The management of sprained ankle.

Ankle sprains are common: one estimate is that there is one per day per 10 000 of the population. 1 Has there been any progress in the management of this so-called minor injury? The important decisions relate to the rupture of ligaments. It is known that the anterior talofibular ligament is almost always the first or only ligament to rupture. Brostrom 2 found that combined ruptures of the anterior talofibular and calcaneofibular ligaments occurred in 20% of cases and that the calcaneofibular ligament alone very rarely ruptured. Chronic instability of the ankle is likely only if both ligaments have been completely torn. 3 The place of physical examination in diagnosis has been reviewed in a series of 160 patients, 4 comparing the accuracy within 48 hours of injury with that at four to seven days. All patients had arthrography but the outcome was not disclosed to the patient or investigator until after the second examination. The specificity and sensitivity of delayed physical examination for the presence or absence of a lateral ligament injury were 84% and 96%, respectively. A reasonably precise clinical diagnosis is possible. Routine radiographs, without stress films, serve to eliminate injuries to adjacent areas such as the dome of the talus or the base of the fifth metatarsal. When an accurate diagnosis has been made, it is generally agreed that grade-I (mild injury, microscopic tears and stretching) and grade-II (partial macroscopic tear) injuries recover fully after non-operative management and early functional rehabilitation. Kannus and Renström 5 analysed 12 prospective randomised studies of grade-III (complete) tears, with both talar tilt and a positive anterior-drawer test. The long-term prognosis was excellent or good in most patients regardless of the treatment (operative repair and cast, cast alone or early controlled mobilisation). Even competitive athletes may be treated functionally at first, since secondary reconstruction or delayed repair for recurrent instability gives good results in the 10% to 20% of patients who may require such operations. In a very few patients, the subtalar ligament complex may also be injured, and it is difficult to distinguish between the contributions of these two joints. The diagnosis of chronic subtalar instability is still unclear. 6 Stress tomography using forced dorsiflexion and supination may help, 7,8 and Broden's view may show an increased gap between the surfaces of the posterior subtalar joint. After an apparently serious ankle injury with negative standard stress tests, patients should have …