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Shumway JD, Vraa D. Short-Term Effect of Manual Therapy & Taping on Subacute Ankle Sprains with Potential Syndesmotic Sprain: A Case Series. J Man Manip Ther 2021; 30:116-123. [PMID: 34511056 DOI: 10.1080/10669817.2021.1974240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
STUDY DESIGN Case Series. BACKGROUND Syndesmotic ankle sprains can occur in up to 17% of ankle trauma and can lead to long-term disability. This study describes the management of seven patients with subacute, high-grade ankle sprains with concerns of concurrent syndesmotic strain utilizing manual therapy and rigid sports taping. METHODS Seven active duty military members with clinically diagnosed, high-grade ankle sprains and concern for syndesmotic sprain participated in this case series. All patients received multi-modal treatment consisting of manual therapy, rigid sports taping, progressive exercises, and proprioceptive training. Decrease in Numeric Pain Rating Scale (NPRS) following manual therapy and taping treatment, number of sessions before discharge, and the Global Rating of Change (GROC) at discharge were retrospectively reviewed. RESULTS All patients demonstrated an immediate decrease in NPRS following treatment on average of 5 points (range, 3-8 points) with a functional asterisk sign. The improvement in pain and function was maintained until the next treatment session with a mean GROC score of +3. The mean time until recovery was 5.4 weeks (range, 1-8 weeks). DISCUSSION A multimodal approach for patients diagnosed clinically with high-grade ankle sprains and concern for syndesmotic sprain was useful to immediately reduce pain and improve function, and improvements were maintained throughout the duration of care. This study is the first to assess a combination of manual therapy and rigid sports taping for the treatment of suspected syndesmotic ankle sprains, and more stringent research is needed to validate the findings. LEVEL OF EVIDENCE Therapy, 4.
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Affiliation(s)
- Joshua D Shumway
- Operational Medicine Readiness Squadron, Langley AFB, VA, United States.,Tactical Sports and Orthopedic Manual Physical Therapy Fellowship, US Air Force Academy, CO, United States
| | - Derek Vraa
- Tactical Sports and Orthopedic Manual Physical Therapy Fellowship, US Air Force Academy, CO, United States
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Netterström-Wedin F, Bleakley C. Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: A systematic review with meta-analysis. Phys Ther Sport 2021; 49:214-226. [PMID: 33774464 DOI: 10.1016/j.ptsp.2021.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
| | - C Bleakley
- School of Health Sciences, Faculty of Life and Health Sciences, Ulster University, Jordanstown Campus, BT370QB, United Kingdom.
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Larkins LW, Baker RT, Baker JG. Physical Examination of the Ankle: A Review of the Original Orthopedic Special Test Description and Scientific Validity of Common Tests for Ankle Examination. Arch Rehabil Res Clin Transl 2020; 2:100072. [PMID: 33543095 PMCID: PMC7853358 DOI: 10.1016/j.arrct.2020.100072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To review the literature, identify and describe commonly used special tests for diagnosing injury to the ligaments of the ankle complex, present the distinguishing characteristics and limitations of each test, and discuss the current evidence for the clinical use of each test. DATA SOURCES Multiple PubMed (1920-2018) and CINAHL (1920-2018) searches were conducted and various musculoskeletal examination textbooks were reviewed to examine common orthopedic tests used to assess the ankle. The articles were reviewed for additional references and the search continued until the original description was found when possible. STUDY SELECTION All articles discussing the performance of the test or its validity (ie, sensitivity and specificity) were reviewed and summarized. DATA EXTRACTION Articles were reviewed for additional references and the search continued until the original description was found when possible. DATA SYNTHESIS The literature was reviewed, commonly used special tests for diagnosing ankle injuries were identified and described, distinguishing characteristics and limitations of each test were presented, and the current evidence for the clinical use of each test was discussed. CONCLUSIONS A complete physical examination is critical in the diagnosis of ankle injuries. The combination of available information such as mechanism of injury, all signs and symptoms, and changes in gait, is key to a conclusive and correct diagnosis. Clinicians should be aware of the severely limited evidence supporting the use of many commonly used special tests. Applying evidence from the literature will improve diagnostic accuracy. Further research is needed to understand the performance ability of special tests, both individually and when grouped as part of a test battery.
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Affiliation(s)
- Lindsay W. Larkins
- Department of Movement Sciences, Athletic Training Programs, University of Idaho, Moscow, ID
| | - Russell T. Baker
- Department of Movement Sciences, Athletic Training Programs, University of Idaho, Moscow, ID
- University of Washington School of Medicine, WWAMI Medical Education Program, Moscow, ID
| | - Jayme G. Baker
- Department of Movement Sciences, Athletic Training Programs, University of Idaho, Moscow, ID
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van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, Denaro V. Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc 2016; 24:1200-16. [PMID: 26704800 DOI: 10.1007/s00167-015-3942-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 12/09/2015] [Indexed: 12/24/2022]
Abstract
PURPOSE The aim of the present study was to perform a systematic review of the current classification systems, and the clinical and radiological tests for the acute isolated syndesmotic injuries to identify the best method of classification and diagnosis allowing the surgeon to choose the appropriate management. METHODS A systematic review of the literature according to the PRISMA guidelines has been performed. A comprehensive search using various combinations of the keywords "classification", "grading system", "ankle injury", "ligament", "syndesmotic injury", "internal fixation", "acute", "synostosis", "ligamentoplasties", "clinical", "radiological" over the years 1962-2015 was performed. The following databases were searched: MEDLINE, Google Scholar, EMBASE and Ovid. RESULTS The literature search resulted in 345 references for classification systems and 308 references for diagnosis methods, of which 283 and 295 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included 27 articles describing classification systems and 13 articles describing diagnostic tests for acute isolated syndesmotic injuries. CONCLUSIONS The ESSKA-AFAS consensus panel recommends distinguishing acute isolated syndesmotic injury as stable or unstable. Stable injuries should be treated non-operatively with a short-leg cast or brace, while unstable injuries should be managed operatively. The recommended clinical tests include: tenderness on palpation over the anterior tibiofibular ligament, the fibular translation test and the Cotton test. Radiographic imaging must include an AP view and a mortise view of the syndesmosis to check the tibiofibular clear space, medial clear space overlap, tibial width and fibular width. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE, Amsterdam, The Netherlands
| | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.
| | - Mattia Loppini
- Department of Orthopaedic and Trauma Surgery, Humanitas Research Hospital, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Pino Florio
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Ludovica Maltese
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Mauro Ciuffreda
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
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Mulligan EP. Evaluation and management of ankle syndesmosis injuries. Phys Ther Sport 2011; 12:57-69. [PMID: 21496767 DOI: 10.1016/j.ptsp.2011.03.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 03/07/2011] [Accepted: 03/09/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ankle injuries are common in sporting activities with damage to the inferior tibiofibular ligaments being notable for their resultant disability and prolonged recovery. OBJECTIVE To provide a synopsis of the current best evidence regarding the recognition and treatment of injury to the syndesmotic ligaments of the ankle. DESIGN Structured narrative overview. METHODS Keyword search of Medline, CINAHL, and PEDro databases for studies published in English from January 1985 to July 2010. In addition, the reference lists from articles obtained were manually searched for relevant literature. SUMMARY This manuscript provides an overview of the distal tibiofibular pathologies, discusses the accuracy, limitations, and prognostic ability of clinical and radiographic examination techniques, and presents a philosophical approach to the rehabilitative management of syndesmotic injuries that integrates known biomechanical influences. CONCLUSION An appreciation for the mechanism of injury and a careful examination can distinguish these injuries from other forms of ankle instability. Proper recognition and immediate attention to the unique complexities of this joint can minimize morbidity and prevent a delayed return to sports.
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Affiliation(s)
- Edward P Mulligan
- UT Southwestern Medical Center School of Health Professions, Department of Physical Therapy, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States.
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van den Bekerom MPJ, de Leeuw PAJ, van Dijk CN. Delayed operative treatment of syndesmotic instability. Current concepts review. Injury 2009; 40:1137-42. [PMID: 19524232 DOI: 10.1016/j.injury.2009.03.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 03/09/2009] [Accepted: 03/09/2009] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To review the literature concerning articles evaluating the delayed operative treatment of isolated syndesmotic instability. MATERIAL AND METHODS The main databases Pubmed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, Current Controlled Trials and Embase were searched from 1988 to September 2008 to identify studies relating to the late reconstruction of the distal tibiofibular syndesmosis after isolated syndesmotic injury. The level of evidence of the included articles was scored. RESULTS Fifteen articles were identified, involving 94 ankles with a delayed reconstruction for isolated syndesmotic instability. CONCLUSION In subacute (6 weeks to 6 months) total ruptures the focus is to restore the normal anatomy by repair of the ruptured ligament with placement of a syndesmotic screw. On base of the literature in combination with experience in clinical practice some guidelines are formulated. If inadequate remnants of the anterior inferior tibiofibular ligament (AITFL) are present, a tendon graft can be used. The insertion of the AITFL on the tibia can be medialised with a bone block and fixed with a screw. For the treatment of persistent widening and late instability these reconstruction techniques have to be used combined with debridement and placement of a syndesmotic screw to protect the reconstruction. Most adequate treatment for chronic syndesmotic instability (>6 months) is the creation of a synostosis to stabilise the distal tibiofibular joint. Late repairs give satisfactory but less favourable outcome as compared to properly treated acute injuries. It is not easy to regain complete stability by means of these secondary procedures.
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Lin CF, Gross ML, Weinhold P. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. J Orthop Sports Phys Ther 2006; 36:372-84. [PMID: 16776487 DOI: 10.2519/jospt.2006.2195] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Syndesmosis injuries are rare, but very debilitating and frequently misdiagnosed. The purpose of this clinical commentary is to review the mechanisms of syndesmotic injuries, clinical examination methods, diagnosis, and management of the injuries. Cadaveric studies of the syndesmosis and deltoid ligaments are also reviewed for further understanding of stress transmission and the roles of different structures in stabilizing the distal syndesmosis. External rotation and excessive dorsiflexion of the foot on the leg have been reported as the most common mechanisms of injury. The injury is most often incurred by individuals who participate in skiing, football, soccer, and other sport activities played on turf. The external rotation and squeeze tests are reliable tests to detect this injury. The ability of imaging studies to assist in an accurate diagnosis may depend on the severity of the injury. The results of cadaveric studies indicate the importance of the deltoid ligament in maintaining stability of the distal tibiofibular syndesmosis and the congruency of the ankle mortise. Intervention programs with early rigid immobilization and pain relief strategies, followed by strengthening and balance training are recommended. Heel lift and posterior splint intervention can be used to avoid separation of the distal syndesmosis induced by excessive dorsiflexion of the ankle joint. Application of a rigid external device should be used with caution to prevent medial-lateral compression of the leg superior to the ankle mortise, thereby inducing separation of the distal syndesmosis articulation. Surgical intervention is an option when a complete tear of the syndesmotic ligaments is present or when fractures are observed.
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Affiliation(s)
- Cheng-Feng Lin
- Center for Human Movement Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7135, USA
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