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I have a surgery set in the near future. The female runner ruptured
her Anterior-Talofibular ligament and has been treated conservatively
in a walking cast for over 4 months. This has failed to heal her pain
and she has decided to have surgery. Has anybody had success in
repairing the ligament and ankle capsule which is swollen? She read
about lateral ankle repair using the peroneal tendons and was very
reluctant to have any of those procedures done. Any tips would be
appreciated. Btw, patient is in her late twenties and in good general
health.

 

Have you tried physical therapy, cortisone injections, or foot orthoses? Have you ruled out talar dome osteochondral injury? Is this a first injury or is she a chronic ankle sprainer? How do you know she ruptured her ATFL?? I would consider sinus tarsi syndrome as a likely diagnosis and avoid surgery in a runner, if at all possible.

 

I tend to not see a ruptured/attenduated ATF as something that is persistently painful months after the event, and with consistent immobilisation in a cast walker. Unstable, yes, but painful? Usually not.

I would suspect the things Kevin has mentioned, or STJ interosseous ligament instability or other pathology in the STJ or ankle.

However, I have seen excellent outcomes with the modified Bronstrom repair of the ATF and capsule for chronic instability.

LL

 

An MRI was done on this patient and a ruptured ATF was seen.
The peroneal tendons were normal and there was a partial tear of the
calcaneal-fibular ligament. The sinus tarsi was normal also. I agree
that a ruptured ATF should not cause the pain that the patient is
having. As far as conservative care, she has been in a short leg walker
and has had a steroid injection. There is a bulge anterior to the ankle
joint possibly suggesting capsulitis. My plan was to go in and try to take
out excessive tissue and repair the ATF ligament, if possible. Any
other suggestions would be appreciated.

 

If you did surgery now, and she has a worsening of her symptoms after only having put her in a brace and given her one cortisone injection, some might argue that you did surgery way too soon and you might be visited by a plaintiff's attorney in a year or two as a result.

Therefore, it would certainly be reasonable to offer physical therapy, by a professional physical therapist, for three times a week, four weeks duration. I would get her out of the brace and into a soft ankle brace that supinates the foot out of the maximally pronated position. I would put her into modified OTC orthoses initially to see if she responded favorably to walking in a less pronated STJ position. Custom foot orthoses may be required eventually.

You also may also consider sending her to another podiatrist who specializes in biomechanics, foot orthoses and sports injuries to see if they can offer any help for the patient. I'm sure the patient would appreciate this gesture and you may learn something beneficial to your patients as a result.

 

DeFrank:
Rupture of the ATF is, of course, common. Although I have repaired literally hundreds of these, I have never had to do an "acute" tear repair. These are always repaired when primary healing has ended and the patient continues to have symptoms or has developed into a "chronic ankle sprainer"
Repair is a simple matter if the original ligament can be found and used, which often is not the case, Graft material (Pegasus or Graft Jacket) is used.
I always do an ankle scope and invariably find either synovitis and or an occult Osteochondral defect or fracture.
As far as a lateral ankle stablization procedure is concerned (peroneal tendon graft or reroute) - patients with isolated ATF damage and / or ankle synovitis are not candidates for this procedure.
Hope this helps
Dr. Steve

 

Is it possible this patient has a tibio-fibular syndesmosis injury. Was this assessed on MRI? These can be quite common in severe ankle inversion injuries and are also very commonly overlooked.