Lateral Ankle Sprain: Why is it so recurrent?

侧踝扭伤是急性肌肉骨骼损伤最常见的位点之一，占踝关节伤害的75％。在美国每天出现超过25,000个踝扭伤。侧踝扭伤是最常见的伤害;从竞争力和休闲运动到日常生活。然而，它们经常被虐待或根本不治疗。这种忽视的最大后果是由于踝肌的弱点导致不稳定的关节的弱点，这是一种复发性踝关节扭伤。

Anatomy

The lateral aspect of the ankle is generally made up of 3 main ligaments; Anterior Talo-Fibular Ligament (ATFL), Calcaneal Fibular Ligament (CFL) and Posterior Talo-Fibular Ligament (PTFL) (See figure 1). These ligaments help to provide stability to the ankle joint by limiting the inversion movement of the ankle in the dorsiflexion and plantarflexion range. When one or more ligaments are stretched beyond the normal range, a sprain results.

脚踝扭转范围从等级到III级的严重程度，这对于超过分类伤害的严重程度是有用的;它还指导治疗和预后。

Grade	Signs and Symptoms
1I级	踝关节扭伤是痛苦的，但与未加注的一侧相比，它们不会增加松弛。这种与ATFL的温和拉伸相关。
二年级	踝关节扭伤是痛苦的，并且在测试上具有增加的松弛。这与ATFL的完全撕裂和CFL的部分撕裂相关。
二年级I	Ankle sprains are usually painful and have an unstable ankle joint on examination. This correlates with complete ruptures of both the ATFL and CFL.

Mechanism of Injury

当脚进入或相对于脚踝的异常程度时，发生侧踝螺纹。踝关节扭伤中最常见的伤害机制是Plantarflexion和反演的组合，其中脚向下指向，紧张atfl。伴随着ATFL和CFL的伤害可能导致可观的脚踝不稳定。PTFL是三种韧带中最强的。它很少受到反转扭伤的伤害。

踝关节扭伤的常见原因包括踩踏或下表面，特别是在穿高跟鞋时;踩下遏制或进入一个洞。在田径运动中，常见的原因包括在跳投后错误地降落，并且必须在网球，足球和赤驼中进行快速定向变化。

When a person sprains his ankle, he may experience:

• pain or soreness
• 肿胀
• 瘀血
• difficulty walking, and/or
• 关节僵硬

These symptoms may vary in intensity, depending on the severity of the sprain. In persons with previous ankle sprains, pain and swelling may be absent. Instead, they may feel that the ankle is wobbly and unstable when they walk. However, the lack of pain does not mean it is safe to return to activity. The pain can subside fairly quickly but that does not necessarily mean that the injured ligaments have healed. Even if the ligaments have healed, there is still a chance of a recurrent ankle sprain because the ligaments will never be as strong as before to stabilise the ankle joint.

Proper classification of the ankle sprain would improve the management and rehabilitation of the ankle sprain to prevent recurrent sprains.

Management

RICER and Anti-Inflammatory Drugs

Managementof the lateral ankle sprain should start the moment it happens. The R.I.C.E.R (Rest, Ice, Compression, Elevation, Review) regime should be enforced within the first 72 hours post-injury.抗炎药可能会推荐。如果脚踝太疼痛，可以提供拐杖，因为踝关节过于疼痛。

文学评论已在2002年的Cochrane审查中使用固定性与早期功能治疗的使用混淆。混合审查是由于缺乏踝扭扭的分类和固定的应用。使用固定化的指导是，在II级和III级扭伤中，踝关节固定约4天，带空气支架或凸轮步行者，将提高预后和回收率。这应该伴随着防止关节僵硬和肌肉削弱的练习¹。

Proper Rehabilitation

适当的康复运动至关重要。这确保了在愈合阶段期间铺设新组织并适当地对准。康复运动应包括四个组成部分^2,3：

1. range of motion exercises,
2. progressivemuscle-strengthening exercises那
3. Benrioceptive /平衡培训，和
4. 特定活动培训。

Range of motion exercises normally begins on the first session of physiotherapy treatment together with soft tissue mobilization to manage the swelling.

超声波和IFC

超声波和IFC也可用于管理肿胀并降低疼痛²。已经证明了压缩绷带或运动疫苗[图2]有效地管理肿胀。

练习和延伸

Gentle strengthening exercises and stretches would commence once the pain and swelling are managed. This would normally start in the 2nd-week post-injury. Theraband exercises to strengthen the evertors and functional exercises like calf raises would be done to improve the strength of the ankle. Calf stretches would prevent tightness of the calf muscles arising to the compensation mechanism which prevents the pain.

Proprioceptive training is also an integral part of the rehab at about this time. Balancing on 1 leg with eyes open and eyes closed are taught as home exercises^4.。In the clinic, balancing on unstable surfaces (e.g. wobble board/rocker-board/dura-disc) will be done. Proprioceptive taping may also be done to speed up the recovery process [Figure 3].

Progression of these exercises will go on until about the 4th week. These exercises would be good enough for non-athletes for them to get discharged.

With athletes, sports specific rehab will need to be done and completed before they return to sports. Criteria for them to return to sports varies from sport to sport. A simple functional test to determine whether they are ready to return to sports will be either doing a triple hop test or a 8m hop test, where the results are compared between the injured ankle and the non-injured one.

Conclusion

预防复发性侧踝关节扭伤是possible. However, proper classification is required. This is so that the appropriate management can be administered.

References

1. Kerkhoffs GM，Rowe BH，Assendelft WJ，Kelly K，Struijs Pa，Van Dijk CN。成人急性侧踝韧带损伤的固定和功能治疗。Cochrane数据库Syst Rev. 2002;（3）：CD003762。
2. Kerkhoffs gm，handoll hh，de bie r，Rowe Bh，Struijs Pa。踝关节踝侧韧带复合物的外科与保守治疗。Cochrane数据库SYST Rev. 2007年4月18日;（2）
3. Jones MH, Amendola AS. Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res. 2007 Feb;455:169-72.
4. Hupperets MD，Verhagen EA，Van Mechelen W.无监督的家庭基础的预科训练对踝扭伤复发的影响：随机对照试验。BMJ。2009年7月9日; 339