off.

Side effects

The enormous forces that act on the surrounding soft tissues and bones when the ligament is torn can lead to malleolar fractures or to torn bony ligaments (avulsion fractures ), which can lead to a free joint body and sometimes to osseous impingement of the joint. In addition, lateral ligament ruptures can cause soft tissue impingement in the upper ankle, with soft tissue structures ( inflammatory synovial membrane, capsular ligament tissue, scar tissue) trapped in the joint. These are mostly located in the front and side sections of the upper ankle joint. If such soft-tissue or bony entrapment disturbs, they may be removed arthroscopically or minimally invasively .

Inversion trauma is also the most common cause of sinus tarsi syndrome .

treatment

While a few years ago the ruptured outer ligament was regularly sutured , today conservative treatment is standard with equally good treatment results . Because the outer ligament is embedded in a joint capsule , it can grow together without surgery after a rupture. Surgical treatment is only recommended if all three ligaments are completely torn and if an operation is requested (e.g. professional athlete) . Both conservative and surgical treatment of a fibular ligament rupture typically result in an inability to work for several weeks.

Conservative treatment

In the treatment of acute joint trauma, non-steroidal anti-inflammatory drugs (NSAIDs) can be used and the joint can be mobilized early . As a systematic review from 2008 showed, the use of NSAIDs, comfrey ointment and manual therapy in an early phase after the injury has, at least for a short time, significantly positive effects on the functionality of the joint. In combination with other therapies such as physiotherapy, manual therapy also has long-term positive effects on healing. On the other hand, NSAIDs are known to block enzymes that are necessary for healing and that patients whose pain is suppressed may put stress on their joint too soon. Physiotherapy and manual therapy are intended to reduce pain and swelling and restore the function of the joint. In order to prevent chronic instability, the joint is immobilized in the acute phase with the help of a splint and later, in the rehabilitation phase, physiotherapeutic exercises (mobilization of the joint, balance exercises). In addition, the can cryotherapy are used.

Inflammatory, proliferative and remodeling phases

In treatment in conservative therapy, a distinction is made between several phases of healing, the duration of which can vary from case to case and which can also overlap: an initial inflammatory phase lasting several days (phase I), and a reparative phase lasting about 5–28 days or proliferative phase of primary healing (phase II), which is characterized by angiogenesis , proliferating fibroblasts and collagen production, and a four to six week remodeling phase (phase III) in which the collagen fibrils and cells of the ligaments mature. In phases I and II, protection from excessive stress is important in order to prevent excessive production of type III collagen and thus the formation of an elongated soft band; In phase III, on the other hand, a gradual increase in the load is necessary to “harden” the ligaments. Physiological stress stimuli during the healing of a torn ligament lead to better organization of the healing tissue and less scarring.

In conservative therapy, the use of an orthosis for at least five weeks is standard. If the swelling is too strong to be able to put on an orthosis, the foot is initially immobilized for a short time (for example two to four days) until the swelling has subsided somewhat, for example by means of a split plaster of paris with relief on forearm crutches with medical thromboembolism prophylaxis . During the first six weeks or so, modification processes take place that adapt to the first mechanical loads.

It has also been tried to treat ligament injuries with hyaluronic acid injections within the first 48 hours after the injury ; however, the empirical data on this method is still limited (as of 2011).

If there is no (longer) swelling at the joint, an orthosis (e.g. Aircast splint) is usually used. It ensures that the torn ligaments cannot be loaded and that the joint can still be moved. A suitable orthosis stabilizes both the outward rotation ( supination ) of the rear foot and the advancement of the talus. Some orthotics prevent not only supination but also plantar flexion, which is considered important for healing in the initial phase. In others, the mobility of the joint in the horizontal direction ("up / down" = flexion / extension ) is hardly restricted, so that, for example, walking or cycling is possible. Sports physicians recommend using a consistent splint no later than 1–2 days after the trauma (or after an operation). The orthosis is worn day and night for the purpose of stabilization, as the muscle tone decreases at night and the foot could therefore sink into an unfavorable position. The decrease in tension during the night would primarily cause a pull on the anterior fibulotalar ligament and the fibulocalcaneare ligament . By wearing the orthosis, the ligaments grow closer together in a way that is more appropriate for the load, and problems with a stiff joint, which would be expected with complete fixation , are avoided. So-called modular orthotics, which enable the ability to move with the orthotic device to adapt to the healing process, have proven to be particularly advantageous.

From the remodeling phase onwards, the further remodeling of ligaments can take months to years.

Physical therapy

Physical therapy is part of conservative therapy in the case of a ruptured ligament . As with other torn ligaments, it can also a. about the absorption of any edema , the improvement of the blood circulation , the loosening of adhesions and the preservation of mobility in compliance with medical guidelines. In addition, there are adapted exercises for the muscles and, if necessary, instructions for using crutches or other aids.

The guidelines of the DGU, ÖGU and DGOOC provide for isometric exercises in the orthosis for the treatment of the outer ligament rupture after an initial phase with elevation, cryotherapy and elastic wrapping . In the course of treatment, manual therapy is often used to improve the mobility of the joint. The guidelines speak of limited, short-term positive effects of manual therapy; Other studies show that lymphatic drainage and manual therapy can lead to decreased swelling and increased mobility of the joint, which improves proprioception and reduces the risk of joint stiffening . Stretching exercises for the Achilles tendon are used because otherwise it can shorten as a result of the injury . According to the guidelines, coordination training, muscle strengthening (peroneal group) and self-reflex training are provided after the orthosis has been removed. With sensorimotor balance training, which the patient can carry out under supervision or independently, new injuries and the resulting recurring ligament instabilities are to be avoided. However, there are conflicting results on proprioceptive training. The effectiveness of additional ultrasound , laser and short-wave therapy for the treatment of the outer ligament rupture has not been proven.

A 2014 review concluded that manual therapy and joint mobilization reduced pain and improved mobility in both acute and subacute or chronic symptoms.

Operative therapy

According to the guidelines of the DGU, ÖGU and DGOOC, the surgical treatment of the lateral ligament rupture "delivers a capsular ligament stability comparable to non-surgical treatment with an insignificant tendency towards higher stiffness and prolonged inability to work [...] as well as a slightly increased risk for the same early functional follow-up treatment Development of post-traumatic osteoarthritis ”.

Up until the late 1980s, almost every acute ankle ligament tear was operated on. Today, ligament ruptures in the upper ankle are usually treated conservatively at first and surgery is only considered if conservative therapy is not effective after six or more months. Any remaining chronic instability can be eliminated with the help of an external ligament . Torn ligaments are also operated on directly in people who place a high load on the injured joint in everyday life, especially top athletes. Surgery may also be indicated in the event of a torn ligament.

If the operation is carried out directly, the parts of the torn ligament can be put together and surgically sutured within the first 14 days after the injury. This is no longer possible later, as these have already been partially dismantled. However, too early an operation can trigger an arthrofibrotic reaction in the joint capsule.

After an operative ligament reconstruction, prophylaxis of the swelling, u. a. through intermittent cooling, through the use of NSAIDs in the first few days after the operation and through consistent elevation of the foot. In the following, hot-cold alternating showers of the foot and manual therapy can be used. A functional step therapy is used, with an initial six-week splint, which limits the flexo-extension of the upper ankle, and with careful early-functional, sensorimotor exercises from the end of the second week.

Impaired driving ability while healing

If the foot is not yet permanently resilient or if an orthosis is necessary, the fitness to drive may be restricted ( inability to drive ).

Complications

With adequate treatment, either conservatively or through surgery, the outer ligament rupture heals completely in most cases. However, chronic symptoms remain in a smaller proportion of those treated. According to a review from 1997, chronic synovitis or tendinitis , joint stiffness, swelling (or tendency to swell), pain, muscle weakness or joint instability remain in 10–30% of those treated . According to a review from 2018, after 1–4 years, 5% –46% of those treated still had pain, 3% –34% recurrent ankle injuries and 33% –55% joint instability; 25% reported anterior impingement.

If a torn ligament is not adequately treated in the early stages of healing, for example by destroying newly formed wound tissue through retraumatisation, the inflammatory phase is prolonged. Other factors such as old age, circulatory problems or diabetes can also delay healing.

If injuries are not healed sufficiently, repeated injuries or chronic joint instability can occur, which can result in further damage. Furthermore, studies suggest that joint instability can be associated with a reduced quality of life and reduced physical activity in those affected.

Grow the tapes insufficient together, it can lead to wear of the cartilage and thus to osteoarthritis come. (See also: Post-traumatic osteoarthritis .)

Ankle injuries and torn ligaments can result in soft tissue impingement on the upper ankle joint due to post-traumatic synovitis and the trapping of scar tissue, resulting in a pain-related restriction of the range of motion of this joint (ankle joint impingement ). This can be an indication for a surgical procedure, for example by removing the trapped tissue using arthroscopy .

Web links

  • Fresh outer ligament rupture on the upper ankle joint , guidelines for trauma surgery of the German Society for Trauma Surgery (DGU) and the Austrian Society for Trauma Surgery (ÖGU), agreed with the guidelines commission of the German Society for Orthopedics and Orthopedic Surgery (DGOOC), August 8, 2017, valid until August 8, 2017 August 2022
  • Ankle sprain , Gesundheitsinformation.de , IQWiG health portal , April 4, 2018
  • G. Vuurberg, A. Hoorntje, LM Wink, BFW van der Doelen, MP van den Bekerom, R. Dekker, CN van Dijk, R. Krips, MCM Loogman, ML Ridderikhof, FF Smithuis, SAS Stufkens, EALM Verhagen, RA de Bie, GMMJ Kerkhoffs: Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline . In: British Journal of Sports Medicine . tape 52 , no. August 15 , 2018, p. 956 , doi : 10.1136 / bjsports-2017-098106 , PMID 29514819 .
  • Entry on outer ligament rupture in the Flexikon , a Wiki of the DocCheck company

Individual evidence

  1. ↑ Jörg Jerosch: Operative Therapy of the Foot and Ankle: Foot Surgery in Clinic and Practice , Deutscher Ärzteverlag, 2009, ISBN 978-3-7691-0488-2 . P. 287 .
  2. ↑ Stacie I. Ringleb, Ajaya Dhakal, Claude Anderson, Sebastain Bawab, Rajesh Paranjape: Effects of lateral ligament sectioning on the stability of the ankle and subtalar joint . In: Journal of Orthopedic Research . tape 29 , no. 10 , October 1, 2011, ISSN  1554-527X , p. 1459–1464 , doi : 10.1002 / jor.21407 (English, wiley.com ).
  3. ↑ MP van den Bekerom, PA Struijs, L. Blankevoort, L. Welling, CN van Dijk, GM Kerkhoffs: What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? In: Journal of Athletic Training . tape 47 , no. 4 , 2012, p. 435-443 , doi : 10.4085 / 1062-6050-47.4.14 , PMID 22889660 , PMC 3396304 (free full text).
  4. ^ National Athletic Trainers' Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes . In: Journal of Athletic Training . tape 48 , no. 4 , 2013, p. 528-545 ( nata.org [PDF]).
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  6. ↑ a b c d e f g h i R. Best u. a .: Current and new concepts in the treatment of acute lateral ligament injuries of the ankle. In: German magazine for sports medicine. Volume 62, No. 3 (2011), pp. 57/62. (PDF; 179 kB)
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  24. ↑ a b c d André Leumann, Monika Horisberger, Alexej Barg, Beat Hintermann, Victor Valderrabano: Follow-up treatment and return to sports after ligament reconstructions on the upper ankle - instructions for the doctor who will follow up the treatment . In: Swiss journal for sports medicine and sports traumatology . tape 60 , no. 2 , 2012, p. 88–91 ( sgsm.ch [PDF]).
  25. ^ RA Hauser, EE Dolan, HJ Phillips, AC Newlin, RE Moore, BA Woldin: Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics . In: The Open Rehabilitation Journal . tape 6 , 2013, p. 1-20 ( benthamopen.com [PDF]). Pp. 6-7.
  26. ↑ Christoff Zalpour: Springer Lexikon Physiotherapie , Springer-Verlag, 2013, ISBN 978-3-642-34730-6 , p. 121 .
  27. ^ RP McGovern, RL Martin: Managing ankle ligament sprains and tears: current opinion . In: Open Access Journal of Sports Medicine . tape 7 , 2016, p. 33-42 , doi : 10.2147 / OAJSM.S72334 , PMID 27042147 , PMC 4780668 (free full text).
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  31. ↑ a b Frans van den Berg: Applied Physiology , Georg Thieme Verlag, 2003, ISBN 978-3-13-116032-4 . P. 140 .
  32. ↑ Christian Hank: From the lateral ligament rupture to chronic instability. Stage-adapted therapy for ankle instability . In: Orthopedic and trauma surgery practice . tape 6 , no. 07-08 , 2017, pp. 396-400 ( online-oup.de [PDF]).
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  38. ^ "In general, the etiology of impingement can be due to post-traumatic synovitis, malunion of fracture, scarring, recurrent sprains or other osseous causes". Quoted from: Z. Berman, M. Tafur, SS Ahmed, BK Huang, EY Chang: Ankle impingement syndromes: an imaging review . In: The British Journal of Radiology . tape 90 , no. 1070 , February 2017, p. 20160735 , doi : 10.1259 / bjr.20160735 , PMID 27885856 , PMC 5685116 (free full text).
  39. ↑ “Ankle impingement and instability are well-recognized complications of ankle sprain.” Quoted from: A. Datir, D. Connell: Imaging of impingement lesions in the ankle . In: Topics in Magnetic Resonance Imaging (TMRI) . tape 21 , no. 1 , February 2010, p. 15-23 , doi : 10.1097 / RMR.0b013e31820ef46b , PMID 21317565 .
  40. ↑ "In almost two thirds of all cases, the impingement of intra-articular scar tissue and of scar strands after ligament ruptures is the most common cause of soft tissue impingement at the ankle". Quoted from: Mellany Galla, Markus Walther: Arthroscopy on ankle and foot: The practical book of techniques and indications , Schattauer Verlag, 2016, ISBN 978-3-7945-2967-4 . Chapter “4 Arthroscopy of the anterior ankle joint”, subchapter “4.1 Indications”, section “4.1.1 Synovitis and soft tissue impingement” p. 82 .
  41. ↑ Z. Berman, M. Tafur, SS Ahmed, BK Huang, EY Chang: Ankle impingement syndromes: an imaging review . In: The British Journal of Radiology . tape 90 , no. 1070 , February 2017, p. 20160735 , doi : 10.1259 / bjr.20160735 , PMID 27885856 , PMC 5685116 (free full text).
  42. ^ KA Ross, CD Murawski, NA Smyth, R. Zwiers, JI Wiegerinck, CJ van Bergen, CN Dijk, JG Kennedy: Current concepts review: Arthroscopic treatment of anterior ankle impingement . In: Foot and Ankle Surgery: Official Journal of the European Society of Foot and Ankle Surgeons . tape 23 , no. 1 , March 2017, p. 1–8 , doi : 10.1016 / j.fas.2016.01.005 , PMID 28159036 .
  43. ↑ JL Tol, CN van Dijk: Anterior ankle impingement . In: Foot and Ankle Clinics . tape 11 , no. 2 , June 2006, p. 297-310, vi , doi : 10.1016 / j.fcl.2006.02.002 , PMID 16798513 .