Prognostic factors of acute ankle sprain: Need for ultrasonography to predict prognosis

Prognostic Values of Clinical and Anthropometric Characteristics in Lateral Ankle Sprain Following Physiotherapy

Lateral ankle sprain (LAS) is a common injury in sports and daily activities. The present study aimed to determine the prognostic value of clinical and anthropometric parameters in predicting LAS recovery after physiotherapy. Twenty-seven patients with acute LAS were included in this cohort study. First, prognostic factors and anthropometric variables were assessed, along with the time elapsed since the injury, pain score on a visual analogue scale (VAS), navicular drop, ankle range of motion (ROM), and ambulation status. Second, patients received physiotherapy, and their recovery status was assessed using the foot and ankle outcome score (FAOS) questionnaire immediately (first evaluation) and one month after physiotherapy (second evaluation). Univariate regression analysis and stepwise regression were used to evaluate the association between prognostic factors and outcome predictability. The results of this paper have shown that ambulation status was significantly correlated with all FAOS subscales in both the first and second evaluations, except for the FAOS-symptoms (FAOS-Sx) and FAOS-quality of life (FAOS-QOL) subscales in the first evaluation. The eversion ROM was significantly correlated with the FAOS-Sx and FAOS-Sports and Recreational activities (FAOS-Sport/Rec) subscales in the first evaluation. Additionally, age, height, and VAS were significantly correlated with FAOS-activity of daily living (FAOS-ADL) in the first evaluation, so this means that ambulation status is a valuable predictor of treatment success immediately and one month after physiotherapy intervention and compared to other FAOS subscales, the FAOS-QOL subscale is a more reliable predictor of the effectiveness of physiotherapy.

Ultrasonographic examination of acute soft tissue lesions in the elbow has good inter-rater reliability and acceptable agreement with magnetic resonance imaging

BACKGROUND

Ultrasonography (US) has been suggested as a valuable complement to clinical and radiologic examinations in elbow trauma. Magnetic resonance imaging (MRI) has been the method of choice, despite fair to moderate inter-rater reliability (IRR). US has potential advantages but is assessor dependent and the IRR scarcely examined. The primary aim of the present study was to investigate IRR for US and secondarily interobserver agreement (IOA) between US and MRI in the acute phase after elbow trauma. Acute phase was defined as 2 weeks and, if applicable, the following weekend. The hypothesis was that US reliability would be at least substantial for complete muscle or ligament lesions.

METHODS

A total of 116 patients (50 men, median age 47 [range 19-87] years) who had an elbow trauma with dislocation and/or fracture were included. Exclusion criteria were prior injury to the same elbow, and US and/or MRI not possible within 16 days. During US, the condition of muscle origins at the epicondyles and collateral and annular ligament complexes was recorded in a predesigned protocol, with the alternatives intact, partially or completely torn. Seventy-two patients had a second US examination the same day by an independent upper extremity surgeon, and 58 of the 116 patients underwent an MRI before or after the US, evaluated by 2 radiologists using the same protocol. IOA and IRR between assessors and modalities were analyzed with kappa statistics and interpreted according to Landis and Koch. Perfect agreement (PA) was reported in percentages.

RESULTS

US examination within 2 weeks was feasible with tolerable discomfort. Defining muscle origins and ligaments as intact or completely torn, the US IRR ranged from substantial to near perfect (kappa 0.63-1, PA 93%-100%). Intact tissues vs. tear (partial and complete tear combined) or intact vs. partial vs. complete tear resulted in kappa values from moderate to substantial and PA 74%-96% with lowest reliability for the muscle origins. The IOA between MRI and US ranged from fair to near perfect for no tear vs. complete tear (kappa 0.25-1, PA 65%-100%). Agreement between no tear and tear (partial and complete together) ranged from fair to substantial (0.25-0.66, PA 63%-89%) and no tear vs. partial or complete tear ranged from fair to moderate (0.25-0.53, PA 50%-79%).

CONCLUSION

US in the acute setting is suitable and reliable for diagnosis of ligament injuries in the elbow and is in addition fast, cheap, and easily accessible. The agreement with MRI seems to vary with the structure assessed and severity of the lesions, ranging from fair to near perfect.

The Role of Ultrasound in the Management of Ankle Sprains and a Clinically Relevant Geisinger Ankle Sprain Sports Ultrasound Protocol

ABSTRACT

Ankle sprains are the most common lower extremity injury in physically active individuals. These injuries are classified as lateral, medial, and/or syndesmotic. Treatment may include functional rehabilitation, bracing, weight-bearing restriction, medications, injections, and surgery. While most sprains heal rapidly, permanent disability and pain may arise. Diagnostic ultrasound has been demonstrated to be accurate in diagnosing ligamentous injuries, but it is often excluded from management algorithms that rely on physical examination alone to diagnose significant injuries. This article proposes a comprehensive, evidence-based diagnostic ankle ultrasound protocol to implement in conjunction with thorough history and physical examination. We also review the current literature to describe where this protocol most improves diagnostic accuracy compared with physical examination alone.

Correction effects of peroneus longus contraction on hallux valgus radiographic parameters

BACKGROUND

Hypermobility of the first tarsometatarsal joint plays an important role in hallux valgus pathogenesis. The peroneus longus is recognized as a dynamic stabilizer of the first tarsometatarsal joint. However, the association between the peroneus longus function and the hallux valgus deformity remains unknown. This study aimed to determine the effect of peroneus longus contraction induced by electrical muscle stimulation on the correction of hallux valgus radiographic parameters in patients with hallux valgus.

METHODS

Thirty-five patients with hallux valgus (47 feet; 2 men, 33 women; mean age 64.9 years) were included. Non-weight-bearing dorsoplantar radiographs of the foot were obtained with and without electrical muscle stimulation of the peroneus longus. Radiographic parameters of hallux valgus deformities, including the hallux valgus angle, intermetatarsal angle, first metatarsal protrusion distance, and distance between the first and second metatarsal bases, were measured and compared between the two conditions.

RESULTS

All hallux valgus radiographic parameters were significantly improved by contraction of the peroneus longus. The median hallux valgus angle decreased by 13.2°. Fewer changes in the hallux valgus angle were identified in patients with severe deformity and geriatric patients.

CONCLUSIONS

Although the peroneus longus muscle has received little attention in the management of hallux valgus, our findings suggest that it has the potential to be a novel conservative approach for treating mild-to-moderate hallux valgus.

Acute Ankle Sprains

Understanding the types of ankle sprains is essential in determining the most appropriate treatment and preventing substantial missed time from sports. Commonly known and recognized is an acute lateral ankle sprain, however, a differentiation should also be made to understand high (syndesmotic) ankle sprains as the mechanism of injury and recovery periods differ between these two types.

Ultrasonography: an interesting imaging method for ligament assessment during the acute phase of closed elbow injuries

PURPOSE

To evaluate whether ultrasonography can be used to explore the medial and lateral ligament structures during the acute phase of a closed elbow injury.

METHODS

A single-center, prospective study performed between December 2019 and June 2020, including patients who suffered a radial head fracture or elbow dislocation. Two radiologists did a blinded analysis using ultrasonography of visibility, injury grade, and presence of bone avulsion for the radial collateral ligament (RCL), lateral ulnar collateral ligament (LUCL), annular ligament (AL), and anterior (MCLant) and posterior bundles (MCLpost) of the medial collateral ligament. The inter-rater agreement was calculated. The ultrasonography findings were compared with the intraoperative findings in the patients who subsequently underwent surgery.

RESULTS

Forty patients were included (28 radial head fractures and 12 elbow dislocations). The inter-rater agreement was strong for all the study parameters (kappa between 0.65 and 1), except for the visibility of the LUCL (kappa 0.52) and the visibility and appearance of the MCLpost (kappa 0.54 and 0.47, respectively). The injured ligaments were thicker than their contralateral counterparts (p < 0.05). In the 10 patients who underwent surgery, the radiological-surgical correlation was 100% for the RCL and medial ligaments and 70% for the LUCL.

CONCLUSION

Ultrasonography is a reproducible examination that can be used to assess the damage to elbow ligaments during the acute phase following an injury. This examination could be incorporated into the exploration protocol for elbow injuries during the preoperative assessment and to adapt the treatment.

Chronic ankle instability has no correlation with the number of ruptured ligaments in severe anterolateral sprain: a systematic review and meta-analysis

PURPOSE

Despite being a significant public health problem, ankle sprains' prognostic factors are largely unknown. This review aimed to systematically analyze the literature on acute ankle sprains to compare the prognosis of a combined anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments rupture with an isolated ATFL rupture in terms of progression to chronic ankle instability and other clinical outcomes.

METHODS

The databases for Pubmed, CENTRAL and Web of Science were searched. Clinical studies reporting the prognostic effect of combined ATFL-CFL rupture versus an isolated ATFL rupture in conservatively treated ankle sprains, with a minimum follow-up of 12 months, were eligible for inclusion. Only studies with a reliable diagnostic method for anterolateral ankle ligaments evaluation, namely ultrasonography, magnetic resonance imaging, arthrography or stress tenography, were included. The relative risk (RR), along with the 95% confidence interval (CI), was used to quantitatively analyze the main outcomes.

RESULTS

Nine papers were selected for inclusion, of which five were suitable for quantitative analysis. None of them found a statistically significant correlation between ligament injury severity and progression to chronic instability. Concerning other clinical outcomes, three studies found a statistically significant correlation between a combined ligament injury and a worse clinical prognosis. From the quantitative analysis, the relative risk (RR) of chronic ankle instability in a single versus a combined ligament rupture showed no significant difference.

CONCLUSION

A significant statistical correlation between a combined ATFL-CFL rupture and chronic ankle instability, compared to an isolated ATFL rupture, was not found. There is, however, fair evidence showing a worse clinical outcome score in the combined ruptures, as well as a decreased return to full sports activities. The use of reliable and accessible diagnostic methods to determine the number of ruptured ligaments might have a role in managing severe ankle sprains.

LEVEL OF EVIDENCE

Level III.

Quick and simple test to evaluate severity of acute lateral ankle sprain

Background/objective

For early return to sports after a lateral ankle sprain (LAS) and recurrence prevention, effective rehabilitation and gradual return to sports should be initiated while predicting the return time based on the appropriate severity evaluation immediately after injury. However, since severity evaluations performed in previous studies required large space and stairs and involved high-revel activity, their use as a test and index to evaluate severity after LAS was not appropriate considering convenience and risk of re-injury. Therefore, a quick and simple test was developed to evaluate the severity of acute LAS. This study aimed to verify the association between ankle function for severity evaluation and anterior talofibular ligament (ATFL) injury type by ultrasonography and to clarify the usefulness for acute LAS severity evaluation of the single-leg loading (SLL) test.

Methods

In total, 50 patients (34 men, 16 women) out of 58 patients who visited our sports clinic within 3 days after acute LAS and who conformed to the study criteria were included in this study. During the first visit, SLL test and objective/subjective ankle joint evaluation were performed. The SLL test consists of single-leg standing, single-leg heel raising and single-leg hopping, and patients were classified into four levels from 1 to 4 according to results. In addition, ultrasonographic evaluation was performed within 1 week after the first visit to evaluate the type of ATFL injury. Type I was defined as intact ATFL, Type II as swollen ATFL with an almost intact fibrillar pattern and Type III as ATFL appearing swollen with a disrupted fibrillar pattern. The relationship between the SLL test and each evaluation item was investigated using Spearman's correlation coefficient.

Results

As a result of the SLL test, 15 patients had Level 1 (30%), 19 Level 2 (38%), 5 Level 3 (10%) and 11 Level 4 (22%). With regard to correlation coefficients of the SLL test, Japanese Society for Surgery of the Foot ankle/hindfoot scale and sports activity were r_s = 0.71 (p < 0.001) and r_s = 0.66 (p < 0.001), respectively, showing a significant positive correlation. SLL test and the type of ATFL injury also showed a significant negative correlation (r_s = −0.58, p < 0.001).

Conclusions

The SLL test was a simple and useful test that can be used as an index to evaluate the severity of acute LAS.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.

Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: A systematic review with meta-analysis

OBJECTIVE

To summarise and evaluate research on the diagnostic accuracy of clinical tests for ligamentous injury of the ankle syndesmosis.

METHODS

CINAHL, Embase, and MEDLINE were searched from inception to February 12, 2021. Studies comparing clinical examination to arthroscopy, magnetic resonance imaging, or ultrasound were considered eligible. Meta-analysis was based on random effect modelling and limited to studies fulfilling all QUADAS-2 criteria. Sensitivity (SN), specificity (SP) and likelihood ratios determined diagnostic accuracy, all with 95% confidence intervals (CI).

RESULTS

Six studies were included (512 participants; 13 clinical tests; 29% median prevalence). No individual test was associated with both high sensitivity and high specificity. Tests with the highest sensitivity were: palpation [SN 92% (95%CI 79-98)] and dorsiflexion lunge [SN 75% (95% CI 64-84%); n = 2 studies]. Tests with the highest specificity were: squeeze test [SP 85% (95% CI 81-89%); n = 4 studies] and external rotation [SP 78% (95% CI 73-82%); n = 4 studies].

CONCLUSIONS

Clinical examination should involve initial clustering of tests with high sensitivity (palpation; dorsiflexion lunge), followed by a test with high specificity (squeeze). However, as these tests cannot definitively stratify syndesmotic injuries into stable vs unstable, decisions on optimal management (conservative vs surgery) require additional imaging or arthroscopy.