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Syndesmosis Sprains: What should our approach be? |
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Syndesmosis Sprains: What should our approach be?
Sports Rounds
April 8, 2004
Glenn Williams, PT
Matt Doyle, ATC
Overview
Ø
Review of
anatomy, injury, treatment, & outcomes
Ø
Case Studies
Ø
Survey Results
Ø
Discussion of
Implications for Iowa Sports Medicine approach
“One aspect of
ankle injuries, for which the most acceptable treatment is the least
clearly defined, is the management of syndesmosis injuries.”
Review of Anatomy
Review of Anatomy
Review of Anatomy
Review of Anatomy
Mechanisms of Injury
Mechanisms of Injury
Mechanisms of Injury
Taylor et al.,
Am J Sports Med, 1992:
Eversion/ER: 39%
(55%)
Inversion: 30%
(18%)
Internal Rotation:
16% (18%)
Plantar Flexion: 2%
Unknown: 13% (9%)
Incidence
Study %
reported
Ø
Cedell GA,
Acta Orthop Scand, 1975 11%
Ø
Hopkinson et
al., Foot & Ankle, 1990 1%
(Retrospective, record had to
note + Squeeze test or TTP of distal syndesmosis)
Ø
Boytim et
al., Am J Sports Med, 1991 18%
Ø
Gerber et
al., Foot & Ankle Int., 1998 17%
More common in collision sports
Ø
104 ankle
injuries (96 sprains, 7 fractures, 1 contusion)
Ø
79% lateral, 17%
syndesmosis, 4% medial
Ø
Football
(10/32), Soccer (2/20), Rugby, LaX, Gymnas. (1/2)
Ø
Incidence
in collision sports > 30%; non-collision < 5%
University of Iowa Experience
August 2002 to Present
All Athletic
Teams 27 % (29/106)
Football
Team 43% (23/53)
Wrestling
Team 66% (4/6)
Last 5
yrs 72% (13/18)
Physical Exam
Ø
Antalgic gait
Difficult to push-off
Ø
Minimal
edema
Ø
Ecchymosis (+/-)
Ø
TTP over the
AITFL, PTFL, & IO membrane
Special Tests
Radiography/Imaging
Ø
Standard Views
AP (WB)
Mortise
ER Stress
Ø
MRI or CT
Ø
Bone Scan?
Radiography/Imaging
Ø
Clear Space
< 6 mm on
AP/mortise Harper & Keller, 1989
< 5 mm on
AP/mortise
Sclafini, 1985
< 5.2 mm in
females
< 6.5 mm in males
Ostrum
et al., 1995
Radiography/Imaging
Ø
Tibiofibular
Overlap
> 6 mm on AP
> 42% of
fibular width Harper & Keller, 1989
> 5.7 mm in
males
> 2.1 mm in
females
> 24% of
fibular width
Ostrum et al., 1995
Diastasis
Ø
Frank: seen on
AP &-or mortise plain films (unstressed)
Ø
Latent: normal
on AP & mortise plain films, but apparent on ER stress radiographs
Edwards & De Lee, Foot & Ankle, 1984
Classification
Treatment of Grade I & II
Ø
Variable (no
formal studies); ranges from no different than lateral to casting / NWB
with crutches for 2 weeks
“Type I injuries
are usually treated with WBAT in an ankle support for comfort. Return
to play is usually twice as long as with a severe lateral sprain.”
Bartolozzi, OKU: Sports Medicine 2, 1999
“After acute pain &
swelling remit (<72 hrs), WBAT is encouraged & a rehabilitation program
is instituted. Treatment is symptomatic with an emphasis on ROM,
strength, & coordination.”
Casillas, In
De Lee & Drez: Orthopaedic Sports Medicine, 2003
Return to Play
Ø
Minnesota Viking
Football players
Ø
6 year period,
18/96 ankle injuries were syndesmosis sprains (18.4%)
Ø
Treatments
required 19.5 vs. 7.8 for lateral; significantly more practices & games
missed
Ø
40% required 4-6
weeks to return, 2/18 missed 6 weeks & had problems all season
Return to Play
Ø
Duke football
players; 44 syndesmosis sprains
Ø
Mean: 31 days to
return
Ø
50% of those w/
repeat x-rays had HTO
Ø
Those w/ HTO
required 11 more days on average to return to play (43 vs. 32 days)
Ø
Overall outcome
at average of 47 months f/u was no worse than w/o HTO
Ø
Boytim (6/8),
Hopkinson (9/10) with repeat x-rays had HTO
Ø
Veltri et al.,
1995 report on 2 NFL players that had recalcitrant symptoms after
syndesmosis sprains; Both had HTO & full recovery after excision
Persistent Disability
Ø
Taylor et al.,
1992: 44 Duke football players with mean 47 month f/u
36% c/o mild-to-moderate
stiffness
23% reported mild-to-moderate
pain
18% mild-to-moderate persistent
swelling
86% reported their function
good/excellent
Persistent Disability
Ø
Gerber et al.,
1998: West Point Cadets
Acceptable outcome: 1) No pain, 2) No
decrease in function, & 3) > 80% opposite side on lateral hop
test
6 weeks: Only 22% of Grade I & 29%
of Grade II/III had acceptable outcomes
6 months: 33% of Grade I (3/9) and
43% of Grade II/III (3/7) had acceptable outcomes
Many self-discharged & returned to
play
Some Gerber study Conclusions
Ø
Extent of the
injury is most likely underestimated because it often looks benign
(little swelling, ecchymosis, gait +)
Ø
Typical
evaluation methods may not have enough precision or may not effectively
target the pathology
Ø
Rehabilitation
should be specific to the injury
Case 1-Syndesmosis
Injury
l
20 year old male
collegiate wrestler
l
No history of
ankle injuries
l
Injured right
ankle during Intrasquad meet while wrestling defending National Champion
Case 1-Syndesmosis
Injury
l
Mechanism:
external foot rotation while taken to the mat
l
Chief complaint
– Pain after
he experienced a large “pop” in leg
Case 1-Syndesmosis
Injury
l
Physical
Examination
– Minimal
swelling at anterior tib-fib ligament
– Point
tender proximally along syndesmosis
– Decreased
ROM secondary to pain
– Strength
testing deferred
– (+)
Squeeze, External Rotation (Kleiger) Fibula translation tests
– (-)
Anterior drawer test
Case 1-Syndesmosis
Injury
l
X-rays ruled out
fracture
l
Stress X-rays
negative for latent diastasis
l
Stress X-rays
repeated two weeks post
l
Diagnosis:
Moderate syndesmotic ankle sprain without diastasis (right ankle)
Case 1-Syndesmosis
Injury
Treatment & Clinical Course
l
PRICE to
decrease swelling/pain
l
AFO and NWB with
crutches
l
Progress to FWB
then d/c AFO “as tolerated”
l
Improve ROM,
strength, dynamic neuromuscular stability
l
Gradual return
to full function
Case 1-Syndesmosis
Injury
Clinical Measures
l
Initial
– Resolution
10%
– Function
20%
– Minor
swelling
– Pain 6 out
of 10
– ROM and
Strength untested
– Functional
tests deferred due to NWB
– Full
compliance
Case 1-Syndesmosis
Injury
Clinical Measures
l
7 days post
– Unknown
progress
– Poor
compliance with only 4 treatments
– Reportedly
began PWB here
– Remains in
AFO
Case 1-Syndesmosis
Injury
Clinical Measures
l
14 days post
– Resolution
45%
– Function
56%
– Minor
swelling
– Pain 1 out
of 10
– ROM and
strength unmeasured
–
Non-compliance with 7 total appearances
– Started FWB
and started weaning from AFO
Case 1-Syndesmosis
Injury
l
3 weeks post
– Manual
progressive resistance exercise in all planes as tolerated
– Airdyne and
progressing to stairclimber
Case 1-Syndesmosis
Injury
Clinical Measures
l
5 weeks post
– Resolution
70%
– Function
80%
– No swelling
– Pain 1 out
of 10
– ROM full
and strength WNL
– Fair
compliance
Case 1-Syndesmosis
Injury
Clinical Measures
l
5 weeks post
– Begins
functional progression with ankle taped
– Drilling
(wrestling skill work)
– Jogging
– Additional
proprioception with BAPS, trampoline balances
Case 1-Syndesmosis
Injury
Clinical Measures
l
7 weeks post
– Returns
from semester break and begins partial participation
– Regular
team warm-up, drilling
– Live
wrestling for 50% of practice
Case 1-Syndesmosis
Injury
Clinical Measures
l
8 weeks post
– Resolution
85%
– Function
91%
– No swelling
– Pain zero
out of 10
– ROM full
and strength WNL
– Fair
compliance
Case 1-Syndesmosis
Injury
l
8 weeks post
(day 56)
– Tolerating
additional volume and increased intensity of wrestling with no negative
progress
– Returned to
full participation on day 58
– Continued
full participation without complications until case was discontinued
Case 1-Syndesmosis
Injury
l
13 weeks post
(90 days)
l
Case
discontinued
– Resolution
100%
– Function
100%
l
Return to
competition is assessed by coaches
Case 2-Syndesmosis
Injury
l
21 year old male
collegiate wrestler
l
No previous
ankle injuries
l
Injured left
ankle wrestling in practice during highest volume/moderate intensity
training phase preparing for post season
l
“Like a Grizzly
Bear on a Gut Pile”
Case 2-Syndesmosis
Injury
l
Mechanism:
external foot rotation when foot caught in the mat while attempting
“duck under” takedown
l
Chief complaint
– Pain in
ankle following a “pop”
– Tightness
in achilles tendon
Case 2-Syndesmosis
Injury
l
Physical
Examination
–
No swelling
–
Point tender 3 cm from
distal fibula proximally along syndesmosis and at distal anterior
tib-fib ligament
–
Decreased ROM secondary to
pain
–
Strength testing 2/5 in all
planes
–
(+) Squeeze, Kleiger,
Fibula translation tests
–
(-) Pound , Anterior drawer
tests
Case 2-Syndesmosis
Injury
l
X-rays
ruled out fracture
l
Diagnosis: Syndesmotic ankle sprain without diastasis (left ankle)
Case 2-Syndesmosis
Injury
Treatment and Clinical Course
l
PRICE to
decrease swelling/pain
l
AFO and
NWB with crutches
l
Progress
to FWB then d/c AFO “as tolerated”
l
Improve
ROM, strength, dynamic neuromuscular stability
l
Gradual
return to full function
Case 2-Syndesmosis
Injury
Clinical Measures
l
Initial
–
Resolution 18%
–
Function 40%
–
No swelling
–
ROM abnormal
–
Strength abnormal
–
Functional tests deferred
due to NWB
–
Full compliance
Case 2-Syndesmosis
Injury
l
Initial
Treatments and Reconditioning
–
Cryocuff and cold whirlpool
for pain and inflammation
–
Electrical Stimulation for
pain and improved ROM
–
Two to three treatments per
day
–
Progressing towards
contrast bath and AROM
Case 2-Syndesmosis
Injury
Clinical Measures
l
3 days
post
–
Resolution 30%
–
Function 55%
–
No swelling
–
No resting pain
–
ROM abnormal
–
Strength abnormal
–
Full compliance
Case 2-Syndesmosis
Injury
l
7 days
post
–
Patient very frustrated by
pain while weight bearing and inability to drill
–
Started to d/c crutches on
day 4
–
Airdyne exercise while
wearing posterior splint
–
Rigorous treatment schedule
continues and low TENS (5-10 Hz at pain threshold intensity) added
Case 2-Syndesmosis
Injury
Clinical Measures
l
Functional Tests at 7 days post
–
Unable to push off
–
Pain with plantarflexion in
posterior ankle
–
Begins shadow
wrestling/stance and motion while taped avoiding push off
–
Top and Bottom Drilling
Case 2-Syndesmosis
Injury
Clinical Measures
l
14 days
post
–
Resolution 65%
–
Function 82%
–
No swelling
–
Pain 2 out of 10
–
ROM WNL
–
Strength WNL
–
Full compliance
Case 2-Syndesmosis
Injury
l
14 days
post
–
Phonophoresis begins for 14
days
–
Begins running in chest
deep water in aquaciser
–
Continues shadow drilling
while ankle taped and supported with posterior orthoplast splint
–
No longer using AFO for
ADLs
–
Begins resistance exercise
on MAAE
Case 2-Syndesmosis
Injury
Clinical Measures
l
3 weeks
post
–
Resolution 82%
–
Function 94%
–
No swelling
–
Pain remains 2 out of 10
–
ROM WNL
–
Strength WNL
–
Full compliance
Case 2-Syndesmosis
Injury
Clinical Measures
l
23 days
post
–
Performing most drilling
activities
–
Begins live wrestling in
limited situations
–
Motion and movement on feet
demonstrates normal function with no pain
–
Full participation as
tolerated status begins
Case 2-Syndesmosis
Injury
Clinical Measures
l
4 weeks
post
–
Resolution 80%
–
Function 90%
–
No swelling
–
Pain 1 out of 10
–
ROM WNL
–
Strength WNL
–
Full compliance
Case 2-Syndesmosis
Injury
Clinical Measures
l
4 weeks
post
–
Continues full
participation and is returned to competition on day 26
–
Functionally normal
–
Wins both matches, one
against #2 ranked wrestler in NCAA by 10-3 score
–
c/o pain following activity
but athlete plans to continue unless major setbacks
Case 2-Syndesmosis
Injury
Clinical Measures
l
5 weeks
post
–
Resolution 91%
–
Function 96%
–
No swelling
–
Pain 1 but post activity
–
ROM WNL
–
Strength WNL
–
Full compliance
Case 2-Syndesmosis
Injury
Clinical Measures
l
7 weeks
post
–
Resolution 97%
–
Function 98%
–
No swelling
–
Pain post activity
complaint
–
ROM and Strength WNL
–
All treatments
discontinued; continues to tape
–
Big 10 and NCAA
Championships
Case 2-Syndesmosis
Injury
Clinical Measures
l
10 weeks
post
–
Season ends with All
American distinction
–
Very painful with casual
walking
–
Returns to AFO and
treatments
–
Off season rest and
recovery?
Case 2-Syndesmosis
Injury
Clinical Measures
l
11 weeks
post
–
Resolution 90%
–
Function 92%
–
No swelling
–
Pain while walking
–
ROM WNL
–
Strength WNL
–
Full compliance
Case 2-Syndesmosis
Injury
Clinical Measures
l
12 weeks
post
–
Resolution 93%
–
Function 95%
l
Begins
wrestling every other day during “off season” although c/o achilles
tightness and pain over anterior tib-fib. ligament
Case 2-Syndesmosis
Injury
Clinical Measures
l
14 weeks
post case discontinued
–
Resolution 100%
–
Function 100%
l
7 months
post
–
Continued pain prompts MRI
l
9 months
post
–
“Wobbly ankle” complaint
Survey Results
1) Do you treat
mild-to-moderate syndesmosis sprains differently than other sprains of
similar severity?
2/3 Yes, 1/3 No
If yes, how does
your Rx differ?
Range:
NWB for a couple weeks (several) PWB (progression as
tolerated)
Limited DF (heel cup/lift)
More
frequent evaluation
Short-leg walker
DRAB
brace
Survey Results
2) What is your
criteria for return-to-sport?
Mostly
general answers (i.e., little to no pain,
normal strength,
normal ROM, can perform)
Run at 80 to 90%,
Single-leg stand, one-leg hop, tip-toe walking, duck walk, combine
skilled movement with functional tasks, good push-off
Standard battery of
tests?
Survey Results
3) In your
experience do mild-to-moderate syndesmosis sprains heal more slowly than
other mild-to-moderate sprains?
Mostly “Yes”
Why?
Mortise
disruption (several), poor vascular supply (a few), greater loads in
ambulation, too aggressive WB and DF early in recovery, decreased DF
ROM, poor PF strength, fibular rotation, multiplanar motion
Survey Results
4) In your
experience is persistent disability (pain, giving-way, swelling, &-or
decreased function) more common in syndesmosis vs. similar severity
lateral sprains?
65% Yes, 35%
No
Survey Results
5) What do you
think are the critical factors in determining whether or not someone has
chronic ankle disability?
Most common:
inadequate healing prior to return to sports
Others:
Severity of injury (difficult to categorize), amount of early WB, Hx of
other injuries, pes planus
1) Do you treat
mild-to-moderate syndesmosis sprains differently than other sprains of
similar severity?
Ø
Should
there be a period of limited weightbearing? If yes, then for how long?
Ø
Is DF to
neutral problematic or is it important in preventing ROM loss (as long
as the loads are low)?
Ø
Isn’t the
real danger rotation & eversion (inversion to a lesser degree)?
Ø
When
should we allow active peroneal strengthening? Use isometrics early?
2) What is your
criteria for return-to-sport?
Ø
Should we
have a standard battery of tests for return-to-sport? If yes, then what?
My recommendations:
Duck
walking
Carioca
Vertical jump (maximal)
Lateral Hop Test
Figure-8 for time (aggressive, dynamic. Rot/ever)
With or without
support?
3) Why do
mild-to-moderate syndesmosis sprains heal slowly?
Ø
Are we
underestimating the severity of the injury?
Ø
Once the
patient is full weightbearing as tolerated, should we educate them to
routinely pivot on the opposite foot for the next month or so?
Ø
Would MRI,
bone scans, or other imaging methods be of assistance?
Homeostasis?
4 & 5) Is persistent
disability more common & what factors determine whether or not someone
will have chronic disability?
Ø
Most
people reported that they believe that the persistent disability is
related to returning to sport prior to adequate healing.
Is this
because:
1) Our
return-to-sport criteria are not adequately identifying
deficiency?
2)
There is a symptom tolerance / healing mismatch that we are not
considering seriously enough?
3) We
are succumbing to the pressures of the competitive sports
“machine” because it is not a “critical”
injury?
Should we develop a set
of guidelines?
Ø
Appoint a
panel to look at this?
Ø
Research?
ØMore
accurate Dx of extent of injury
ØTreatment
strategy
ØStart
small, demonstrate success, then expand to larger prospective study
ØN
is obviously an issue
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