Ankle Lateral Collateral Ligaments

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Ankle injuries in sport accounts from 10 to 30% off all sport related injuries (4, 8, 10), while is estimated ankle injury rates to occur to 1 per 10,000 people per day (4, 10, 17, 38). It is suggested in the USA over 25,000 ankle injuries occur daily (39, 49, 66-68), and the UK, 5,000 ankle injuries per day (39, 49, 68). The 85% of all ankle injuries concern the lateral complex of the ankle (64). Medial ankle injury accounts for 10% of all ankle injuries while the rest rare 5% is advocated to injury to the distal tibiofibular joint (High syndesmotic sprain) (45).

Lateral ankle sprains (LAS) has high incidence at sports (3, 7, 17, 28, 65) that includes jumping-landing (19, 30, 65, 73), sharp manoeuvres (28) and running (44). Sports that involve such activities and have high incidence of LAS are basketball, football association and volleyball (2, 28, 44, 65). A major predisposition for LAS is a previous lateral ankle injury (2, 3, 17, 50). McKay et al (2001) reported that basketball players with a previous ankle injury were five times more likely to suffer a repeated ankle injury. Suggesting the 70% to 80% of the athletes that sustained an ankle injury to report ankle injury reoccurrence (8, 17, 65, 66, 68). Further McKay et al (2001) investigation also observed that players that wore shoes with aircells had two times higher risk for LAS incidence.

Is reported that 40% to 73% of the individual that suffers from LAS develops residual symptoms from week six up to 18 months post injury (7, 8, 17, 46, 65, 68). The residual problems are described as pain, swelling, stiffness, weakness and instability (7, 16, 17;).

Repetitive lateral ankle injury has been characterised as chronic ankle instability (CAI) caused by mechanical, functional or a combination of both factors (7, 17, 65). Tropp (2002) defined mechanical ankle instability (MAI) as ankle movement beyond the physiologic limit of the ankle’s range of motion. Mechanical instability factors are pathological laxity, altered arthrokinematics, degenerative and synovial changes (17). Great concern is raised when mechanically stable ankles present with functional ankle instability (FAI) symptoms and eventually lead to mechanical ankle deficits (15-17, 40).

The feeling of “giving away” at the ankle was first described by Freeman et al (1965) where he stated that the subjective feeling of “giving away” to be product of motor in-coordination due to articular de-afferentiation. Hertel (2000^b; 2002^c) provided a modified definition for FAI which has been accepted by others (62, 67) and states that functional instability is the occurrence of recurrent ankle instability and the sensation of joint instability due to the contributions of proprioceptive and neuromuscular insufficiencies. The elements of FAI have been distinguished to affect postural control, proprioception, strength and altered neuromuscular function (6, 16, 17).

Further this work will expand exclusively to the lateral ankle ligaments biomechanics, anatomy, pathomechanics, pathophysiology, diagnosis, rehabilitation modalities and a short brief of the surgical methods. The content of this work refers to educational concern and up to date information for Athletic trainers (ATC), Sport rehabilitators (GSR), sport medicine doctors, osteopaths, medical students, orthopaedic surgeons, and physiotherapists were diagnosis and assessment is permitted. Additionally this work DOES NOT represent the opinion of the website owners. Were the work is not mine is been referenced or quoted accordingly.

Biomechanics and anatomy of the ankle and lateral collateral ligaments:

The ankle joint is been characterised as a modified uniaxial hinge joint (15, 17 48). Though is consisted by 3 articulations the talocrural joint, the subtalar joint, and the distal tibiofibular syndesmosis. Those joints work in synergy to allow synchronized movement at the rearfoot. The talocrural and subtalar joint each have an oblique axis of rotation allowing coordinated movements (Hertel^c 2002; Hubbard^a, Hertel 2006). The motions occurring at the ankle complex are plantarflexion-dorsiflexion, inversion-eversion and internal-external rotations (17, 22).

The talocrural joint is formed by the talus, tibia and fibula also known as the ankle mortise. The talacrural axis is formed by the lateral and medial malleoli. It passes slightly anterior to the frontal plane as it continues through the tibia but slightly posterior to the frontal plane as it passes through the fibula (17, 22). The talus is wedge shaped, wider anteriorly than posteriorly allowing external rotation and posterior glide of the talus during dorsiflexion and internal rotation and anterior glide of the talus during plantar flexion (9, 22). During those movements the fibula (typically forgotten during a rehabilitation regime) is also affected producing minimal movement to facilitate movement during normal functional activities.

The proximal/ superior tibiofibular joint is a synovial joint whilst distal/inferior tibiofibular joint is a syndesmosis (9). During normal mechanical function the proximal and distal tibiofibular joints glide superiorly (9, 22, 48). Further during dorsiflexion the distal tibiofibular joint combines lateral movement away from the tibia bringing the interosseous membrane and tibiofibular ligaments in a horizontal alignment (22). During plantarflexion the momentum is reversed with the fibula gliding inferiorly and internally rotating toward the tibia at the distal portion while the proximal joint glides inferiorly (9, 22, 48). Previous injury of knee or ankle affecting proximal tibiofemoral biomechanics is connected with hamstring injuries (72).

Maintaining joint homeostasis during activities or functional joint stability is coordination between static and dynamic elements surrounding a joint (36, 54). The static (passive) components are the ligaments, joint capsule, skin, fascia, cartilage, friction, and the bony articulations (36, 54). Dynamic stability is the result of feedforward and feedback neuromotor control over the muscles surrounding the joint affecting their biomechanical and physical properties of the joint that include range of motion, muscle strength and endurance (54). More simply dynamic joint stability is the cocontraction of the muscles during activities to minimize forces between the ground and ankle foot complex (25).

When the ankle joint is axially loaded, the bony articulations are the primary stabilizers resisting inversion moment to at the talocrural joint (17, 39, 53). Subtalar joint axis during activities, such as running and walking, passes lateral in relation to the axially compressive forces causing the joint to evert and protect the ankle from inverting (29, 31).

The talocrural joint is further stabilized from the lateral collateral ligament of the ankle (15, 17-19, 39 48, 53, 55). Ligamentous function is theorized i) to provide proprioceptive information due to the proprioceptive end organs that innervated them ii) provide stability at joint function by preventing excessive motions acting as checkreins such as when in platarflexion bony stability is lost and replaced by the ligaments and iii) ligaments act as guides to direct motion (55).

The lateral ligamentous complex of the ankle that is commonly implicated in ankle sprains (55), is composed of 3 ligaments the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL) (15, 17-19, 39 48, 53, 55).

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ATFL

Anterior talofibular ligament (ATFL) anatomical size varies among the literature. The ATFL been consider a thickening of the tibiotalar capsule (19, 53) is thickness is 2mm, the length 15-20 mm and the width 6-10mm (19, 39, 53). It originates from the anterior tip of the fibula from where inserts at the neck of talus at an angle of 45 degrees (17-19, 39, 48, 53). The ATFL at neutral position is at rest position and becomes taunted with platarflexion further is a primary stabiliser preventing anterior displacement of the talus from the mortise and excessive inversion and internal rotation of the talus on the tibia (17-19, 39, 48, 53, 55).

CFL

Calcaneofibular ligament (CFL) shape is like a rounded cord that has length 20-30mm, width 4-8mm and 3-5mm thickness (19). There are conflicting reports for the origin of the CFL in the literature were some support that originates from the apex of the tip of the lateral malleolus (17, 39, 53, 55) others support that the attachment on the anterior border of the fibula just below the origin of the anterior talofibular ligament (18-19). The ligament courses medially, posteriorly, and inferiorly from its fibular origin at a mean angle of 133 degrees from the long axis of the fibula to the calcaneal insertion. The CFL in contrast with the ATFL becomes taunt with dorsiflexion acting as a true collateral ligament and restricts excessive inversion, internal rotation and supination of both the talocrural and subtalar joints (17-19).

PTFL

Last of the lateral collateral ligament is the posterior talofibular ligament origin from the medial surface of the lateral malleolus and courses medially in a horizontal fashion to the posterior aspect of the talus (17-19, 55). The PTFL has length 30mm, width 5mm and 5-8mm thickness (19). The function of the ligament is to restraint inversion and internal rotation of the loaded talocrural joint (17). The PTFL same as the CFL is in a slack during plantarflexion and becomes taunted with dorsiflexion (19).

Subtalar joint

The complex anatomical structure of the subtalar joint will not be extensively discussed in this section as it is characterized as difficult to examine my manual special testing as their the sensitivity and specificity of those tests is unknown (22, 38). Further critical point of consideration will be provided to enhance readers understanding and probably the clinical interested for development of valid and reliable special testing other than radiographs (Based on the Ottawa ankle rules), subtalar stress radiographs, subtalar arthrography or stress tomography (38).

The subtalar joint is formed by the talus and the calcaneus and, like the talucrural joint, plays a critical role in converting torque between the lower leg and the foot (17). The subtalar joint axis allows triplanar movements to produce supination and pronation effect. Supination is accomplished by the combined effect of inversion and internal rotation hence pronation is accomplished by the combined effect of eversion and external rotation (22). The is formed by two joints a anterior and a posterior in which share a common axis of rotation that axis is an oblique axis of rotation, which averages a 42° upward tilt and 23° medial angulation from the perpendicular axes of the foot (17, 22).

The plethora ligamentous support of the subtalar joint makes further difficult to provide a better understanding mostly due to disagreement in the terminology that is used in the literature (17). The most important ligaments that will be discussed are the deep ligaments of the subtalar joint also been described as the ‘‘cruciate ligaments” of the subtalar joint the cervical and interosseous ligaments (17, 19).

The cervical ligament is found at the anterior and lateral to the interosseous ligament and runs from the cervical tubercle of the calcaneus just medially the extensor digitorum brevis and runs upwards anteriorly and medially to attach at the talar neck (17, 19). Cervical ligament is been suggested to be the strongest ligaments providing support to both the anterior and posterior joints and resisting supination as shown from in vitro kinematic experiments (17) while is taunt during inversion (19).

The interosseous talocalcaneal ligament (ITCL) sometimes called the ligament of the canalis tarsi. Hertel^c (2002) best describes the anatomical structure and also use to describe the ITCL. More specific Hertel^c 2002 suggests that the “ITCL lies just posterior to, and courses more medially than, the cervical ligament. The ITCL originates on the calcaneus just anterior to the posterior subtalar joint capsule and runs superiorly and medially to its insertion on the talar neck. Because of its diagonal orientation and oblique fiber arrangement across the joint, portions of the ITCL are taut throughout pronation and supination” (17).

Neural interventions:

Plexuses from the sacrum and lumbar are responsible for the motor and sensory supply of the ankle complex stem (17). Tibial, deep peroneal, and superficial peroneal nerves are responsible for the muscles motor supply. Sensory supply mainly derives from the sural and sapnenus nerves and the 3 nerves motioned above. The lateral ligaments and joint capsule of the talocrural and subtalar joints areextensively innervated by mechanoreceptors that contribute to proprioception (17). Important role to the functional ankle instability are the muscle spindles of the peroneals muscles and the γ-motorneurons (17, 22). Attention during examination to the common peroneal nerve is strongly suggested. The common peroneal nerve (CPN) derives from the sciatic nerve and runs behind the lateral collateral ligament (LCL) of the knee to exit just before the LCL distal attachment to penetrate the peroneus longus (PL) proximal tendon and below the fibular head to create the peroneal tunnel to further divide into the deep, superficial and recurrent peroneal nerves (43). Based on the track of the CPN and the biomechanics of the fibula that are mentioned before, it can be assumed that a faulty positioning of the proximal fibular head may cause an impingement or traction at the peroneal tunnel. Additional it should be noted to this latter theory that the superficial peroneal nerve is stretched by inversion and the deep peroneal nerve by plantarflexion (27). A high velocity trauma that results in 12% further elongation of a nerve lead to irreversible functional deficit. Though the total length of the nerves are not changed by more than 12%, though the lower section can be increased by 15% during inversion trauma (27).

Pathomechanics/ mechanism of injury:

From the lateral ankle ligament complex the ATFL is been found to have the lowest load failure at 140 Newton in contrast with the CFL that has 260 newton load to failure (Mann^a et al 2002). The PTFL is suggested to the strongest and injury occurs with dislocation of talus from mortise or fracture (17, 38, 40). Isolated complete rupture of the ATFL was present in 65% of all ankle sprains and combined injury involving the ATFL and the CFL occurred in 20% at the clinical study was carried out by Brostrom (cited at 38, 39).

The most common mechanism for lateral ligament injuries is a situation where the ankle goes into a combination of plantar flexion and inversion (7, 17, 31, 38-40, 53). The foot when undergoes into plantarflexion, it dissociates from the bony talar contribution to talocrural stability, the ligamentous structures replace the stability (39). As already mentioned the ATFL is taunt during plantarflexion and is a primary stabiliser preventing anterior displacement of the talus from the mortise and excessive inversion and internal rotation of the talus on the tibia (17-19, 39, 48, 53, 55) whilst the CFL becomes taunt with dorsiflexion acting as a true collateral ligament and restricts excessive inversion, internal rotation and supination of both the talocrural and subtalar joints (17-19 ). Situations that are found to be related to injury mechanism concern activities such as walking, running and landing on an opponent’s foot or bump or a stone (39, 53). The extent of tissue damage that occurs during an injury is depended on the direction and magnitude of the forces and the position of the foot and ankle during the trauma (38).

The incidence of subtalar-joint injury in patients suf­fering acute lateral ankle sprains has been estimated to be as high as 80% (17, 64). There is limited research investigating the role of physical-examination techniques in the diagnosis of subtalar injuries (64). The mechanism of subatalr joint was only able to be found in the literature in a combination of MOI and grading system format.

Subtalar joint injury can occur in either plantar flexion or dorsiflexion. Forceful supination with the foot in plantar flexion tears the ATFL (and possibly the cervical ligament), followed by either disruption of the CFL and lateral capsule (type 1) or tearing of the interosseous talocalcaneal ligament (type 2). When the ankle is in dorsiflexion, the ATFL is not under tension and remains uninjured though it causes injury tears to the CFL, the cervical ligament, and the interosseous talocalcaneal ligament (type 3). A type 4 subtalar sprain is a rupture of all lateral and medial capsuloligamentous components of the posterior tarsus. This injury occurs as the foot moves from dorsiflexion to plantar flexion while forceful hindfoot supination occurs (17)

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Evaluation:

Subjective:

In case of an athlete he or she may report that ‘‘rolled’’ over the outside of his or her ankle. Patient may report that landed on an opposing player’s foot or uneven ground, or mis-steped. Further as far by the authors knowledge an unpublished mechanism of injury based on authors empirical observation is been noted to occur during a lateral lunge such as in tennis back hand stroke. Despite that sharp cutting manoeuvres are been advocated as reason (28) for injury occurrence have not been further analysed and specifically defined that may assist the examiner to create a better understanding and may be another great area to expand on for future dissertations and research. The patient/athlete may report that immediately after the injury experienced a sudden, intense pain localised to the lateral side of the ankle over the ATFL especially on its fibular insertion and/or on the CFL are most commonly located at the calcaneal insertion. They may also state that they heard a ‘‘snap’’ during the trauma. Though, feeling a tearing sensation or hearing a snap does not appear to correlate with the severity of the injury. Complains of pain and discomfort when they try to weight bear on the injured extremity may also be reported. Some may report that experience instability of the ankle with a feeling that the ankle ‘gives way’ when they try to use the leg (38,39).

Objective:

Typically the patient is not seen until several hours after the injury, with generalised swelling and pain making the evaluation more difficult and unreliable. Ecchymosis can occur 24 to 48 hours lateral side of the injured ankle is usually discoloured, appearing blue and yellow due to haematoma organisation and resorption. Ecchymosis can also occur in the retrocalcaneal bursal area and along the heel because of the potential space available for swelling and the pooling effect of gravity. Haematoma is characteristic of 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. It is important that the entire ankle and foot are examined to ensure no other injuries have occurred (38,39, 64). Acute symptoms of subtalar sprains are similar to, and can occur with or be masked by, lateral ankle-ligament sprains. Subtalar joint tenderness is a significant characteristic but is difficult to differentiate from the tibiotalar joint because of the close proximity swelling and complex anatomy (Lynch^a 2002).

Is been suggested through the literature that after a LAS a patient to present with sensorimotor dysfunction (16, 17). Nitz and colleagues (1985 cited at 16, 17) found decreased peroneal conduction velocity that is a factor of FAI. In that study Nitz and colleagues (1985 cited at 16, 17) examined 66 patients with LAS and found that 17% of grade II and and 86% of grade III found slowed NCV of the common peroneal nerve. Additionally 10% percent of grade II injuries and 83% of grade III injuries were accompanied by slowed NCV of the tibial nerve, Further Bullock-Saxton (1994) that examined 361 subject that suffered from LAS and found decreased proprioception and decreased neuromuscular (inhibition) function of the gluteus medius.

Friel et al (2006) recruited 23 subjects that were suffering from CAI and examined to determine the relationships between hip muscle strength and chronic ankle sprains and hip muscle strength and ankle range of motion. Results of that study also demonstrated that subjects with unilateral chronic ankle sprains had weaker hip abduction strength and less plantarflexion range of motion on the involved sides (Friel et al 2006). Gluteus medius dysfunction produces further pathological situations such as Trendelenburg gait, iliotibial band friction, patellofemoral pain syndrome, anterior cruciate ligament (ACL) and other knee injuries and last ankle injuries (Presswood et al 2008)

Special testing:

Stability tests performed in a clinical setting are the anterior drawer test is more specific for assessing the integrity of the ATFL, and the talar tilt test is more specific for detecting injury to the CFL. The tests strongly recommended to be performed between 4 and 7 days post injury, when the acute pain and swelling may have subsided and the patient is able to relax during the examination (38, 39). Dijk et al (1996 cited at 53) study showed that specificity and sensitivity of delayed physical examination for the presence or absence of a rupture to the ATFL were found to be 84% and 96% respectively, and the delayed examination, gave information of ligament quality that equalled arthrography examination.

Is best to initiate examination with active range of motion (AROM). The rationale behind the AROM will show the ability and willingness of the patient and quality of movement (31,59). Further Safran et al (1998) suggested that is important to assess active ROM to exclude Achilles tendon rapture. The pain sensation and the reduce ROM provide information about damage to a musculotendinous structure (59). Slutz, Houglum and Perrin (2005) advise that when assessing the range of motion if no movement occurs without pain, the examiner should speculate for an injury at neural tissue. Further when examine the range of motion in respect to what is been discussed what you should expect during platarflexion or during dorsiflexion? Further the use of passive range of motion to evaluate ligamentous and musculotendinous end feels and integrity should be also performed 4 to 7 days post injury(38, 39, 59).

The use of manual muscle testing (MMT) should be also consider to assess gluteus medius function Kendal et al (2005) offers a detailed MMT for both functions of gluteus medius. Further MMT to the muscles responsible for ankle motion may show weakness but may be effect of selective inhibition that the body initiates to protect the injured site (14, 25, 46; 69). The effect of muscle weakness of the injured ankle after LAS is extensively research but elucidation for muscle weakness presence remains debatable in the literature as some have found weaknesses to the evertors (30 70) other to the invertors (14, 46, 69) and others in plantarflexion (11).

Special testing description:

ATFL-Anterior drawer

To perform the anterior drawer test, the patient should be sitting with the knee flexed to relax the calf muscles and prevent the patient from actively guarding against the examiner. The sensitivity of the test can be improved by placing the ankle in 10^o of plantar flexion. The examiner grasps the heel firmly in one hand and pulls forward while holding the anterior aspect of the distal tibia stable with the other hand. Increased anterior translation of the talus with respect to the tibia is a positive sign and indicates a tear of the ATFL, particularly if the translation is significantly different from the opposite side (38). Abnormal laxity is consider as an absolute anterior displacement of 10mm or a side-to-side difference of >3mm

Talar tilt- CFL

The talar tilt test is defined as the angle produced by the tibial plafond and the dome of the talus in response to forceful inversion of the hindfoot. The talar tilt test is performed with the ankle in the neutral position. The examiner holds the heel stable while trying to invert the heel with respect to the tibia. The talus and calcaneus must be grasp as a unit to limit subtalar motion during the test. As in the anterior drawer examination, the results from the talar tilt test are difficult to interpret, but as a general rule, more than 10^o difference from the normal side is considered abnormal (38).

Medial subtalar-glide test

The test is performed as the examiner holds the talus in subtalar neutral with one hand and glides the calcaneus medially on the fixed talus with the other hand. This test is a modification of a joint mobilization technique (15, 64).

Stress radiographs:

Stress radiographs should be consider based on the Ottawa Ankle Rules (OAR) (38, 39). The use of the OAR is suggested to reduce the number of unnecessary x-rays performed is significantly reduced while maintaininga near-100% sensitivity for detecting fractures. The criteria of the OAR are (i) tenderness at the posterior edge or tip of the medial or lateral malleolus, (ii) inability to bear weight (4 steps) either immediately after the injury or in the emergency room; or (iii) pain at the base of the fifth metatarsal and if verified are predictors of those patients with ankle sprains who should have an x-ray (38, 39, 64). Further we enable the reader to search further on the OAR especially for those working pitch side aid. The use of tuning fork along with the OAR have not been study in the literature and may be a useful area to expand future papers or dissertations on such subject to further recommend the use of the tuning fork and OAR on pitch side or at clinical setting.

Further the use of x-rays will not affect the treatment protocol. If the is rationale for performing radiographs then standard x-rays should include routine anteroposterior and lateral views as well as ananteroposterior view of the foot in 15 to 20° of internal rotation so to result in viewing the mortise. Is recommended during the radiographs stress tests should be performed as they increase the sensitivity (39). The most commonly used criteria for the anterior drawer stress test are those of who defines abnormal laxity as an absolute anterior displacement of 10mm or >3mm side-to-side difference. As for what constitutes abnormal talar tilt as a general rule, 10° greater than the uninjured ankle is considered to be pathological (39, 53).

Grading lateral ankle ligament sprains:

The subtalar joint grading system is already mentioned above. In clinical practice the terms grade I (mild), grade II (moderate) and grade III (severe) injuries are often used (39). Despite that the latter is the simplest form is worth mentioning the Davis and Trevino staging system evaluation to be more analytical (41). Grade I injuries involve ligament stretch without tearing, presenting little swelling or tenderness, minimal or no functional loss and no mechanical joint instability. A grade II injury is a partial ligament tear with moderate pain, swelling and tenderness over the involved structures, there is some loss of joint motion and mild to moderate joint instability. A grade III injury is a complete ligament rupture with significant swelling, haemorrhage and tenderness, there is loss of function, abnormal joint motion and instability (38, 39, 41, 53).

Treatment:

Ankle injuries management with grades 1 and 2 are treated with functional rehabilitation that includes early motion and use of ankle support and early weight bearing that results in a disability of eight days for a grade I and 15 days for a grade II. The functional approach follows the biological continuum of the inflammatory response (39, 42, 53).

Initially treatment is directed in reducing swelling preventing further secondary hypoxic cell damage and allow healing process to take place (39, 42, 53, 57). Myers and colleagues (2003) studied the peroneus longus and brevis and tibialis anterior (TA) reactions to a high speed inversion perturbation and during walking and running on a treadmill pre and post an anaesthetic blockage or placebo solution to the ATFL and CFL at 13 health subjects. Authors observed a decreased muscle EMG muscle-firing amplitude for both sudden perturbation and dynamic tasks regardless the solution applied when compared to pre testing results. Myers et al (2003) eluded the results to the effect of joint effusion similar in that found for the knee joint, affecting motoneuron pool recruitment, strength, and muscle activity.

Arthrogenic muscle response (AMR) is an ongoing reflex reaction of the musculature surrounding a joint after distension or damage to structures of that joint or joint effusion. The AMR involves inhibition or facilitation of a muscle’s motoneuron pool excitability and is associated with altered neuromuscular activation patterns around injured joints and is thought to occur in response to distorted articular sensory receptors after joint injury (51, 58).

Exercises that places the injured site in an elevated state and along with muscular contractions or activity it may increase swelling reduction by the increased hydrostatic pressure created at the venous and lymphatic return caused by elevation and change in tissue osmolality and increased blood flow because of the activity (63).

Protection by tape or ankle brace and not any form of cast is suggested to prevent excess formation of the weaker type III collagen that can contribute to chronic elongation of the ligament (39, 42, 53). Despite that ankle braces and taping techniques do not offer any biomechanical protection are found to improve proprioception (18).

Functional stress stimulates the incorporation of stronger replacement collagen. Functional rehabilitation goals are to regain ROM, strength, proprioception, and sport specific training. Therefore functional rehabilitation initiates on the day of injury and continues until pain-free gait and activities are regained. Achilles tendon stretching should be begin within 48 to 72 hours of injury, regardless the ability of weight bearing. Once ROM is achieved and swelling and pain are controlled, the patient is ready to progress to the strengthening phase of rehabilitation of weight-bearing capability (39, 42, 53).

Strength and conditioning training protocols for the ankle or drills will not be discussed as they are many among the literature. Though strength deficits as residual disability at the functional unstable ankle has been reported even before Freemans coined worked by Bonnin (1950 cited at 25). Bonnin (1950) suggested that if a lever is created due to a rotational translation away from the midline may overstress the ligaments resulting to frequent sprains (cited at 25). Bosein and colleagues (1955) followed 113 subjects and found peroneal weakness in 29 patients (22%), examined by manual muscle testing. In addition at 23 (66%) of the 35 cases reporting residual changes and ankle symptoms showed peroneals weakness, attributing their findings overstretching of the peroneal muscles. Authors (Bosien, Staples, Russell 1955) suggested eversion resistance exercises should the treatment of choice for patients with residual symptoms after ankle sprain. Wilkerson, Pinerola and Caturano (1997) investigated the evertors and invertors muscles isokinetic strength performance at 15 subjects with CAI and 15 subjects who had sustained a grade II LAS. Inversion results showed greater discrepancy between sides and authors agreed with Ryan’s (1994) findings and suggestion of reflexive inhibition. Wilkerson, Pinerola and Caturano (1997) further suggested that during a closed kinetic chain activity the importance of invertor’s eccentric control for lateral displacement from the centre of gravity thus preventing the lateral border to act as fulcrum that will result in an unexpected inversion (14, 69). Konradsen^b, Olesen and Hansen (1998) investigated maximal isometric eversion strength at 44 subjects that had sustained a grade II and III and with no previous history at either ankle. Subjects were designated to perform the test at week 1, 3, 6 and 12 post injury though 38 subjects were able to perform the test at week 3 post injury and the rest at week six. Results of the investigation showed a significant decrease in strength, though mean values increased from week 6 and onward without great differences when compared to health contralateral ankle. It difficult from the sample studies presented to elude to possible strength deficits and contraction mode deficit. Is best to address all surrounding muscles acting around the ankle joint. Additionally to the gluteus medius inhibition is strongly recommend to address the whole lower kinetic chain and avoid possible cumulative injury cycle effect since postural control is maintained by ankle or hip strategy (13, 17)

Proprioceptive drills again plenty can be found at the literature. Rehabilitation is an art based on the individuals ability to heal, functional demands and capabilities. There is no actual cookbook but there are rules i) what is the science behind it ii) is it specific to the problem or sport iii) is it safe. Proprioceptive training has been thorough discussed in the literature to improve ankle stability and reduce risk of injury. Freeman first proposed possible lesion of the mechanoreceptors at the lateral joint capsule and ligaments due to their lower tensile strength (16, 40). Proprioception, part of the sensorimotor system (SMS) (36), concerning functional joint stability refers to the afferent information from mechanoreceptors, of the muscle, tendon, bone and joint ligaments and capsule, to the central nervous system (CNS) regarding information of muscle length and tension as well joint position and motion (35, 36). Hence the theory suggests that there could be a delayed or diminished reflex response of the peroneals muscles to a sudden inversion stress because of altered afferent information from the mechanoreptors of the joints ligaments and capsule (40). Further during normal gait the lateral border of foot, during the swing phase passes 5mm above the ground and a incorrect information about the foot positioning may predispose it to injury (31-33).

Voluntary or involuntary mechanical deformation of the passive and active components will cause action potential that will be processed and become aware by the central nervous system and identify movement and position. Proprioceptive information also intervene voluntary and involuntary motor responses for coordinated movement (24).

Sports specific training:

Sport specific training involves functional movement that occur at a specific sport. A therapist must have a thorough understanding of the sport biomechanics, physiology, psychology and injury occurrence. For example sport specific of a sprinter with hamstring tear or gluteus maximus strain will performed 6 repetions at hip extensions machine or will do 6 step ups with loading. The 6 repetitions are corresponding to the strides a sprinter makes to complete the 100m race. A footballer with a severe ankle sprain depending on the position on the field must be trained according to the physiology of the game. Physiological demands of the game require from the young athletes to carry out 6-12 sprints and the older athlete to perform 20 sprinting bouts during a match every 90 seconds lasting up to 4 seconds that may cover in total 1.0-1.32 Km of the total distance mentioned before (20, 60, 71). Additionally is suggested that football players during a match may accomplish up to 1400 activities lasting two to four seconds such as, in average, 15 tackles, 10 jumps for heading and every 70 seconds a high intensity run (60). As can be seen more that one aspects of the sport must be consider in the sports specific rehabilitation training.

Arthrokinematics restrictions - Hypomobility:

Mulligan was the first to suggest arthrokinematic restriction after lateral ankle sprain. Further suggested that the distal tibiofibular joint is pulled forward during inversion which in combination with swelling is cause a positional fault (22). Though is also found that the fibula may also be faulty positioned more posterior (23). The anterior displacement affects the talucrular joint axis that is brought anteriorly that Puts the ATFL in a slack that may have an effect to the stress test (22).

It is also found that the talus subluxates anterior after an inversion ankle sprain (9, 22). Limitation at the talocrular joint kinematic result in limited dorsiflexion (22). Reduced dorsiflexion has been shown to resolve after a session of manipulation in contrast with a 6 month of stretching (9).

Allowing the ATFL to heal at elongated state the mechanical stability is compromised. Altered joint mechanics during healing will force tissue to heal at elongated state. Tissue exposed to excessive forces creates altered feedback to the neuromuscular system (9).

Surgical methods and considerations:

Grade 3 injuries may undergo surgical repair and follow similar rehabilitation approach and return to sport activities in four months (53, 72). Rehabilitation wise they follow the same path with grades I and II in respect to the healing process. Surgical techniques as already mentioned will briefly be discussed. More than 50 surgical modifications are suggested to exist for repair at the ankle (53). The most famous are the Watson-Jones operation for instability, Chrisman-Snook technique, Williams procedure and the Brostrom technique. Surgery path should be considered only if symptoms persist after a functional rehabilitation program. Clinical presentation must include the subjective report of giving away true mechanical instability demonstrated by provocative tests such as the anterior drawer or talar tilt, either clinically or with stress radiography (1).

The Chrisman-Snook technique is been suggested to provide much beter results in functional unstable ankles. The Chrisman-Snook technique advantage is that less lateral weakness is produced because only half of the peroneus brevis tendon is used for the graft though restricted subtalar motion with that procedure has been found.Furthermore, this is a tenodesis procedure and is a nonanatomical and does not restore normal biomechanics (53). The proximal tendon is weaved anterior to posterior through a drill hole in the fibula and posterior to anterior in a calcaneal bone tunnel and sutured to itself in the region of the anterior talofibular ligament (1).

The Brostrom technique is an anatomical reconstruction that further benefits from package repair of both ATFL and CFL in contrast with other techniques. Over 45 years has passed since the Brostrom technique was first introduced and remains the initial preferred technique. The concept of the Brostrom technique is based on anatomical reconstructions, were tissues of the damaged ligaments are used. Good results have been obtained with a modified Brostrom technique the Peterson procedure that includes shortening of the ligament, repair through bony tunnels, and imbrication with local tissue. After an anatomical reconstruction splint is applied for eight days to secure wound healing and, thereafter, a removable walking boot is applied for five weeks. Dorsiflexion and plantar flexion exercises after eight days or as early as possible out of the boot two to three times a day (53).

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