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ATFL rupture is surgery needed?


Ankle sprains are one of the most common musculoskeletal injuries. They can account for 15-20% of all musculoskeletal injuries. The ankle is supported laterally by the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL), whilst the medial aspect is supported by the deltoid ligament. The most common ankle sprain is forcible inversion (rolling your ankle outwards) which causes damage to the ankle support laterally.

How is this diagnosed?

A subjective and physical examination is done by the doctor or physiotherapist. Talar tilt test and an anterior draw test are performed to determine the laxity in the ligaments. If laxity is present usually an Ultrasound or MRI is performed to confirm the diagnosis. This is to rule out any avulsion fractures and to assign a grade to the tear or tears in the ligaments. A grade 1 tear is mild, causing a stretch of the ATFL causing a tear of some of the ligament fibers. Grade 2 is classified as moderate, causing a significant amount of ligament fibers to be torn. Grade 3 is severe, which indicates rupture of the ligament with possible damage to the other supporting ligaments (CFL and PTFL).

Management?

Conservative management is often similar regardless of the grade of the tear.

This includes:
● RICER: Rest, Ice , compress, elevate, protect
● Immobilisation: Typically not necessary for a grade 1 tear. However, is performed on grade 2 tears until the individual is pain-free. Grade 3 tears can be immobilised for the first two weeks.
● Rehabilitation: Early rehabilitation is key. Not only does it get you back to normal activities quicker it can help to prevent chronic instability. Range of motion exercises are given, commonly an ankle brace can be prescribed, gentle proprioceptive exercises are introduced as well as strengthening of the supporting muscles and ligaments.

Surgical approach

Acute ankle injuries are always managed non-operatively first. If you have a grade 3 ligament rupture you may require surgical intervention. If you have been referred to an orthopedic surgeon and are waiting to see them, it is best to start a conservative rehabilitation program while you wait. Often surgeons will ask you to complete 3 months of conservative rehabilitation with your physiotherapist.

Surgery can be performed if there is an osteochondral defect, loose bodies or tendon tears. However, this is highly individual. The evidence of the benefit of surgical intervention has been mixed. Often surgery is not recommended on acute ankle sprains. A Cochrane review failed to demonstrate a benefit of surgery compared to conservative treatment.

What does this mean?

In summary, if you have a Grade 3 ATFL tear, surgery isn’t always required. If it is safe, speak to your physiotherapist and doctor to start conservative treatment as soon as possible. Often you could be waiting weeks, if not months to see a surgeon. This can be time spent doing rehabilitation on the injury to ensure the best possible outcome for yourself.

If you are looking for a physiotherapy near Sinnamon Park, we will be able to help! All our physios will be able to treat any ankle injuries, and help you get back to your best self.

Click here to book now with one of our physiotherapists!

Read more….

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Chaudhry, H., Simunovic, N., & Petrisor, B. (2015). Cochrane in CORR ®: surgical versus
conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults
(review). Clinical orthopaedics and related research, 473(1), 17–22.
https://doi.org/10.1007/s11999-014-4018-7

Hubbard, T. J., & Hicks-Little, C. A. (2008). Ankle ligament healing after an acute ankle sprain: an
evidence-based approach. Journal of athletic training, 43(5), 523–529.
https://doi.org/10.4085/1062-6050-43.5.523

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