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Br
_j
Sports
Med
1997;31:1
1-20
Ankle
ligament
injuries
Per
A
F
H
Renstr6m,
Lars
Konradsen
Injuries
to
the
ligaments
of
the
ankle
are
often
called
"low
ankle
sprains".
If
the
tibiofibular
ligament
or
the
syndesmosis
is
injured
it
is
called
a
"high
ankle
sprain".
Inversion
sprains
with
injury
to
the
lateral
ligaments
of
the
ankle/foot
complex
are
by
far
the
most
common.
They
occur
with
an
estimated
frequency
of
one
injury
per
10
000
people
per
day,
amounting
to
about
27
000
injuries
each
day
in
the
United
States.'
2
Although
many
injuries
are
treated
outside
medical
establishments,
7-10%
of
those
who
are
visiting
the
emergency
departments
of
the
hospitals
in
Scandinavia
have
sprained
ankles.3
Ankle
injuries
are
the
most
common
injuries
in
sports
and
recreational
activity.i"12
For
this
reason, probably,
these
injuries
tend
to
occur
primarily
to
young
people.'3
The
sprained
ankle
also
remains
the
most
common
injury
regardless
of
whether
the
sport
is
primarily
an
upper
or
a
lower
extremity
sport.
Garrick7
noted
that
injuries
to
the
ankle
accounted
for
53%
of
injuries
occurring
during
basketball
and
for
3
1
%
of
those
occurring
during
soccer.
Reviewing
41
soccer
teams,
Ekstrand
and
Tropp'4
found
ankle
sprains
to
account
for
17
to
21
%
of
the
injuries.
The
"high
ankle
sprain"
usu-
ally
occurs
as
the
result
of
an
eversion
injury
in
combination
with
fractures
or
lesions
to
the
deltoid
ligament.
Isolated
syndesmosis
injuries
occur
in
3%
of
the
cases.
This
article
will
deal
mainly
with
the
lateral
ligament
complex.
Department
of
Orthopaedics
and
Rehabilitation,
McClure
Musculoskeletal
Research
Center,
The
University
of
Vermont,
Stafford
Hall
428B,
Burlington,
Vermont
05405-0084
USA
P
A
F
H
Renstr6m
Department
of
Orthopaedics,
Gentofte
Hospital,
University
of
Copenhagen,
Copenhagen,
Denmark
L
Konradsen
Correspondence
to:
Dr
Renstrom.
Accepted
for
publication
17
December
1996
Ankle
biomechanics
The
passive
stability
of
the
ankle
is
the
respon-
sibility
of
the
ligaments
and
the
bony
con-
straints
of
the
ankle
joint,
while
the
active
sta-
bility
depends
on
muscular
support.
The
talus
has
no
muscular
insertion.
Active
motion
depends
on
the
long
foot
muscles
inserting
into
other
tarsal
or
metatarsal
bones.
Dorsiflexion
and
inversion
are
effected
by
the
extensor
hal-
lucis
longus
and
the
anterior
tibial
muscles.
Dorsiflexion
and
eversion
are
guided
by
the
peroneus
tertius
muscles
and
extensor
digito-
rum
longus
and
brevis
muscles.
Plantar
flexion
and
eversion
are
effected
by
the
peroneus
lon-
gus
and
brevis
muscles.
Plantar
flexion
and
inversion
are
regulated
by
the
flexor
hallucis
longus,
the
flexor
digitorum,
and
the
posterior
tibial
muscles.'5
The
ligaments
of
the
ankle
can
be
divided
into
the
lateral
group,
the
medial
group,
and
the
ligaments
of
the
syndesmosis.
The
lateral
ankle
ligament
complex
is
traditionally
considered
to
consist
of
the
anterior
talofibular
(ATFL),
the
calcaneofibu-
lar
(CFL),
and
the
posterior
talofibular
(PTFL)
ligaments.
However,
in
inversion
the
subtalar
ligaments,
especially
the
cervical
ligament,
the
interosseous
ligament,
and
the
ligaments
spanning
the
calcaneocuboid
and
the
talonavicular
joints,
also
have
to
be
considered.
Many
studies
have
been
done
on
talotibial
ligaments
to
gain
insight
into
how
they
function
together
to
stabilise
the
joint.
Of
the
talotibial
ligaments,
the
ATFL
is
a
thin
6-10
mm
wide,
20
mm
long,
and
2
mm
thick'6
weak
ligament,
being
essentially
a
thickening
of
the
anterior
ankle
joint
capsule.
It
passes
from
the
distal
anterior
origin
of
the
lateral
malleolus
to
the
talus
in
front
of
the
proximal
part
of
the
lateral
articular
surface.
In
neutral
position
its
direction
is
parallel
to
a
long
axis
of
the
foot
and
in
full
plantar
flexion
it
is
more
parallel
with
the
tibia
(fig
1).
The
CFL
is
a
20-25
mm
long
rounded
ligament with
a
diameter
of
6-8
mm.'6
It
is
an
extra-articular
ligament
closely
associated
with
the
peroneal
tendon
sheath.
It
runs
obliquely
downwards
and
backwards
to
be
attached
to
the
lateral
surface
of
the
calcaneus.
There
is
a
great
variety
in
its
direction
and
in
its
attachment
sites."'
A
rupture
to
this
ligament
will
also
cause
a
rupture
of
the
tendon
sheath,
and
occasionally
also
damage
the
peroneal
tendons.
The
ATFL
acts
as
a
primary
restraint
against
plantar
flexion,
as
well
as
internal
rotation
of
the
foot.'7
In
strain
studies
Renstrom
et
al"
found
that
the
strain
of
the
ATFL
significantly
increases
with
increasing
plantar
flexion.
In
the
neutral
position
the
ligament
is
relaxed.'9
The
CFL
does
not
have
an
independent
role
in
talotibial
joint
stability,
but
acts
instead
as a
guide
for
the
axis
of
subtalar
motion.'7
In
dorsi-
flexion
the
ligament
has
increased
strain.'8
In
a
normal
standing
position
the
ligaments
remain
relaxed.
The
lateral
talocalcaneal
(LTCL)
extends
from
the
talus
to
the
calcaneus
and
blends
its
fibres
with
CFL
and
ATFL
fibres.
The
exact
incidence
of
injury
to
this
ligament
is
not
known.
Transecting
the
subtalar
ligaments
results
in
very
limited
increase
in
motion
when
measured
in
degrees,
but
as
they
have
very
lim-
ited
motion
in
the
first
place
the
increase
after
rupture
is
about
40%.2°
The
incidence
of
rup-
ture
here
is
also
unknown.
The
PTFL
connects
the
posterolateral
tu-
bercle
of
the
talus
to
the
medial
aspect
of
the
lateral
malleolus.
The
PTFL
has
an
average
diameter
of
6
mm.
In
plantar
flexion
and
in
the
neutral
position
the
ligament
is
relaxed,
whereas
in
dorsiflexion
the
ligament
is
tensed.'5
The
clinical
significance
of
PTFL
injuries
is
somewhat
unclear,
but
it
is
not
com-
monly
damaged.
The
ATFL,
CFL,
and
PTFL
ligaments
function
as
a
unit
for
the
talotibial
complex,
though
one
may
resist
a
specific
motion
depending
upon
foot
position.2'
1 1
Renstrom,
Konradsen
B
Figure
1
(A)
Anterior
talofibular
(at])
ligament
runs
parallel
to
the
axis
of
the
foot
when
the
foot
is
in
neutral
position.
Cf
=
calcaneofibular
ligament.
(B)
When
the
foot
is
in
plantarflexion,
the
anterior
talofibular
ligament
assumes
a
course
parallel
to
the
axis
of
the
tibia
and
fibula.
Through
the
full
range
of
motion
the
ATFL
and
CFL
act
in
synergy22"2
(fig
1).
As
the
foot
plantar
flexes,
the
strain
in
the
ATFL
increases
while
the
strain
in
the
CFL
decreases.'8
Shybut
et
a125
measured
ankle
ligament
loads
directly
by
using
implanted
buckle
transducers.
The
results
indicated
that
ligament
loads
remain
low
within
the
functional
range
of
motion
(10
degrees
of
dorsiflexion
to
20
degrees
of
plantar
flexion).
This
supports
the
concept
that
ankle
ligaments
act
as
kinematic
guides
rather
than
primary
restraints
during
normal
activity.
Stormont
et
al26
studied
the
stabilising
capacity
of
the
ligaments
and
articular
surface
in
the
ankle
with
and
without
physiological
loading.
With
loading,
the
results
indicated
that
the
articular
surface
becomes
an
impor-
tant
stabiliser,
accounting
for
30%
of
stability
in
rotation
and
100%
of
stability
in
inversion.
Without
loading,
the
results
indicated
that
the
primary
and
secondary
ligamentous
con-
straints
vary
with
testing
modes
and
ankle
position.
Mechanism
of
injury
The
extent
of
tissue
damage
that
will
occur
with
the
trauma
depends
not
only
on
the
mechanism
and
magnitude
of
the
forces
that
act
on
the
ankle
but
also
on
the
position
of
the
foot
and
ankle
during
the
trauma.'5
The
most
common
mechanism
causing
lateral
ligament
injuries
is
a
situation
where
the
ankle
goes
into
a
combination
of
plantar
flexion
and
inversion.
The
ATFL
tears
first
fol-
lowed
by
rupture
of
the
anterolateral
capsule.
With
further
inversion,
the
CFL
will
be
ruptured
followed
by
variable
injury
to
the
PTFL
and
the
anterior
part
of
the
deltoid
liga-
ments.27
With
weight
bearing,
the
articular
surface
can
provide
30%
of
stability
in
rotation,
and
100%
stability
in
inversion.26
This
ability
is
a
function
not
only
of
the
axial
load
but
also
of
the
close
packed
position.28
Ankle
destabilisa-
tion
thus
occurs
during
loading
and
unloading,
but
the
joint
is
stable
once
it
is
fully
loaded.
Frequency
of
lesions
caused
by
inversion
sprains
Owing
to
the
ATFL's
vulnerable
position
in
plantar
flexion,
it
is
the
most
commonly
ruptured
ligament
in a
lateral
ankle
sprain..323
29-34
In
1964
Brostrdm'6
surgically
explored
105
sprained
ankles
and
found
an
isolated
ATFL
tear
present
in
about
two
thirds
of
the
cases.
The
second
most
common
injury
was
a
combined
rupture
of
the
ATFL
and
CFL,
occurring
in
about
20
to
25%
of
the
cases.'3
1634
Other
isolated
ligamentous
injuries
are
relatively
uncommon.'316
The
PTFL,
for
instance,
is
a
very
strong
ligament
and
is
rarely
injured
except
in
severe
ankle
trauma.2935
Ligamentous
lesions
after
acute
inversion
sprains
cannot,
however,
be
seen
in
such
a
lim-
ited
scope.
Thus
Brostr6m'3
noted
that
in
a
group
of
321
patients
with
acute
ankle
sprains,
19%
had
signs
of
injury
to
the
bifurcate
or
the
dorsal
calcaneocuboid
ligaments,
or
both.
Gerner-Smidt36
in
a
combined
study
of
chil-
dren
and
adults
found
that
22%
of
the
patients
sustained
lesions
to
the
talonavicular
or
the
calcaneocuboid
ligaments,
or
both,
and
Holmer
et
alP7
found
clinical
evidence
of
isolated
calcaneocuboid/calcaneocervical
or
talonavicular
ligament
lesions
in
15-25%
of
inversion
injuries.
Meyer
et
ar'
evaluated
40
patients
with
acute
ankle
sprains
(it
is
not
mentioned,
but
they
must
have
been
consid-
ered
clinically
grade
II
to
III)
with
subtalar
arthrograms.39
Apart
from
lesions
to
the
lateral
tibiotalar
joint
ligaments,
17
patients
(43%)
showed
contrast
leaks
into
the
sinus
tarsi,
sug-
gesting
interosseous
ligament
rupture.
Some
of
these
patients
were
operated
on
and
the
cervi-
cal
ligament
was
often
found
to
be
severed
too.
Chondral
or
osteochondral
lesions
of
the
talar
dome
have
been
noted
by
Taga
et
al'0
in
89%
and
by
van
Dijk'`
in
66%
of
acute
inversion
injuries.
In
1991
Grana"4
found
chondral
lesions
in
80%
and
osteochondral
lesions
in
6.5%
of
acute
ankle
injuries.
Lesions
to
peroneal
tendons
ranging
from
total
tendon
rupture
or
insertion
site
fracture
to
longitudi-
nal
slits
occur,
and
the
tendon
injuries
are
often
overlooked.42
Injury
to
the
superficial
and
deep
peroneal
nerves
ranging
from
the
rare
condition
of
complete
nerve
palsy4344
to,
what
seems
to
be
much
more
common,
discrete
conduction
velocity
changes
have
been
noted.4546
In
rarer
cases
fractures
to
the
cuboid,
the
anterior
process
of
the
calcaneus,
and
the
lateral
process
of
the
talus
have
been
diagnosed
after
an
inversion
injury.4749
Grading
lateral
ligament
injury
Clinically,
sprains
of
the
lateral
ankle
have
been
classified
in
three
groups
based
on
severity.4
A
grade
I
injury
involves
stretch
of
the
ligament
without
macroscopic
tearing,
little
swelling
or
tenderness,
slight
or
no
functional
loss,
and
no
mechanical
instability
of
the
joint.
A
grade
II
injury
is
a
partial
macroscopic
tear
of
the
liga-
ment
with
moderate
pain,
swelling,
and
tenderness
over
the
affected
structures.
Some
loss
of
motion
and
mild
or
moderate
instability
12
Ankle
ligament
injuries
of
the
joint
occurs.
In
a
grade
III
injury,
there
is
complete
rupture
of
the
ligament
with
severe
swelling,
haemorrhage,
and
tenderness.
There
is
loss
of
ability
to
bear
weight
on
the
foot,
lim-
ited
function,
and
considerable
abnormal
motion
and
instability
of
the
joint.
An
im-
proved
and
validated
classification
of
ankle
sprains
is
needed.
The
terms
mentioned
above
were
validated
by
Lindenfeld50
and
found
to
be
quite
subjective.
Others
prefer
to
classify
lateral
ligament
injuries
as
single
or
double
ligament
tears.
A
single
injury
would
imply
lesions
to
only
the
ATFL,
a
double
injury
would
affect
both
the
ATFL
and
the
CFL.
The
distinction
in
clinical
terms
is
difficult
here
also.
Diagnosis
Diagnosing
the
extent
of
an
acute
lateral
ligament
injury
is
not
considered
very
accurate
because
of
pain,
swelling,
and
muscle
tender-
ness.'5
In
the
first
few
days
after
injury
local
palpational
pain
is
often
diffuse,
with
no
maxi-
mal
point
of
tenderness.'
51
52
The
extent
of
swelling
does
not
depend
only
on
the
magni-
tude
of
the
ligamental
injury
but
also
on
the
initial
treatment.
Extensive
swelling
is
a
predic-
tor
of
ligament
rupture,
but
the
positive
predictive
value
has
been
found
to
be
only
60-70%.5
The
characteristic
haematoma
suggesting
ligament
rupture
usually
does
not
develop
during
the
first
few
days,
and
joint
range
of
motion
is
mainly
determined
by
the
severity
of
pain
and
does
not
differ
between
simple
sprains
and
ligament
rupture.5455
Fur-
thermore,
the
interobserver
variation
of
the
acute
examination
concerning
tenderness,
swelling,
discoloration,
and
the
anterior
drawer
sign
is
considerable.56
The
anterior
drawer
sign
seems
to
be
a
good
predictor
of
lateral
ligament
disruption.
Brostrom30
found
that
the
anterior
drawer
sign
was
positive
in
all
of
239
patients
with
ligament
rupture.
His
examination
was,
however,
done
with
general
or
local
anaesthe-
sia.
Without
anaesthesia
he
could
only
elicit
a
positive
drawer
sign
in
two
patients.
Based
on
these
results
van
Dijk57
suggests
that
the
physical
examination
should
be
delayed
four
to
five
days
after
the
initial
injury.
The
specificity
and
sensitivity
of
delayed
physi-
cal
examination
for
the
presence
or
absence
of
a
rupture
to
the
ATFL
were
found
to
be
84%
and
96%
respectively,
and
the
delayed
examin-
ation,
done
by
observers
of
varying
degrees
of
experience,
gave
information
of
ligament
qual-
ity
that
equalled
that
of
arthrography.
After
four
to
five
days
a
combination
of
tenderness
at
the
level
of
the
anterior
talofibular
ligament,
lateral
haematoma
discoloration,
and
a
positive
drawer
sign
indicated
a
ligament
lesion
in
95%
of
the
cases.
A
negative
drawer
test
and
the
absence
of
discoloration
always
indicated
an
intact
ligament.
Radiographs
to
exclude
fractures
are
sug-
gested
according
to
the
Ottowa
strategy
for
ankle
injury.58
Plain
radiographs
are
taken
if
there
is
bone
tenderness
at
the
tip
or
posterior
aspect
of
the
lateral
malleolus,
at
the
tip
or
posterior
aspect
of
the
medial
malleolus,
at
the
navicular
tuberosity
or
at
the
base
of
the
fifth
metatarsal,
or
if
the
patient
is
unable
to
bear
weight
immediately
after
injury
and
at
the
ini-
tial
examination.
With
these
rules
the
authors
could
reduce
the
use
of
radiographs
from
80%
to
63%
of
the
injuries.
Treatment
of
lateral
ligament
lesions
TREATMENT
OF
GRADE
I
AND
II
SPRAINS
In
the
presence
of
a
grade
I
or
grade
II
injury
it
is
universally
agreed
that
recovery
is
fast
with
non-operative
management
and
the
prognosis
is
good.455'5
Jackson
et
at5
found
that
early
mobilisation
resulted
in
a
disability
of
eight
days
for
a
grade
I
and
15
days
for
a
grade
II
injury.
Functional
treatment
including
early
motion
and
use
of
ankle
support
and
early
weight
bearing
is
today
the
accepted
treatment
for
grade
I
and
II
ankle
sprains.
TREATMENT
OF
GRADE
III
SPRAINS
In
the
case
of
grade
III
lateral
ligament
lesions
the
treatment
of
choice
that
is,
whether
to
operate,
to
immobilise
in
a
cast,
or
to
allow
early
controlled
mobilisation,
is
more
contro-
versial.
The
key
consideration
being
the
question
of
whether
ligament
healing
with
adequate
tension
can
be
achieved
equally
well
with
early
controlled
mobilisation
as
with
direct
visualisation
and
suturing.
If
the
ankle
is
kept
from
excess
inversion
or
dorsal
or
plantar
flexion
the
strain
in
the
lateral
ligaments
remains
low,'8
allowing
for
adequate
healing
conditions
without
elongation
within
this
range
of
guided
motion.
With
the
develop-
ment
of
lower
extremity
magnetic
resonance
imaging
scanning,
studies
have
visualised
that
total
ligament
(grade
III)
ruptures
do
heal
with
ligamental
continuity
if
there
is
early
mobilisa-
tion.
There
is
thus
experimental
evidence
sup-
porting
ankle
ligament
healing
in
the
presence
of
early
mobilising
treatment.
Clinically
many
uncontrolled,
non-
randomised
studies
have
shown
mechanical
stability
and
satisfactory
subjective
results
after
both
operative
and
conservative
treatment.
Of
the
many
papers
available,
only
12
could
be
considered
prospective
and
randomised30
55
60-69
when
a
comparison
between
operative
and
conservative
treatments
was
performed
by
Kannus
and
Renstr6m.35
Six
of
these
consid-
ered
the
three
treatment
groups
in
question:
operation,
immobilising
and
early
mobilising
modalities30
62 63 65
66
69
and
the
results
and
con-
clusions
based
on
these
reports
will
be
mentioned
in
the
following.
Duration
of
follow
up
ranged
from
six
months
to
3.8
years,
which
is
considered
adequate
time
to
identify
persist-
ent
disability.
Results
were
evaluated
using
selected
outcome
parameters.
Return
to
work
or
physical
activity
was
reported
in
four
of
the
studies
that
included
three
treatment
modali-
ties.30
6166
69
They
concluded
that
return
to
work
was
two
to
four
times
faster
after
functional
treatment
than
after
operation
or
immobilisa-
tion
in
a
cast.
Return
to
pre-injury
level
of
activity
was
found
to
be
faster
after
conserva-
tive
treatment
than
after
operative
treatment
in
four
cases.6
62 66 69
The
opposite
was
found
in
13
Renstrom,
Konradsen
three
studies.0
55
63
and
no
difference
was
found
in
the
remaining
five.
Pain,
swelling,
or
stiffness
with
activity
could
be
evaluated
in
four
of
the
studies
involving
three
treatment
groups.62636669
The
studies
failed
to
show
any
differences.
In
the
three
studies
that
included
three
therapy
groups
and
included
mobility
of
the
ankle,306669
mobility
was
found
to
be
superior
after
functional
treat-
ment
compared
with
the
other
two
methods.
Better
mechanical
stability
has
been
the
pri-
mary
argument
for
operation.
Assessment
of
mechanical
stability
calls
for
an
objective
measurement
with
the
evaluation
of
talar
tilt
and
anterior
drawer
on
stress
radiographs.
Based
on
five
studies
evaluating
the
three
different
treatments,62
65
66
68
69
equal
stability
results
were
found.
Functional
instability
is
not
a
well
defined
entity
but
designates
repeated
inversion
inju-
ries
that
are
either
unprovoked
or
the
result
of
very
little
provocation.
Functional
instability
seems
to
be
a
late
disability
in
15
to
60%
of
lat-
eral
ligament
injuries
depending
on
the
defini-
tion
applied.
In
the
studies
that
reported
on
functional
instability'062666971
opinions
di-
verged,
but
no
one
treatment
seemed
superior
to
the
others
in
minimising
the
chances
of
late
instability.
The
scientific
basis
for
treating
chronic
functional
instability
is
discussed
later
in
this
review.
The
review
of
Kannus
and
Renstrom35
concludes
that
functional
treatment
is
the
treatment
of
choice
when
treating
grade
III
acute
lesions
of
the
lateral
ligaments.
Recent
comparative
studies
do
not
change
this
view.
Konradsen
et
a
f2
and
Eiff
et
al3
concluded
that
in
first
time
lateral
ankle
sprains,
although
both
immobilisation
and
early
mobilisation
prevent
late
residual
prob-
lems
and
ankle
instability,
early
mobilisation
allows
early
return
to
work
and,
possibly,
is
more
comfortable
for
patients.
In
a
recent
pro-
spective
study
comparing
surgery
with
func-
tional
treatment
in
ankle
ligament
tears
Kaik-
konen
and
coworkers74
found
that
early
mobilisation
gave
better
results
than
surgery
plus
mobilisation
in
treatment
of
complete
tears
of
lateral
ligaments
of
the
ankle.
Nine
months
after
injury
excellent
to
good
scores
were
achieved
in
87%
of
the
functionally
treated
patients
and
60%
of
the
surgically
treated
patients
respectively.
In
a
meta-
analytical
article
Schrier75
found
functional
treatment
was
superior
to
immobilisation
in
casts,
reducing
both
ankle
instability
and
the
cost
of
treatment.
Sommer
and
Schreiber76
considered
the
cost-benefit
aspects
by
comparing
immobilisa-
tion
in
a
plaster
cast
followed
by
immobilisa-
tion
with
a
brace,
with
early
mobilisation
using
a
brace
only.
Early
functional
therapy
proved
to
be
the
treatment
with
the
least
direct
costs.
Leanderson
and
Wredmark77
in
a
study
of
73
patients
with
grade
II
and
III
sprains
treated
with
either
early
mobilisation
or
immobilisa-
tion
found
that
the
socioeconomic
savings
were
potentially
significant
with
ankle
brace
treat-
ment.
Nationally,
the
potential
yearly
savings
in
Sweden
using
this
treatment
were
estimated
to
be
eight
million
American
dollars.
The
treat-
ment
of
choice
thus
remains
functional
treat-
ment.
If
acute
surgery
is
considered
necessary
the
indications
could
according
to
Leach
and
Schepsis78
be
(a)
a
history
of
momentary
talocrural
dislocation
with
complete
ligamen-
tous
disruption,
(b)
a
major
clinical
anterior
drawer
sign,
(c)
10
degrees
more
tilt
on
the
affected
side
with
stress
inversion
testing,
(d)
clinical
or
radiographic
suspicion
of
tears
in
both
the
ATFL
and
CFL,
and
(e)
osteochon-
dral
fracture.
Most
techniques
described
for
repair
of
acute
ligament
injuries
are
similar
to
that
of
Brostr6m.'0
The
results
after
acute
sur-
gery
are
in
general
very
good
with
return
to
sport
in
10
to
12
weeks.
This
must
still
be
compared
with
the
three
to
six
weeks
after
functional
treatment.
Acute
treatment
protocol
BIOLOGICAL
BACKGROUND
In
the
post-injury
phases
of
an
acute
severe
ankle
injury,
an
ideal
treatment
and
rehabilita-
tion
programme
should
fulfil
four
require-
ments'5:
1
The
RICE
principle:
rest,
ice
(cold),
compression,
and
elevation
aims
to
minimise
haemorrhage,
swelling,
inflammation,
cellu-
lar
metabolism,
and
pain
in
order
to
offer
the
best
possible
conditions
for
the
healing
process.s780
2
Protection
of
the
injured
ligaments
during
the
first
one
to
three
weeks
is
required.
In
this
phase
of
healing
(the
proliferation
phase),
protective
ankle
support
is
followed
by
undisturbed
fibroblast
invasion
of
the
injured
area,
which
leads
to
undisturbed
proliferation
and
production
of
collagen
fibres.
Mobilisation
too
early
in
inversion
leads to
more
prolonged
type
III
collagen
formation
with
weaker
healing
tissue
than
during
optimal
immobilisation.8"8'
Protec-
tion
is
also
needed
to
prevent
secondary
injuries
and
early
distension
and
lengthening
of
the
injured
ligaments.
3
About
three
weeks
after
the
injury
the
maturation
phase
of
the
collagen
and
the
formation
of
final
scar
tissue
begins."8'-
In
this
phase
the
injured
ligaments
need
controlled
mobilisation,
and
perhaps
even
more
importantly,
the
ankle
itself
must
avoid
the
deleterious
effects
of
immobilisation
on
joint
cartilage,
bone,
muscles, tendons,
and
ligaments.8
8390
Controlled
stretching
of
muscles
and
movement
of
the
joint
enhance
the
orientation
of
collagen
fibres
parallel
with
the
stress
lines
(that
is,
the
normal
col-
lagen
fibres
of
the
ligaments),
and
they
can
prevent
the
atrophy
caused
by
immobilisa-
tion.8°82
Repeated
exercises
will
also
increase
the
mechanical
and
structural
properties
of
the
ligaments.9'
4
About
four
to
eight
weeks
after
the
injury
the
new
collagen
fibres
begin
to
withstand
almost
normal
stress,
and
the
goal
for
reha-
bilitation
is
rapid
recovery
and
full
return
to
work
and
sports.
If
treated
according
to
the
guidelines
men-
tioned
above,
each
component
of
the
ankle
is
14
Ankle
ligament
injuries
ready
for
a
gradually
increasing
mobilisation
and
rehabilitation
programme,
keeping
in
mind
that
final
maturation
and
remodelling
of
the
injured
ligaments
takes
a
long
time-from
six
to
12
months.
Residual
disability
after
inversion
injury
Inadequate
rehabilitation
is
the
primary
cause
of
residual
disability
after
ankle
sprains.
Many
athletes
return
to
sports
before
they
are
fully
rehabilitated
and
therefore
they
are
often
subjected
to
reinjury
or
additional
injury.
Examination
may
show
loss
of
range
of
motion,
especially
limited
dorsiflexion,
and
atrophy
of
lower
leg
muscles.
Residual
disability
after
ankle
inversion
injury
can
be
divided
into
primarily
instability
problems
and
pain-giving
entities.
CHRONIC
ANKLE
INSTABILITY
Chronic
ankle
instability
can
be
subdivided
into
mechanical,
functional,
and
subtalar
insta-
bility
and
the
sinus
tarsi
syndrome.
Mechanical
instability
Mechanical
instability
is
characterised
by
ankle
mobility
beyond
the
physiological
range
of
motion,
which
is
identified
on
the
basis
of
a
positive
anterior
drawer
or
talar
tilt
test,
or
both.92
The
radiographic
criteria
for
mechani-
cal
instability
vary.
Most
authors
agree,
how-
ever,
that
mechanical
instability
is
present
when
there
is
more
than
10
mm
of
anterior
translation
on
one
side
or
the
side-to-side
difference
is
over
3
mm
or
the
talar
tilt
is
more
than
9
degrees
on
one
side,
or
the
side-to-side
difference
is
more
than
3
degrees.93
Pure
mechanical
instability
of
the
ankle
is
seldom
the
sole
independent
reason
for
the
develop-
ment
of
late
symptoms.
Mann
et
al,
showed
that
81%
of
patients
with
radiographically
documented
instability
experienced
recurrent
sprains.94
Functional
instability
Functional
instability
is
the
chronic
disability
after
an
ankle
inversion
injury
that
can
be
attributed
to
lateral
ankle
ligament
deficiency
and
is
characterised
by
"giving
way"
problems.
Forty
eight
per
cent
of
patients
with
an
acute
first
time
sprain
have
recurrent
sprains
and
26%
report
frequent
sprains.94
The
definition
of
the
symptom
is
ambiguous
and
the
patho-
genesis
is
unclear.
It
does
not
seem
to
be
dependent
on
the
grade
of
the
initial
injury69
nor
does
it
correlate
with
the
degree
of
initial
mechanical
instability.6'
64
69-95
No
histological
ligamentous
changes
except
scarring
have
been
found
in
chronic
ankle
disability.30
As
anatomical
studies
showed
the
presence
of
mechanoreceptors
in
joint
ligaments
and
capsule,
and
clinical
studies
showed
decreased
postural
control
in
patients
with
functional
instability,
Freeman
et
al
suggested
that
func-
tional
instability
was
due
to
motor
incoordina-
tion
secondary
to
a
proprioceptive
disorder.96
Postural
control
was
later
measured
objectively
using
stabilometry
by
Tropp95
who,
like
Free-
man,
found
increased
postural
sway
in
subjects
with
functionally
unstable
ankles.
It
is,
how-
ever,
clear
that
functional
instability
is
a
complex
syndrome
where
mechanical,
proprio-
ceptive,
and
muscular
disabilities
either
alone
or
in
combination
are
at
fault.
Known
factors
include
mechanically
insufficient
ligaments,
peroneal
muscle
weakness,95
subtalar
instabil-
ity,97
and
proprioceptive
deficit.996
Although
increased
postural
swaying
has
been
used
as
a
measure
for
a
proprioceptive
deficit,
there
is
no
direct
causal
connection
between
swaying
with
an
increased
amplitude
when
balancing
on
one
foot
and
sustaining
recurrent
inversion
injuries.
Rather
it
seems
reasonable
to
assume
that
a
common
and
superior
deficit
is
responsible
for
both
disabilities.
The
nature
of
such
a
disability
remains
unclear.
The
latency
of
the
peroneal
muscles
has
been
found
to
be
significantly
slower
in
functionally
unstable
ankles
by
some98.'00
but
not
by
others.10'-'03
An
increased
error
in
detecting
ankle
inversion
movement
or
in
matching
ankle
inversion
angles
has
again
been
found
by
some'04-'06
but
not
by
others.'07
There
is,
however,
evidence
that
(a)
a
proprio-
ceptive
deficit
may
result
after
an
acute
ankle
inversion
injury,
46
70
108
(b)
proprioceptive
de-
fects
measured
in
different
ways
are
seen
in
subjects
with
functional
instability,
and
(c)
models
exist
that
may
explain
how
measurable
kinaesthetic
deficits
may
cause
an
increased
frequency
of
ankle
inversion
injuries
(Konrad-
sen
et
al,
unpublished
data).
Subtalar
instability
The
incidence
of
subtalar
sprains
is
unknown,
but
it
is
widely
accepted
that
most
subtalar
ligamentous
injuries
occur
in
combination
with
injuries
of
the
lateral
ligaments
of
the
ankle
(fig
2).
Subtalar
instability
is
estimated
to
be
present
in
about
10%
of
patients
with
lateral
ankle
instability.
The
symptoms
of
chronic
subtalar
instability
include
giving
way
episodes
during
activity
and
a
feeling
of
instability
when
walking
on
uneven
ground.
These
symptoms
may
coincide
with
chronic
talocrural
instability
and
therefore
careful
clinical
examination
is
necessary.
Localised
tenderness
on
palpation
over
the
subtalar
joint
is
suggestive
of
a
sub-
talar
sprain.
The
diagnosis
can
be
verified
with
subtalar
arthrography38
or
a
subtalar
stress
view
or
stress
tomography.
Functional
treatment
similar
to
the
regimen
used
for
lateral
sprains
is
the
treatment
of
choice.
Surgery
with
non-anatomical
proce-
dures
has
been
described.'09110
Anatomical
repairs,
however,
show
equally
good
re-
sults.97
"'I
Sinus
tarsi
syndrome
The
sinus
tarsi
syndrome
is
often
accompanied
by
a
feeling
of
instability
and
giving
way
of
the
ankle.
Seventy
per
cent
of
the
patients
will
have
experienced
a
severe
inversion
sprain.92
If
the
calcaneofibular
ligament
is
torn
the
interos-
seous
talocalcaneal
ligament
occupying
the
sinus
will
often
also
be
sprained.
This
sprain
will
cause
synovitis
in
the
sinus
tarsi
with
rather
localised
pain.
The
diagnosis
can
be
made
based
on
a
complaint
of
pain
and
tenderness
of
the
sinus
tarsi
combined
with
the
giving
way
15
Renstrom,
Konradsen
Figure
2
Forceful
inversion
of
the
hindfoot
in
neutral
flexion.
Tearing
of
the
calcaneofibular,
the
cervical,
and
the
interosseous
ligaments.
(From
Meyer
JM,
Garcia
J7,
Hoffmeyer
1P
Fritchy
D.
The
subtalar
sprain.
A
roentgenographic
study.
Clin
Orthop
1988;226:169-73.)
feeling.
The
pain
and
the
giving
way
feeling
can
usually
be
relieved
by
local
injections
of
anaes-
thetic
and
corticosteroids.
Excision
of
tissue
filling
the
sinus
tarsi
can
give
good
results
if
conservative
treatment
fails.
TREATMENT
OF
CHRONIC
INSTABILITY
Rehabilitation
With
the
uncertain
pathogenesis
of
functional
ankle
instability
the
elements
of
treatment
pro-
tocols
will
rest
primarily
on
personal
experi-
ences
and
not
so
much
on
scientific
data.
Before
deciding
upon
surgical
treatment,
a
well
planned
rehabilitation
programme
based
on
peroneal
muscle
strengthening
and
coordina-
tion
training
should
be
carried
out.
Regaining
muscle
strength
is
primarily
achieved
by
increasing
neural
activation
through
function-
ally
oriented
training
and
dynamometer
train-
ing.
'12
In
functional
training
the
patient
is
required
to
activate
his/her
musculature
in
normally
occurring
activities.
Dynamic
stabil-
ity,
including
proprioceptive
information,
motor
control,
and
appropriate
muscle
force
development,
will
be
enforced
by
the
training.
Treatment
of
the
proprioceptive
ankle
deficit
consists
of
a
progressive
series
of
coordination
exercises
to
re-educate
the
ankle.
Tropp95
found
a
significant
improvement
in
balance
during
single
limb
stance
in
subjects
with
a
functionally
unstable
ankle
after
six
weeks
of
balance
board
exercises
(fig
3).
The
same
group
reported
a
decrease
in
the
frequency
of
inversion
injuries
and
ankle
giving
way
feelings
when
compared
with
an
untrained
control
group
with
unstable
ankles.
Tropp9"
also
found
that
the
subjects
in
question
showed
a
change
in
their
strategy
of
single
limb
stance,
going
from
a
broken
chain
strategy
before
training
to
the
normal
inverted
pendulum
strategy
after
completed
training.
So
it
may
well
be,
as
suggested
by
Glencross
and
Thornton,'04
that
Figure
3
Tilt
board
training
is
an
excellent
way
to
return
neuromuscular
control
to
the
injured
ankle.
rehabilitation
was
as
much
a
relearning
pro-
gramme
as
it
was
a
physical
recovery
after
injury.
Often
the
injured
subjects
themselves
have
a
clear
feeling
of
a
perception/
proprioception
deficit
in
the
ankle
joint
area-
they
cannot
"feel"
the
ankle
as
they
used
to.
When
this
feeling
returns
it
seems
to
coincide
with
complete
rehabilitation.
Leanderson
et
al'08
found
that
return
of
single
limb
balance
to
normal
values
coincided
with
a
subjective
feel-
ing
of
full
rehabilitation
in
dancers.
It
can,
however,
be
argued
that
in
this
group
balance
during
single
limb
stance
was
as
much
a
specific
functional
test
as
an
unspecific
test
for
ankle
proprioception.
In
summary,
training
proprioceptive
func-
tion
through
coordination
exercises
using
uni-
lateral
balance
boards,
uniaxial
and
multiaxial
teeter
boards,
and
jumping
ropes
relies
prima-
rily
on
empirical
data
but
produces
very
favourable
results.
Restitution
of
normal
func-
tion
relies
on
the
individual's
subjective
feeling
of
return
to
normal
sensation.
Full
effect
of
training
is
achieved
within
10-12
weeks
as
evaluated
by
postural
sway.95
About
50%
of
patients
with
functional
insta-
bility
will
regain
satisfactory
functional
stability
after
such
a
programme."'
EXTERNAL
SUPPORT
When
considering
the
mechanical
effect
of
the
different
external
support
modalities
it
is
important
to
remember
that
even
though
they
do
increase
the
resistance
to
inversion,
the
effect
cannot
be
compared
with
that
of
active
evertor
muscles.
Ashton-Miller
et
al'.'
found
that
active
evertor
muscles,
acting
isometrically
on
a
15
degrees
inverted
ankle,
can
provide
more
than
three
times
the
protection
against
16
Ankle
ligament
injuries
further
ankle
inversion
than
tape
or
an
orthosis
worn
inside
a
three-quarter-top
shoe.
Tape
The
primary
purpose
of
taping
is
to
provide
increased
stiffness
to
the
ankle
and
a
semirigid
and
sometimes
rigid
splinting
around
it.
Stud-
ies
have
shown
that
taping
the
ankle
prevents
ankle
injuries.
Garrick
et
al
found
that
the
combination
of
taping
prophylactically
and
the
use
of
high
top
shoes
in
basketball
reduced
the
frequency
of
ankle
sprains.
'
4a
Lindenberger
et
all5
found
that
tape
had
a
significant
prophy-
lactic
effect
in
handball
team
players
who
were
studied
prospectively
for
two
full
seasons.
Six
top
level
teams
participated
in
the
first
year.
In
three
teams
the
players
wore
tape
and
in
the
other
three
teams
the
players
did
not.
During
the
first
season 13
ankle
sprains
occurred
all
in
the
non-taped
group.
In
the
second
season
nine
teams
participated.
Twenty
one
ankle
sprains
occurred
and
20
of
these
were
in
the
non-taped
group.
Contrary
to
this,
several
studies
have
shown
that
tape
loses
as
much
as
50%
of
its
support-
ive
effect
after
only
10
minutes
of
active
exercise"'-"8
and
offers
virtually
no
support
after
one
hour."9
The
mechanism
behind
the
effect
of
ankle
taping
thus
remains
unclear.
However,
tape
does
not
only
restrict
extensive
joint
motion
but
also
enhances
proprioceptive
feedback
mechanism
and
shortens
the
recruit-
ment
time
of
the
dynamic
ankle
stabilisers.'20
Many
athletes
may
have
a
skin
reaction
to
tape
and
therefore
skin
protection
may
be
used.
There
seems
to
be
no
difference
in
support
between
tape
directly
on
the
skin
and
tape
with
skin
protections.
Because
of
these
skin
problems,
tape
is
used
mostly
by
top
ath-
letes
and
not
by
recreational
athletes.
Braces
The
use
of
ankle
orthoses
has
increased
over
the
past
decade.
In
contrast
with
tape
the
mechanical
effect
of
a
brace
does
not
wear
off
with
activity
as
shown
by
Shapiro
et
al.'2'
Not
many
clinical
trials
have
been
per-
formed
judging
the
effect
of
ankle
bracing
on
the
frequency
of
ankle
inversion
injuries.
In
a
retrospective
trial
Rovere
et
al'22
found
a
reduc-
tion
of
sprains
in
football
using
a
lace-on
cloth
brace.
Tropp
et
al5
in
a
prospective
study
showed
the
effect
of
a
semirigid
ankle
brace
in
reducing
the
frequency
of
injuries
in
soccer
players,
and
in
a
prospective
randomised
study
Sitler
et
al'23
found
that
ankle
stabilisers
signifi-
cantly
reduced
the
frequency
of
ankle
injuries
but
not
their
severity
in
a
group
of
basketball
players
at
West
Point,
New
York.
The
resist-
ance
to
an
eversion
moment
seems
to
be
the
same
for
ankle
braces
as
that
for
newly
applied
tape."4
Like
tape,
braces
have
been
shown
to
have
a
proprioceptive
enhancing
effect.'24
There
have
been
discussions
about
the
effect
on
performance
of
tape
and
braces.
In
sprinting
a
reduction
in
maximal
speed
has
been
found
by
most,'25
but
not
by
all.'26
For
vertical
jumping
most
studies
also
show
that
a
brace
decreases
ability..
.2.'2
Opinions
about
bracing
compared
with
taping
vary,
with
some
studies
showing
a
smaller
effect
and
others
a
larger
detrimental
effect
of
tape
compared
with
braces.
It
must
be
noted
that
most
of
the
stud-
ies
were
done
on
subjects
with
stable ankles.
The
use
of
an
ankle
brace
or
taping,
or
both,
is
recommended
as
they
both
give
support
against
ankle
inversion
when
the
evertor
muscles
are
relaxed
and
increase
the
maximal
resistance
to
inversion
with
evertor
muscles
activated.
They
do
seem
to
be
able
to
enhance
proprioceptive
awareness,
and
to
decrease
the
frequency
of
inversion
injuries
and
decrease
the
severity
of
the
injuries
in
groups
with
functionally
unstable
ankles.
The
role
of
shoes
Biomechanical
studies
support
the
use
of
high
top
shoes
for
ankle
sprain
prevention
because
they
limit
extreme
range
of
motion,
provide
additional
proprioceptive
input,
and
decrease
external
stress
on
joints.'29
Clinical
trials,
how-
ever,
have
not
shown
that
the
effect
of
this
bio-
mechanically
improved
stability
translates
into
a
lower
rate
of
ankle
sprains
in
high
top
shoes.
Further
studies
are
needed.
Supportive
treatment
modalities
Passive
physical
therapy
modalities
are
often
recommended
to
promote
healing
in
the
early
rehabilitation
phase.
The
most
commonly
used
are
ultrasound,
temperature
contrast
baths,
short
waves,
and
various
current
treatments
including
dynamic
or
interference
current
therapy,
or
electrogalvanic
stimulations.
Of
these
different
types
of
passive
physical
therapy,
only
cryotherapy
has
been
proved
to
be
effective.130
Non-steroidal
anti-inflammatory
drugs
have
been
studied
in
prospective
randomised
double
blind
trials,
and
found
to
be
more
effective
than
placebo
for
ankle
tenderness,
swelling,
and
pain,
though
the
difference
was
not
striking
and
seemed
to
disappear
during
an
extended
follow
up.3
130
In
subjects
with
chronic
post-injury
swelling,
moist
heat
packs,
warm
whirlpool
baths,
contrast
baths, electrogalvanic
stimulation,
and
intermittent
pneumatic
compression
have
been
tried.4
Prospective
randomised
studies
have
shown
that
only
the
last
alternative
has
an
independent
ability
to
reduce
the
amount
of
swelling.131
132
Table
1
Classification
of
operative
treatments
for
chronic
ankle
ligament
injury
Non-anatomical
reconstruction
Non-anatomical
reconstruction
Endogenous
Peroneal
tendon
Watson-Jones
Evans
Chrisman-Snook
Other
Plantaris
Partial
Achilles
tendon
Free
autogenous
graft
Exogenous
Carbon
fibre
Bovine
xenograft
Anatomical
repair
Direct
suture
Imbrication
and
repair
to
bone
Local
tissue
augmentation
17
18
Renstrdm,
Konradsen
AS
B
J~~
K~
Figure
4
Anatomical
reconstruction
of
chronic
ankle
ligament
instability.
(A)
Elongated
ligaments
are
divided
3
to
5
mm
from
insertion
of
the
fibula.
(B)
Bone
surace
of
the
distal
end
of
the
fibula
is
roughened
to
form
a
trough
to
promote
ligament
healing.
Holes
are
drilled
through
the
distalfibula.
(C)
Mattress
sutures
are
used
to
fix
the
distal
stump
of
the
ligaments
and
the
capsule
to
the
fibula.
The
sutures
are
tightened
while
the
foot
is
held
in
dorsiflexion
and
eversion.
(D)
The
proimal
ends
of
the
ligaments
are
imbricated
over
the
distal
portion.
Surgery
for
chronic
instability
Chronic
ankle
instability,
as
demonstrated
by
pain,
recurrent
giving
way,
and
positive
stress
tests,
is
often
treated
surgically.
A
combination
of
mechanical
and
functional
instability
is
the
most
commonly
reported
indication
for
sur-
gery.
More
than
50
procedures
or
modifica-
tions
have
been
described
for
treating
chronic
ankle
instability,
and
these
can
be
loosely
grouped
as
non-anatomical
reconstructions
or
anatomical
repairs
(table
1).
Non-anatomical
reconstructions
use
other
structures
or
materials
to
substitute
for
the
injured
ligaments.
Structures
commonly
used
for
grafting
are
fascia
late
and
the
peroneus
brevis
tendons
in
procedures
such
as
Watson-
Jones,
Evans,
and
Chrisman-Snook.
Numer-
ous
modifications
of
these
classic
procedures
have
been
described.
The
Chrisman-Snook'09
modification
of
the
Elmslie
procedure
is
the
most
widely
used
non-anatomical
reconstruc-
tion.
In
four
clinical
series
with
a
total
of
100
ankles,
more
than
90%
of
patients
had
good
or
excellent
results,
and
stability
was
more
than
95%
of
the
normal
ankle.
Reported
complica-
tions
included
neuromas
in
0
to
16%
of
patients,
restricted
dorsiflexion
in
about
20%,
and
restricted
inversion
to
some
degree
in
all
patients.
An
advantage
of
the
Chrisman-Snook
procedure
is
that
less
lateral
weakness
is
produced
because
only
half
of
the
peroneus
brevis
tendon
is
used
for
the
graft.
A
criticism
of
the
procedure
has
been
that
it
results
in
restricted
subtalar
motion.
Furthermore,
these
tenodesis
procedures
are
non-
anatomical
and
do
not
restore
normal
biomechanics."33
Although
short
term
results
are
excellent,
long
term
results
may
not
be
as
good.
Thus
Karlsson
et
a193
found
that
the
Evans
static
tenodesis
was
satisfactory
in
fewer
than
50%
of
cases
after
a
mean
follow
up
period
of
14
years.
Anatomical
reconstructions,
in
which
the
tissues
of
the
damaged
ligaments
are
used,
have
become
increasingly
popular
as
they
per-
mit
reconstruction
without
sacrificing
any
nor-
mal
tissue.3093
14
Brostrdm
in
196630
reported
that
direct
suture
repair
of
chronic
ankle
ligament
injuries
was
possible
even
many
years
after
the
initial
injuries
and
that
the
ends
of
the
ligament
could
be
found.
Others
reported
that
the
elongated
ligaments
had
healed
encased
in
a
fibrous
scar
tissue.
Several
authors
have
reported
successful
imbrication
or
shortening
and
replantation
of
the
ligaments
to
obtain
a
more
anatomical
reconstruction.
We
have
obtained
good
results
with
a
modified
Bros-
trom
technique
(Peterson
procedure)
that
includes
shortening
of
the
ligament,
repair
through
bony
tunnels,
and
imbrication
with
local
tissue93
14
(fig
4).
This
anatomical
technique
repairs
both
the
ATFL
and
CFL.
The
non-anatomical
reconstructions,
except
for
the
Chrisman-Snook
modification
of
the
Elmslie
procedure,
repair
only
the
ATFL.
Repair
of
the
CFL
is
important,
because
insuf-
ficiency
of
this
ligament
may
be
a
factor
in
the
development
of
subtalar
instability.
The
post-
operative
treatment
after
an
anatomical
recon-
struction
is
a
splint
for
eight
days
to
secure
wound
healing
and,
thereafter,
a
removable
walking
boot
for
five
weeks.
The
patient
starts
with
dorsiflexion
and
plantar
flexion
exercises
after
eight
days
or
as
early
as
possible
out
of
the
boot
two
to
three
times
a
day.
Return
to
sport
is
usually
possible
in
three
months.
Anatomical
repair
of
both
the
ATFL
and
the
CFL
through
bony
tunnels
produces
good
long
term
results
and
is
recom-
mended
as
the
initial
procedure
in
most
cases.
If
anatomical
repair
fails,
a
tenodesis
procedure,
such
as
the
Chrisman-Snook
re-
construction,
is
a
good
alternative.
A
non-
anatomical
reconstruction
is
also
indicated
in
patients
with
moderate
arthritis
or
lax
joints.
1
Makhani
JS.
Diagnosis
and
treatment
of
acute
rupture
of
the
various
components
of
the
lateral
ligaments
of
the
ankle.
Am
J
Orthop
1962;4:224-30.
2
McCulloch
PB,
Holden
P,
Robson
DJ,
et
al.
The
value
of
mobilisation
and
nonsteroidal
anti-inflammatory
analgesia
in
the
management
of
inversion
injuries
of
the
ankle.
BrJ7
CGin
Pract
1985;39:69-72.
3
Viljakka
T,
Rokkanen
P.
The
treatment
of
ankle
sprain
by
bandaging
and
antiphlogistic
drugs.
Ann
Chir
Gynaecol
1983;72:66-70.
4
Balduini
FC,
Vegso
JJ,
Torg
JS,
et
al.
Management
and
rehabilitation
of
ligamentous
injuries
to
the
ankle.
Sports
Med
1987;4:364-80.
5
Brand
RL,
Black
HM,
Cox
JS.
The
natural
history
of
inad-
equately
treated
ankle
sprain.
Am
-f
Sports
Med
1977;5:
248-9.
6
Fiore
RD,
Leard
JS.
A
functional
approach
in
the
rehabili-
tation
of
the
ankle
and
rear
foot.
Athletic
Training
1980;15:
231-5.
7
Garrick
JG.
The
frequency
of
injury,
mechanism
of
injury
and
epidemiology
of
ankle
sprains.
Am
if
Sports
Med
1977;
5:241-2.
8
Garrick
JG,
Requa
RK.
The
epidemiology
of
foot
and
ankle
injuries
in
sports.
CGin
Sports
Med
1988;7:29-36.
9
Glick
JM,
Gordon
RB,
Nashimoto
D.
The
prevention
and
treatment
of
ankle
injuries.
Am
if
Sports
Med
1
976;4:
136-
41.
10
Hardaker
WT,
Margello
S,
Goldner
JL.
Foot
and
ankle
injuries
in
theatrical
dancers.
Foot
Ankle
1
985;6:59-69.
Ankle
ligament
injuries
19
11
Lassiter
TE
Jr,
Malone
TR,
Garrett
WE
Jr.
Injury
to
the
lateral
ligaments
of
the
ankle
(review).
Orthop
Clin
North
Am
1989;20:629-40.
12
McConkey
JP.
Ankle
sprains,
consequences
and
mimics.
Medicine
and
Sports
Science
1987;23:39-55.
13
Brostrom
L.
Sprained
ankles
III:
Clinical
observations
in
recent
ligament
ruptures.
Acta
Chir
Scand
1965;130:560-
9.
14
Ekstrand
J,
Tropp
H.
The
incidence
of
ankle
sprains
in
soccer.
Foot
Ankle
1990;11:41-4.
15
Van
Dijk
CN.
On
diagnostic
strategies
in
patients
with
severe
ankle
sprain.
Amsterdam,
Holland:
University
of
Amster-
dam,
1994.
16
Brostrom
L.
Sprained
ankles
I:
anatomic
lesions
in
recent
sprains.
Acta
Chir
Scand
1964;128:483-95.
17
Rasmussen
0.
Stability
of
the
ankle
joint.
Analysis
of
the
function
and
traumatology
of
the
ankle
ligaments.
Acta
Orthop
Scand
Suppl
1985;211:1-75.
18
Renstrom
P.
Wertz
M,
Incavo
S,
et
al.
Strain
in
the
lateral
ligaments
of
the
ankle.
Foot
Ankle
1988;9:59-63.
19
Colville
MR,
Marder
RA,
Boyle
JI,
et
al.
Strain
measurement
in
lateral
ankle
ligaments.
Am
Jf
Sports
Med
1990;18:
196-200.
20
Kjaersgaard-Andersen
P,
Wethelund
JO,
Helmig
P,
et
al.
The
stabilizing
effect
of
the
ligamentous
structures
in
the
sinus
and
canalis
tarsi
on
movements
in
the
hindfoot.
An
experimental
study.
Am
j
Sports
Med
1988;16:512-6.
21
Cass
JR,
Morrey
BF,
Chao
KY.
Three-dimensional
kinematics
of
ankle
instability
following
serial
sectioning
of
lateral
collateral
ligaments.
Foot
Ankle
1984;5:142-9.
22
Cawley
PW,
France
EP.
Biomechanics
of
the
lateral
ligaments
of
the
ankle:
an
evaluation
of
the
effects
of
axial
load
and
single
plane
motions
on
ligament
strain
patterns.
Foot
Ankle
1991;12:92-9.
23
Dias
LS.
The
lateral
ankle
sprain:
an
experimental
study.
J
Trauma
1979;19:266-9.
24
Ozeki
S,
Yasuda
K,
Kaneda
K.
Simultaneous
measurement
of
strain
changes
and
determination
of
zero
strain
in
the
collateral
ligaments
of
the
human
ankle.
36th
Annual
Meeting,
Ortho-
paedic
Research
Society,
1990.
25
Shybut
GT,
Hayes
WC,
White
AA.
Normal
patterns
of
liga-
ment
loading
among
the
lateral
collateral
ankle
ligaments.
29th
Annual
Meeting,
Orthopaedic
Research
Society,
1983.
26
Stormont
DM,
Morrey
BF,
An
KN,
et
al.
Stability
of
the
loaded
ankle.
Relation
between
articular
restraint
and
pri-
mary
and
secondary
static
restraints.
Am
Jf
Sports
Med
1985;13:295-300.
27
Rasmussen
0,
Kromann-Andersen
C,
Boe
S.
Deltoid
liga-
ment.
Functional
analysis
of
the
medial
collateral
ligamen-
tous
apparatus
of
the
ankle
joint.
Acta
Orthop
Scand
1983;
54:36-44.
28
Smith
RW,
Reischl
SF.
Treatment
of
ankle
sprains
in
young
athletes.
Am
Jf
Sports
Med
1986;14:465-7
1.
29
Brand
RL,
Collins
MD.
Operative
management
of
ligamentous
injuries
to
the
ankle.
Clin
Sports
Med
1982;1:
117-30.
30
Brostrom
L.
Sprained
ankles
V
-
treatment
and
prognosis
in
recent
ligament
ruptures.
Acta
Chir
Scand
1966;135:
537-50.
31
Glasgow
M,
Jackson
A,
Jamieson
AM.
Instability
of
the
ankle
after
injury
to
the
lateral
ligament.
J
Bone
joint
Surg
[Br]
1980;62:
196-200.
32
Kjaersgaard-Andersen
P,
Frich
LH,
Madsen
F,
et
al.
Insta-
bility
of
the
hindfoot
after
lesion
of
the
lateral
ankle
ligaments:
investigations
of
the
anterior
drawer
and
adduction
maneuvers
in
autopsy
specimens.
Clin
Orthop
1991;266:
170-9.
33
Leonard
MH.
Injuries
of
the
lateral
ligaments
of
the
ankle.
A
clinical
and
experimental
study.
J7
Bone
Joint
Surg
[Am]
1949;31:373-7.
34
Lindstrand
A.
New
aspects
in
the
diagnosis
of
lateral
ankle
sprains.
Orthop
Clin
North
Am
1976;7:247-9.
35
Kannus
P,
Renstrom
P.
Current
concepts
review:
treat-
ment
for
acute
tears
of
the
lateral
ligaments
of
the
ankle.
Jf
Bone
Joint
Surg
[Am]
199
1;73:305-12.
36
Gerner-Smidt
M.
Ankle
fractures
in
children.
Copenhagen,
Denmark:
University
of
Copenhagen,
1963.
37
Holmer
P,
S0ndergaard
L,
Konradsen
L,
et
al.
Epidemiol-
ogy
of
sprains
in
the
lateral
ankle
and
foot.
Foot
Ankle
1994;15:72-4.
38
Meyer
JM,
Garcia
J,
Hoffmeyer
P,
et
al.
The
subtalar
sprain.
A
roentgenographic
study.
Clin
Orthop
1988;226:
169-73.
39
Taillard
W,
Meyer
JM,
Garcia
J,
et
al.
The
sinus
tarsi
syn-
drome.
Int
Orthop
1981;5:1
17-30.
40
Taga
I,
Shino
K,
Inoue
M,
et
al.
Articular
cartilage
lesions
in
ankles
with
lateral
ligament
injury.
Am
Jf
Sports
Med
1993;21:120-6.
41
Grana
WA.
Chronic
pain
persisting
after
ankle
sprain.
Journal
of
Musculoskeletal
Medicine
1990;7:35-49.
42
Sammarco
GJ.
Peroneal
tendon
injuries.
Orthop
Clin
North
Am
1994;25:109-22.
43
Hyslop
GH.
Injuries
to
the
deep
and
the
superficial
pero-
neal
nerves
complicating
ankle
sprain.
Am
J
Surg
1941;51:
436-8.
44
Stoff
MD,
Greene
AF.
Common
nerve
palsy
following
inversion
ankle
injury:
a
report
of
two
cases.
Physical
Therapy
1
982;62:
1463-4.
45
Nitz
Al,
Dobuer
JJ,
Kersey
D.
Nerve
injury
and
grades
II
and
III
ankle
sprains.
AmJySports
Med
1985;13:
177-82.
46
Kleinrensink
GJ,
Stoeckart
R,
Meulstee
J.
et
al.
Lowered
motor
conduction
velocity
of the
peroneal
nerve
after
inversion
trauma.
Med
Sci
Sports
Exer
1994;26:877-83.
47
Norfray
JF,
Groves
HC,
Rogers
LF,
et
al.
Common
calca-
neal
avulsion
fracture.
Am
7
Roentgenol
1980;134:
119-23.
48
Heckman
JD,
McLean
MR.
Fractures
of
the
lateral
process
of
the
talus.
CGin
Orthop
1985;199:108-13.
49
Noble
J,
Royle
SG.
Fracture
of
the
lateral
process
of
the
talus:
computed
tomographic
scan
diagnosis.
Br
J
Sports
Med
1992;26:245-6.
50
Lindenfeld
TN.
The
differentiation
and
treatment
of
ankle
sprains.
Orthopedics
1988;11:203-6.
51
Stepanuk
M.
Arthrography
of
the
ankle
joint
in
the
diagnosis
of
acute
ankle
sprains.
Journal
of
the
American
Orthopedic
Association
1977;76:52936.
52
Cass
JR,
Morrey
BF.
Ankle
instability:
current
concepts,
diagnosis,
and
treatment.
Mayo
Clin
Proc
1984;59:
165-70.
53
Van
der
Ent
FWC.
Lateral
ankle
ligament
injury.
Rotterdam:
Elinkwijk,
Utrecht,
1984.
54
Nilsson
S.
Sprains
of
the
lateral
ankle
ligaments.
An
epide-
miological
and
clinical
study
with
special
reference
to
dif-
ferent
forms
of
conservative
treatment.
Part
I.
Journal
of
Oslo
City
Hospital
1982;32:3-29.
55
Prins
JG.
Diagnosis
and
treatment
of
injury
to
the
lateral
ligament
of
the
ankle.
A
comparative
clinical
study.
Acta
Chir
Scand
1978;Suppl.
486
56
Stiell
IG,
McKnight
RD,
Greenberg
GH,
et
al.
Interob-
server
agreement
in
the
examination
of
acute
ankle
injury
patients.
Am
J
Emerg
Med
1992;10:
14-17.
57
van
Dijk
CN,
Lim
LSL,
Bossuyt
PMM,
et
al.
Physical
examination
is
sufficient
for
the
diagnosis
of
sprained
ankles.
Bone
Joint
Surg
[Br]
1996;78:958-62.
58
Stiell
IG,
McKnight
RD,
Greenberg
GH,
et
al.
Implemen-
tation
of
the
Ottawa
ankle
rules
[see
comments].
JAA'A
1994;271:827-32.
59
Jackson
DW,
Ashley
RL,
Powell
JW.
Ankle
sprains
in
young
athletes.
Relation
of
severity
and
disability.
Clin
Orthop
1974;101:201-15.
60
Clark
BL,
Derby
AC,
Power
GRI.
Injuries
of
the
lateral
ligament
of
the
ankle.
Conservative
vs.
operative
repair.
Can
Jf
Surg
1965;8:358-63.
61
Evans
GA,
Hardcastle
P.
Frenyo
AD.
Acute
rupture
of
the
lateral
ligament
of
the
ankle.
To
suture
or
not
to
suture?
J
Bone
Joint
Surg
[Br]
1984;66:209-12.
62
Freeman
MAR.
Treatment
of
ruptures
of
the
lateral
ligament
of
the
ankle.
J
Bone
Joint
Surg
[Br]
1965;47:661-
8.
63
Gr0nmark
T,
Johnsen
0,
Kogstad
0.
Rupture
of
the
lateral
ligament
of
the
ankle:
a
controlled
clinical
trial.
Injury
1980;11:215-8.
64
Klein
J,
Schreckenberger
C,
Roddecker
K.
Operative
or
conservative
treatment
of
recent
rupture
of
the
fibular
ligament
in
the
ankle.
A
randomized
clinical
trial.
Unfallchirurgie
1988,91:154-60.
65
Korkala
0,
Rusanen
M,
Jokipii
P,
et
al.
A
prospective
study
of
the
treatment
of
severe
tears
of
the
lateral
ligament
of
the
ankle.
Int
Orthop
1987;11:
13-17.
66
M0ller-Larsen
F,
Wethelund
JO,
Jurik
AG,
et
al.
Compari-
son
of
three
different
treatments
for
ruptured
lateral
ankle
ligaments.
Acta
Orthop
Scand
1988;59:564-6.
67
Niedermann
B,
Andersen
A,
Andersen
SB,
et
al.
Rupture
of
the
lateral
ligaments
of
the
ankle:
operation
or
plaster
cast?
A
propective
study.
Acta
Orthop
Scand
198
1;52:579-
87.
68
Sommer
HM,
Arza
D.
Functional
treatment
of
recent
rup-
tures
of
the
fibular
ligament
of
the
ankle.
Int
Orthop
1989;
13:157-60.
69
Van
Moppes
FI,
Van
den
Hoogenband
CR.
Diagnostic
and
therapeutic
aspects
of
inversion
trauma
of
the
ankle
joint.
Amsterdam,
Holland:
Free
University,
1982.
70
Freeman
MA.
Instability
of
the
foot
after
injuries
to
the
lateral
ligament
of
the
ankle.
J
Bone
Joint
Surg
[Br]
1965;
47:669-77.
71
Korkala
0,
Lauttamus
L,
Tanskanen
P.
Lateral
ligament
injuries
of
the
ankle.
Results
of
primary
surgical
treatment.
Ann
Chir
Gynaecol
1982;71:161-3.
72
Konradsen
L,
H0lmer
P,
S0ndergaard
L.
Early
mobilizing
treatment
for
grade
III
ankle
ligament
injuries.
Foot
Ankle
199
1;12:69-73.
73
Eiff
MP,
Smith
AT,
Smith
GE.
Early
mobilization
versus
immobilization
in
the
treatment
of
lateral
ankle
sprains.
Am
J
Sports
Med
1994;22:83-8.
74
Kaikkonen
A,
Kannus
P,
Jdrvinen
M.
A
performance
test
protocol
and
scoring
scale
for
the
evaluation
of
ankle
inju-
ries.
Am
J
Sports
Med
1994;22:462-9.
75
Schrier
I.
Treatment
of
lateral
collateral
ligament
sprains
of
the
ankle:
a
critical
appraisal
of
the
literature.
Clin
J
Sport
Med
1995;5:187-95.
76
Sommer
HM,
Schreiber
T.
Early
functional
conservative
therapy
of
a
fresh
fibular
rupture
of
the
capsular
ligament
from
a
socioeconomic
point
of
view.
Sportverletz
Sport-
schaden
1993;7:40-6.
77
Leanderson
J,
Wredmark
T.
Treatment
of
acute
ankle
sprain.
Acta
Orthop
Scand
1995;66:529-3
1.
78
Leach
RE,
Schepsis
AA.
Acute
injury
to
ligaments
of
the
ankle.
In:
Evarts
CM,
ed.
Surgery
of
the
musculoskeletal
sys-
tem.
Vol
4.
New
York:
Churchill
Livingstone,
1990:
3887-
913.
79
Burry
HC.
Soft
tissue
injury
in
sport.
Exerc
Sport
Sci
Rev
1
975;3:275-30
1.
80
Jarvinen
M,
Letho
M. The
effect
of
early
mobilization
and
immobilization
on
the
healing
process
following
muscle
injuries.
Sports
Med
1993;15:
78-89.
81
Jiirvinen
M.
Healing
of
a
crush
injury
in
rat
striated
muscle
with
special
reference
to
treatment
of
early
mobilization
and
immobilization.
Turku,
Finland:
University
of
Turku,
1976.
20
Renstrdm,
Konradsen
82
Letho
M.
Collagen
and
fibronectin
in
healing
skeletal
muscle
injury:
an
experimental
study
in
rats
under
variable
conditions
of
physical
exercise.
Turku,
Finland:
University
of
Turku,
1983.
83
Montgomery
JB,
Steadman
JR.
Rehabilitation
of
the
injured
knee.
Clin
Sports
Med
1985;4:333-43.
84
Akeson
WH,
Amiel
D,
Woo
SL-Y
Immobility
effects
on
synovial
joints:
the
pathomechanics
of
joint
contracture.
Biorheology
1980;17:95-100.
85
Alves
J,
Alday
R,
Ketcham
D,
Lentell
G.
A
comparison
of
the
passive
support
provided
by
various
ankle
braces.
J
Orthop
Sports
Phys
Ther
1992;15:10-18.
86
Jozsa
L,
Jdrvinen
M,
Kannus
P,
et
al.
Fine
structural
changes
in
the
articular
cartilage
of
the
rat's
knee
following
short-term
immobilisation
in
various
positions:
a
scanning
electron
microscopical
study.
Int
Orthop
1987;11:129-33.
87
Jozsa
L,
Thoring
J,
Jdrvinen
M,
et
al.
Quantitative
alterations
in
intramuscular
connective
tissue
following
immobilization:
an
experimental
study
in
the
rat
calf
mus-
cles.
Exp
Mol
Pathol
1988;49:267-78.
88
Jozsa
L,
Reffy
A,
Jarvinen
M,
et
al.
Cortical
and
trabecular
osteopenia
after
immobilization.
A
quantitative
histologi-
cal
study
of
the
rat
knee.
Int
Orthop
1988;12:169-72.
89
Noyes
FR.
Functional
properties
of
knee
ligaments
and
alterations
induced
by
immobilization.
Clin
Orthop
1977;
123:210-42.
90
Ogata
K,
Whiteside
LA,
Andersen
DA.
The
intra-articular
effect
of
various
postoperative
managements
following
knee
ligament
repair:
an
experimental
study
in
dogs.
Clin
Orthop
1980;150:271-6.
91
Woo
SL,
Inoue
M,
McGurk-Burleson
E,
et
al.
Treatment
of
the
medial
collateral
ligament
injury.
II:
Structure
and
function
of
canine
knees
in
response
to
differing
treatment
regimens.
Am
J
Sports
Med
1987;15:22-9.
92
Renstrom
P.
Kannus
P.
Injuries
of
the
foot
and
ankle.
In:
DeLee
JC,
Drez
DJ,
eds.
Orthopaedic
sports
medicine:
princi-
ples
and
practice.
Vol
2.
Philadelphia:
Saunders,
1994:
1705-67.
93
Karlsson
J,
Bergsten
T,
Lansinger
0,
et
al.
Reconstruction
of
the
lateral
ligaments
of
the
ankle
for
chronic
lateral
instability.
J
Bone
joint
Surg
[Am]
1988;70:581-8.
94
Mann
G,
Eliashuvo
0,
Perry
C.
Recurrent
ankle
sprain:
literature
review.
Israel
Journal
of
Sports
Medicine
1994;4:
104-13.
95
Tropp
H.
Functional
instability
of
the
ankle
joint.
Linkoping,
Sweden:
Linkoping
University,
1985.
96
Freeman
MAR,
Dean
MRE,
Hanham
IWF.
The
etiology
and
prevention
of
functional
instability
of
the
foot.
J7
Bone
joint
Surg
[Br]
1965;47:678-85.
97
Harper
MC.
The
lateral
ligamentous
support
of
the subta-
lar
joint
(review).
Foot
Ankle
1991;11:354-8.
98
Konradsen
L,
Ravn
JB.
Prolonged
peroneal
reaction
time
in
ankle
instability.
IntJ
Sports
Med
1991;12:290-2.
99
Karlsson
J,
Lansinger
0.
Lateral
instability
of
the
ankle
joint.
Clin
Orthop
1992;276:253-61.
100
L6efvenberg
R,
Karrholm
J,
Sundelin
G.
Prolonged
reaction
time
in
patients
with
chronic
lateral
instability
of
the
ankle.
Am
J
Sports
Med
1995;23:414-7.
101
Isakov
E,
Mizrahi
J,
Solzi
P,
et
al.
Response
of
the
peroneal
muscles
to
sudden
inversion
of
the
ankle
during
standing.
International
Journal
of
Sports
Biomechanics
1986;2:100-9.
102
Brunt
D,
Andersen
JC,
Huntsman
B,
et
al.
Postural
responses
to
lateral
perturbation
in
healthy
subjects
and
ankle
sprain
patients.
Med
Sci
Sports
Exerc
1992;24:
171-6.
103
Johnson
MB,
Johnson
CL.
Electromyographic
response
of
peroneal
muscles
in
surgical
and
nonsurgical
injured
ankles
during
sudden
inversion.
Journal
of
Sports
Physical
Therapy
1993;18:497-501.
104
Glencross
D,
Thornton
E.
Position
sense
following
joint
injury.
Jf
Sports
Med
Phys
Fitness
198
1;21:23-7.
105
Garn
SN,
Newton
RA.
Kinesthetic
awareness
in
subjects
with
multiple
ankle
sprains.
Phys
Ther
1988;68:
1667-71.
106
Jerosch
J,
Hoffstetter
I,
Bork
H,
et
al.
The
influence
of
orthoses
on
the
proprioception
of
the
ankle
joint.
Knee
SurgSports
TraumatolArthrosc
1995;3:39-46.
107
Gross
MT.
Effects
of
recurrent
lateral
ankle
sprains
on
active
and
passive
judgement
of
joint
position.
Phys
Ther
1987,-67:
1505-9.
108
Leanderson
J,
Eriksson
E,
Nilsson
C,
et
al.
Proprioception
in
classical
ballet
dancers:
a
prospective
study
of
the
influ-
ence
of
an
ankle
sprain
on
proprioception
in
the
ankle
joint.
Am
7
Sports
Med
1996;24:370-4.
109
Chrisman
OD,
Snook
GA.
Reconstruction
of
lateral
ligament
tears
of
the
ankle.
Jf
Bone
joint
Surg
[Am]
1969;51:904-12.
110
Clanton
TO.
Instability
of
the
subtalar
joint
(review).
Orthop
Clin
North
Am
1989;2:583-92.
111
Karlsson
J,
Renstrom
P.
Subtalar
ankle
instability.
Scand
J
Sports
Med
(in
press).
112
Grimby
G.
Clinical
aspects
of
strength
and
power
training.
In:
Komi
PV,
eds.
Strength
and
power
in
sport.
Oxford:
Blackwell
Scientific,
1992:
338-56.
113
Karlsson
J,
Lansinger
0.
Chronic
lateral
instability
of
the
ankle
in
athletes.
Sports
Med
1993;16:355-65.
114
Ashton-Miller
JA,
Ottaviani
RA,
Hutchinson
C,
et
al.
What
best
protects
the
inverted
weightbearing
ankle
against
fur-
ther
inversion.
Am
_J
Sports
Med
1996;24:800-9.
114a
Garrick
JG,
Requa
RK.
The
role
of
external
support
in
prevention
of
ankle
sprains.
Med
Sci
Sports
1973;5:200-3.
115
Lindenberger
U,
Reese
D,
Andreasson
G,
et
al.
The
effect
of
prophylactic
taping
of
ankles.
Gothenburg,
Sweden:
Chalm-
ers
Technical
University,
1985.
116
Fumich
RM,
Ellison
AE,
Guerin
GJ
et
al.
The
measured
effect
of
taping
on
combined
foot
and
ankle
motion
before
and
after
exercise.
Am
J
Sports
Med
1981,9:165-70.
117
Rarick
GL,
Bigley
G,
Karst
R.
The
measurable
support
of
the
ankle
joint
by
conventional
methods
of
taping.
J7
Bone
Joint
Surg
[Am]
1962;44:1183-90.
118
Larsen
E.
Taping
the
ankle
for
chronic
instability.
Acta
Orthop
Scand
1984;55:551-3.
119
Myburgh
KH,
Vaughan
CL,
Isaacs
SK.
The
effect
of
ankle
guards
and
taping
on
joint
motion
before,
during,
and
after
a
squash
match.
Am
_J
Sports
Med
1984;12:441-6.
120
Karlsson
J,
Bergsten
T,
Lansinger
0,
et
al.
Surgical
treatment
of
chronic
lateral
instability
of
the
ankle
joint.
A
new
procedure
(review).
Am
Jf
Sports
Med
1989;17:268-
73;discussion
273-4.
121
Shapiro
MS,
Kabo
JM,
Mitchell
PW,
et
al.
Ankle
sprain
prophylaxis:
an
analysis
of
the
stabilizing
effects
of
braces
and
tape.
Am
Jf
Sports
Med
1994;22:78-82.
122
Rovere
GD,
Clarke
TJ,
Yates
CS.
Retrospective
compari-
son
of
taping
and
ankle
stabilizers
in
preventing
ankle
injuries.
Am
Jf
Sports
Med
1988;16:228-33.
123
Sitler
M,
Ryan
J,
Wheeler
B,
et
al.
The
efficacy
of
a
semi-
rigid
ankle
stabilizer
to
reduce
acute
ankle
injuries
in
bas-
ketball.
A
randomized
clinical
study
at
West
Point.
Am
Jf
Sports
Med
1994;22:454-61.
124
Nishikawa
T,
Grabiner
MD.
Ankle
braces
influence
the
reflex
amplitude
of
muscle
in
response
to
stretch.
42nd
Annual
Meeting,
Orthopaedic
Research
Society,
1996.
125
Greene
TA,
Wright
CR.
A
comparative
support
evaluation
of
three
orthoses
before,
during
and
after
exercise.
J7
Orthop
Sports
Phys
Ther
1990;11:453-66.
126
Burks
RT,
Marcus
R,
Bean
BG,
Barker
HB.
Analysis
of
athletic
performance
with
prophylactic
ankle
devices.
Am
Jf
Sports
Med
1991;19:104-6.
127
Coffman
JL,
Mize
NL.
A
comparison
of
ankle
taping
and
the
Aircast
sport-stirrup
on
athletic
performance.
Athletic
Training
1989;24:
123-8.
128
Gross
MT,
Everts
JR,
Roberson
SE.
Effect
of
Donjoy
ankle
ligament
protector
and
Aircast
sport-stirrup
orthoses
on
functional
performance.
J7
Orthop
Sports
Phys
Ther
1994;19:150-6.
129
Barrett
J,
Bilisko
T.
The
role
of
shoes
in
the
prevention
of
ankle
sprains.
Sports
Med
1995;20:227-80.
130
Cote
DJ,
Prentice
WE
Jr,
Hooker
DN,
et
al.
Comparison
of
three
treatment
procedures
for
minimizing
ankle
sprain
swelling.
Phys
Ther
1988;68:1072-6.
131
Airaksinen
0,
Kolari
PJ,
Herve
R,
et
al.
Treatment
of
post-
traumatic
oedema
in
lower
legs
using
intermittent
pneumatic
compression.
ScandJ7
Rehabil
Med
1988;20:25-
8.
132
Airaksinen
0.
Changes
in
posttraumatic
ankle
joint
mobil-
ity,
pain,
and
edema
following
intermittent
pneumatic
compression
therapy.
Arch
Phys
Med
Rehabil
1989;70:341-
4.
133
Tohyama
H,
Beynnon
BD,
Renstrom
P,
Pope
MH.
Laxity
and
stiffness
of
normal
and
reconstructed
ankles
using
Chrisman-Snook
procedure.
61st
Annual
Meeting,
Ameri-
can
Academy
of
Orthopaedic
Surgeons.
134
Althoff
B,
Peterson
L,
Renstrom
P.
A
simple
reconstructive
procedure
of
chronic
ligament
injuries
of
the
ankle.
Laker-
tidningen
1981;78:2857-61.
