SYSTEMATIC REVIEW OF MANAGEMENT OF LATERAL ANKLE LIGAMENT INJURY IN ATHLETES
1.1 Introduction
Ankle injuries are the most occurring musculoskeletal sprains. The range of ankle twist in generally all sports is fifteen to twenty percent. The most prevalent mechanism of injury the foot is inverted and adducted within plantar flexion. Mechanism of this injury may result in lateral ankle ligament. Anterior talofibular ligament injury with complete medical ligaments points to the instability of the anterolateral rotary. (van den Bekerom, 2013) Calcaneofibular ligament transection enhances talus to tilt or slant. Injuries of the ankle ligaments are mainly categorized based on the severity.
The first category denotes a mild ligament stretching excluding the instability of the joint or formation of raptures that are microscopic. The second category is an incomplete split of the ligament with moderate pain and inflammation. There exist purposeful limits and instability which is minor to moderate. Characteristically, patients having problems in weight bearing. The third category is known to be severe (McCriskin, 2015)is simply an intense rapture of the ligament marked with inflammation, pain, and hematoma. The grade three sprains are marked with functional damage along with instability.
Healing of biological ligament can be sectioned into three distinct phases, namely inflammatory phase that occurs till ten days after experiencing trauma, proliferation phase that ensues after the fourth and eighth week, and the re-modeling phase or phase of maturation that follows until one year after trauma. There may be an individual variation the duration of the separate phases. Numerous treatments and management alternatives have been proposed namely, surgery, balancing training, functional (Lau, 2018)treatment or management with bandages, immobilization, and tape or separate Ankle braces. Currently, most medical professional highly suggests the employment of non-surgical management and treatments for lateral ankle injuries in athletes.
Numerous studies indicate that lateral ankle injuries are very serious than normally believed because various patients grow chronic complications after developing injuries. Symptoms developed after succumbing to lateral ankle injuries comprise chronic instability, chronic pain, and recurring inflammation. Studies show that within the first year following succumbing to injury, players are two times susceptible to a recurring injury of the ankle. Malliaropoulos (2009) established that inferior acute lateral ankle injuries lead to increased risks of another injury occurring as compared to high grade severe lateral ankle injuries.
Increased chances of failure following management or handling of lateral ankle injury in athletes may be described through overlooking into linked lesions, namely injuries within the cartilage. Unnecessary management in terms of the distinct grades of injury and phases of healing may form another cause of elevated failure rate in the management of adjacent ankle injuries. Investigating the kind of treatment or management alternative is (Delahunt, 2018) the best suitable option in managing lateral ankle injuries in athletes. The principal aim of this review is to conduct a systematic review and identify various treatment and management strategies for a lateral ankle injury. This paper performs a systematic review of literature on treatment and management alternatives of lateral ankle sprains. The review accentuates on answering the following questions:
- Does evidence exist of non-surgical or surgical treatments of lateral ankle injuries in athletes?
- Is there any proof of immobilization or functional treatment of lateral ankle injuries in athletes?
- Does proof of neuromuscular exercise for lateral ankle injury rehabilitation exist?
- Is there confirmation of neuromuscular exercise for lateral ankle injury prevention amongst athletes?
1.2 Methods
An inclusive search for literature articles was done using google scholar and MEDLINE database to select articles that are peer-reviewed, most of which are concerned with the treatment and management of lateral ankle injuries with regard to the statement by PRISMA. In the case of a systematic review, separate arrangements or groupings of keyword were employed which comprised of an ankle injury, ankle tendon injury, ankle injuries and surgical management and treatment, ankle injury and exterior support, ankle injury and functional treatment, an ankle injury and neuromuscular exercise. After identification of each keyword in different databases mainly PubMed, the button for “see all” was activated for the search of related peer-reviewed articles. The list of references belonging to the various article was thoroughly screened for pointing out appropriate and pertinent publications.
Only modern articles available within the last ten years were singled out for evaluation. The main reason behind the using articles written in the last ten years is that several studies published remained previously encompassed in the Meta-analyzes. Article search stayed limited to articles written only in English. Some of the articles that were excluded from the search were mainly those that reflected on the management and treatment of ankle injuries or dislocations. In the case that a potential randomized trial had been included within the meta-analyses, this kind of experimental study was also omitted.
Selection of patient remained restricted to adult of sixteen years of age or more. The only articles that were considered were those of first level proof. Information obtained from study works of lower levels of evidence could only be accepted in case they were included within a meta-analysis. Retrospective research work, case reports, expert perception, cohort researches, anecdotal proof, and case series were not put into consideration.
In any case, a target study was obtained, the abstract was examined to figure out the application of any of the criteria for exclusion of articles. If at all the study was found to be eligible and legitimate, the whole text of the article was analyzed. The identified articles must be suitable to respond to a single research question earlier listed in the introduction section.
1.3 Results
1.3.1 Meta-analysis concerning treatment and management alternatives for lateral ankle ligament injuries
Three distinct meta-analyses were identified concerning the treatment and management of lateral ankle ligament injuries. Petersen et al. (2013) analyzed different trials providing a comparison of non-operative and operative management and treatments. The meta-analysis portrayed substantial distinctions favoring operative management and treatment in case of pre-injury sport level; ankle injury continuous occurrence, long-lasting pain, functional and subjective variability when employing the model based on fixed effect. These distinctions are not robust in the case of the model of random effects, nor in case of the elimination of a trial which is of low quality that had great consequences.
Practical consequences of the statistically and substantially elevated event of objective instability in conservatively trial subjects that were treated became uncertain. The limited proof was evident for the recovery period that took too long, and increase events of the stiffness of the ankle, impairment in the mobility of the ankle, and problems in patients treated through the operation.
Additional meta-analysis according to Lai & Sit (2018) provides a comparison of research work concerned with immobilization and functional treatments. The research displays statistically substantial variations favoring functional treatment as compared to immobilizations for seven parameters in the outcome namely the rate of returning to sports, duration of returning to sports, rate of returning to work, inflammation and treatment and management satisfaction.
Within the third meta-analysis, Hunt and Lawson (2019) compare the impacts of distinct kinds of exterior support and assistance for majorly non-surgical treatments of lateral ankle ligament injuries amongst athletes. This research portrayed that ankle reinforcement through lace-up shows much outcome in case of persistent inflammation for temporary follow-up when related with ankle reinforcement through semi-rigid support, to tape, and an elastic bandage. The utilization of semi-rigid ankle reinforcement results in a substantially reduced instability rate, short duration to resume (Feger, 2017) athletics as compared to the use of an elastic bandage. The treatment of lateral ankle ligament injury using the tape method leads to considerably more problems, majority parts of the skin experiencing irritations when a comparison is done during treatment and management by an elastic bandage.
1.3.2 Randomized measured trials concerning operational versus non-operational treatment
Antonowicz et al. (2018) examined the repair of suture accompanied by six weeks of cast management and treatment versus functional treatment within patients or athlete having a third-grade injury. Functional treatment and management comprised of the employment of an aircraft ankle brace for a duration of three weeks. This study indicates the occurrence of continuous injury between one of five in the operational group and seven of eight in the group of practical management. No variation in the score of the ankle and within the talar slant and anterior drawer as confirmed by radiography on stress. The osteoarthritis rate of the second grade as detected on the MRI proved to be greater in patients treated from surgical procedures as compared to those of functional treatment.
Vuurberg et al. (2018) carried out the examination of patients upon repair of the suture of the lateral ankle ligament accompanied by functional treatment and functional management only. During this research, there was no detection within the mean outcome of the score obtained from the clinic and the stability of the angle was assessed using stress radiography. Within the category with functional treatment only, however, eight of one hundred and thirty-two patients succumbed from a state of instability two years later of follow up as compared to none within the surgical category. After operational repair, patients or athletes resumed substantially faster to complete athletic in contrast to patients undergoing functional treatment and management only.
1.3.3 Randomized measured trials regarding external support
Witjes et al. (2012) show that the Karlsson score is considerably increased during the Air-cast ankle brace grouping than within the group of the elastic bandage at ten days and also one month. The outcomes from the trials conducted by CAST posits that a limited immobilization period within a treatment or cast below the knee using a semi-rigid orthosis leads to quicker recovery compared to the case that the athlete is only provided tubular compression bandage. The study also indicates the absence in variation between the cast done below the knee, tubular compression bandage, and semi-rigid orthosis at nine-months follow up.
Cruz-Díaz et al. (2015) did a comparison between semi-rigid versus tape orthosis. Pain and functional outcome were identical within the two-management grouping. Patient giving reports on satisfaction and comfort in the period of treatment was considerably elevating and the skin problem rate was substantially reduced in the brace grouping.
McGovern & Martin (2016) Conducted an examination of the first, second, and third-grade injury patients. The study indicates that the first and second-grade injury management through semi-rigid brace joined with a flexible wrapping made patients resume usual mobile and step mounting compared to the provision of only a semi-rigid brace. If the third-grade injuries, a walking cast for a maximum of ten days followed by stimulating made subjects to resume their usual walking style and step mounting at similar intervals in time. Follow up for six months of every severely injured group exposed no variation between the management and treatment for injury frequency, the motion of the ankle, and function of the ankle. Walls et al. (2016) give a comparison between elastic stockings and Tubi-grip bandage. The research established that firmness which is elastic enhances lateral ankle ligament injury recovery.
1.3.4 Randomized measured experimental studies concerning the result of exercise for management and treatment of acute injuries to the ankle ligament
In the study (Wilson, 2015) there was a considerate decrease in lateral ankle injuries during the group that trained. A couple of studies established that conservative treatment and management of lateral ankle ligament injuries together with constantly supervised training exercises do result in variations in the prevalence of the injuries. One of the research work portrays that athletes receiving balanced board exercise become much active
1.3.5 Randomized measured trials regarding the consequence of exercise for treatment and management of ankle injury
Studies show that a training program that is balanced considerably decreases the dangers of lateral ankle ligament injuries only within athletes’ sub-group with a past ankle injury. Successive Verhagens trial economic (Doherty, 2017) assessment displays that balancing of training might be the most efficient and cost-effective in the sense that it is directed at athletes with past histories of ankle sprains.
1.3.6 Randomized measured trials regarding the preventive consequence of braces
Within the general studies reviewed, braces tend to be employed in the prevention of ankle sports injuries such as football, volleyball, and basketball. Feger et al. (2017) discovered that utilizing braces decreases that events of ankle injuries within asymptomatic players or athletes in sports like basketball and football. Kerkhoffs et al. (2016) provide a comparison of the use of tape and brace to prevent ankle injuries. In this research, there exists no dissimilarity in the rate of sprain, however, the management and treatment duration for every athlete is suggestively greater in the group using tape.
1.4 Discussion
Using this systematic review, various answers to the previous questions are answered.
1.4.1 Surgical against the non-operative treatment of lateral ankle ligament sprains
Currently, operative treatment and management have a minimum role to play in in the management of severe injuries of the ankle. In several reviews, non-surgical treatment is the most recommended. As a consequent, Tassignon et al (2019) show that operative ankle ligament rebuilding is highly beneficial in terms of the rate of recurrence for ankle sprains, the event of chronic complications of the ankle and subject and objective ankle instability. On the basis of the evidence gathered from different studies, it can be concluded that the primary advantage of operative repair of ankle injury is that mechanism variability and degree of recurrence is less joint in contrast to non-surgical treatment and management. Weighing the benefits and limitations of operational and non-operational management of acute injuries to the ankle ligament, it may be concluded that the common first, second, and third grades lateral ankle ligament injuries are manageable without surgical operation. On the other hand, in terms of the advantages, surgical treatment must not be ignored. The signal for surgical reconstruction ought to be determined.
1.4.2 Proof of immobilization or functional treatment
Most of the studies reviewed established that practical management seems a promising strategy for the treatment and management of acute injuries to the ankle ligament in contrast to long-lasting immobilization that takes four to six weeks. These outcomes, however, must be cautiously interpreted and understood, since many differences are insignificant after excluding the trials of low quality. Numerous trials are reported in a poor manner and there are several amongst the useful management assessed. Other studies recommend that in the inflammatory stage, treatment ought to be focused on evading additional swelling and continuing injury, therefore improving the process of healing.
1.4.3 Proof of neuromuscular exercise for lateral ankle injury rehabilitation
Numerous studies hypothesize that coordinating and balancing exercise may diminish proprioceptive deficits connected with a lateral ankle ligament injury. The modern theory posits that coordination and balance training might bring about local and central impacts on the sensory-motor system. Consensus, however, is inadequate with regards to the clinical proof of the effectiveness and efficiency of such interventions. Other research works establish that conservative treatment and management of lateral ankle ligament sprains joined with controlled training or physical exercise in contrast with conservative management and treatments only after a severe ankle injury entirely does not result to variation in the rate of twists or in recoveries that are individual. In conclusion, balancing physical exercises may be applied after an acute ankle injury with efforts of reducing the forthcoming lateral ankle injuries amongst athletes.
1.4.4 Confirmation of neuromuscular exercise for lateral ankle injury prevention
Based on the systematic review conducted on various articles, the studies indicate that the rate of ankle injury is substantially reduced after balancing work out within a group of athletes with a past ankle injury. Athletes without a medical history on injuries of the ankle, there is the tendency towards a minor rate of injury in the exercising group. In summary, according to the systematic review, it can be confirmed that balanced exercise may be employed with efforts to decrease forthcoming occurrences of ankle injuries in athletes with a past ankle injury.
1.5 Limitations of the systematic review
Efforts created to have level one proof research studies to respond to the review questions were remarkable. Despite this success, there were huge variations in terms of the quality of the approaches or methods used and the results obtained. Basing one the disadvantages of the search conducted, pharmacological management and treatments of lateral ankle ligament injuries were completely excluded.
1.6 Future direction
In spite of the existence of proof from the meta-analysis, numerous patients suffer from chronic complication after lateral; ankle ligament injury. Thus, there lies a reason to consider several questions for the ankle injury treatment and management remaining to be an unresolved concern. Unresolved concerns such as the criteria and duration for sports return, time of protection of the ankle through exterior support, diagnostics and employment of connected injuries.
1.7 Conclusion
Weighing the disadvantages and advantages of no-operative and operative treatment and management of lateral injuries to the ankle ligament, it may be concluded that the majority of the first, second, and third grades of lateral ankle ligament injuries are capable of being managed absent surgery. The suggestion of operating repair must always be established by an individual. The conducted systematic review firmly second the adaptation of non-surgical management and managing of lateral ankle injuries with a temporary immobilization for the third category accompanied using semi-rigid brace. Injuries of Type I and type II can be treated best using a semi-rigid brace. Neuromuscular exercise ought to assist practical recovery immediately after an injury of the ankle. Balanced exercises prove to be efficient in the prevention of ankle injuries in an athlete with past injuries. Braces form part of effective ways of managing ankle injuries in athletes.
