DOES A PLAYER REQUIRE SURGERY?

– Written by Pieter d’Hooghe, Bruno Olory, Qatar, Gino Kerkhoffs, Netherlands, and Theodorakys Marin Fermin, Venezuela

INTRODUCTION

The ankle joint is a synovial hinge joint with movements in the sagittal plane. The hinge is formed between the distal epiphyses of the tibia and fibula, interlocked like a mortise, and articulating with the talus in a highly congruent joint¹.

Ankle and foot trauma is widespread in elite Handball, with ankle sprains in the leading. Most athletes have complete healing and recovery after adequate treatment but some develop chronic instability, causing impairments during physical activities².

The lateral collateral ankle complex is the most frequently affected. Approximately 85% of such injuries are due to inversion sprains of the lateral ligaments, 5% are eversion sprains of the medial collateral ligament, and 10% are inferior tibiofibular syndesmotic injuries. The anterior talofibular ligament (ATFL) is the most common component of the lateral collateral ankle complex to be injured in an ankle sprain^3-5.

Knowledge of the biomechanics of the foot and ankle joints is essential for understanding the specific handball-related injuries and ignite the appropriate management and future prevention.

This article will mainly discuss the surgical considerations of ankle instability in handball players, essentially focusing on mechanical ankle instability.

Epidemiology

In general, cute ankle sprains are underreported because they are usually self-treated, especially in a non-athletic patients but can constitute up to 30% of injuries seen in sports medicine outpatient clinics⁶. Ankle sprains show gender differences, with female competitors being 25% more likely to sustain such injury than male competitors^7-11. Female handball players are more at risk of acute first-time inversion sprain than those participating in other sports (Box 1)⁷.

Injury Biomechanics

The type of ankle injury depends on 2 factors: the foot’s position at the time of impaction and the direction of the force. The typical mechanism of injury is an inversion of the plantarflexed foot (70%–91%)^17-19. Even more, in the presence of relative weakness of the lateral collateral ligament complex (90%–95%)^17,18 with a diminished ATFL load-to-failure (approximately 150 N)^20,21.

Additionally, the calcaneofibular(CFL) ligament can be injured due to an adduction force when the foot is in dorsiflexion or neutral positions, as well as the posterior talofibular ligament, which can be torn due to forced dorsiflexion.

The injury mechanism can also guide the diagnosis of potentially associated lesions, including osteochondral injuries of the talar dome, fractures, and damage to the peroneus tendons or superficial nerve.

TREATING ANKLE SPRAINS

Despite the high frequency of ankle sprains in elite handball, the ideal management is controversial, and a significant percentage of athletes sustaining an ankle sprain never fully recover^22-24. Studies show that around 70% of athletes experiencing a first-time ankle sprain will recur in the future or may develop chronic ankle instability^23,25-27. A ligament tear remains the most crucial factor in determining the management and predicting the return to sport (RTS). The ankle sprain grading system is vital to differentiate between grade I sprains, in which there is only stretching or microtears; from grade II and III sprains, in which there is a tear in addition to a varying degree of instability²⁸. The treatment modalities for acute ankle sprain include the following:

Nonpharmacologic Treatment

The acronyms POLICE (protection, rest, optimal loading, ice, compression, and elevation) can summarize the management of acute ankle sprains²⁹.

Protection and rest

A systematic review that studied the effectiveness of external ankle supports in preventing ankle sprains among athletes who had suffered a previous ankle injury showed that 70% had fewer ankle sprains with bracing or taping than those who did not wear prophylactic support³⁰. Protective measures include cast splints, air or plastic splints, and Velcro or lace-up braces. Ankle taping can also increase ankle stability but taping is less effective than bracing in preventing ankle sprains because it is highly dependent on the expertise of the individual who performs the taping^30-32.

Data about the ideal duration of protective measures are scarce. However, according to the biology of ligament healing, it is generally accepted that a minimum of 1 year of protective ankle bracing or taping during sports activities is needed for all athletes who have sustained partial or complete (grade II or III) ankle ligament tear.

Optimal loading

The preferred management of grade II and III lateral ankle sprains is immobilization with an external splint while allowing early weight-bearing. All studies recommend early weight-bearing in the treatment of acute ankle sprain. Even complete grade III ankle sprains show a better healing tendency with early weight-bearing³³. Clinical researchers have shown that early weight-bearing optimizes the positioning of the torn collateral ligaments for healing while encouraging restoration of the “closed-pack” position of the ankle joint³⁴.

Ice

The available literature has advocated cryotherapy in the form of ice cups, ice packs, chemical cold packs, and cooling unit devices. Ice decreases pain and presumably reduces swelling after an ankle sprain³⁵. There is a controversy among researchers about the preferred cryotherapy protocol, with some recommending application for 20 to 30 minutes and others advising for 10 minutes and repeating the application at least 3 to 4 times per day during the first 5 days of treatment³⁶.

Compression and elevation

It is used to control interstitial bleeding and swelling during the acute phases of the ankle sprain. This can be done by bandaging or using easy-to-apply compression sleeves that can be reused daily³⁷.

Rehabilitation

The rehabilitation program is still mainstream in managing handball ankle injuries, and a good training program is essential. Functional rehabilitation comprises an organized and structured program for recovery of the physical and technical skillsfor optimal sports performance, focusing on pain relief and compensating functional impairment³⁸. The rehabilitation program should include cryotherapy, edema relief, optimal weight-bearing management, range of motion exercises for ankle dorsiflexion improvement, triceps surae stretching, isometric exercises and peroneus muscles strengthening, balance and proprioception training, and bracing/taping. Despite the evidence showing no differences in outcomes comparing supervised and self-administered programs, the former may allow faster progression^12,38. Following stricter protocols for treatment will hopefully reduce the high incidence of long-term disability that currently results from severe ankle sprains.

Pharmacologic treatment

Evidence supports using nonsteroidal anti-inflammatory drugs during the acute phase of ankle sprain^39-41. The National Athletic Trainers’ Association endorses using nonsteroidal anti-inflammatory drugs in managing ankle sprain as credible. These drugs reduce pain and swelling while improving short term functional improvement⁴². However, some authors warn against using them, especially long-term use because it may lead to delayed ligament healing⁴³.

Outcomes

Although ankle sprains are one of the most common injuries in handball, their outcomes are often unclear. About 70% of athletes report full recovery at 2 weeks to 36 months², most occurring within the first 6 months⁴⁴. However, 3% to 30% of patients who reported recurrent episodes at 2 weeks to 96 months after the initial sprain may develop longer-term residual pain and instability^45-47. Moreover, participation in competitive sports like elite handball has been correlated with residual ankle instability and dysfunction (Table 1)^44,48.

The management of ankle injuries in handball varies and depends on the injury’s severity and concomitant injuries^49,50. Most athlete cases are treated conservatively, mainly when there is no associated fracture. To date, no clinical indicator can be used to identify those who may develop recurrent instability or disability requiring a rehabilitation program or surgery. Furthermore, radiological findings do not necessarily reflect the severity of a player’s presentations and recovery time (Box 2).

HOW TO GET THE ATHLETE BACK TO THE GAME?

After an acute handball-related ankle sprain, it is hard to predict precisely when an athlete can RTS¹².

The current literature lacks formal criteria to assist in the decision to RTS of athletes with a ligamentous ankle injury.

There is strong evidence that residual disability of ankle joint injury is often caused by an inadequate rehabilitation and training program and early RTS⁵⁹. Therefore, the athletes should start their criteria-based rehabilitation and gradually progress through the programmed activities. For example, the medical team focuses firstly on painfree straightforward jogging or cycling before progressing to running with cutting or a change of direction (agility T-test or zigzag test).

Furthermore, medical teams must develop ankle-specific programs for handball athletes performing through pain. Skill-related activities such as pivoting and cutting must be added to the proposed training program when the athlete is pain-free or has mild symptoms with the previously programmed activities. It is helpful to evaluate the effectiveness of the rehabilitation protocol by using self-reported ankle scoring systems (e.g., Foot and Ankle OutcomeScore [FAOS])⁶⁰. However, functional performance tests are used to assess the athlete’s ability to perform sport-specific skills and to prepare him/her for the next level of training⁴². Therefore, data from these outcomes must be evaluated during the rehabilitation protocol as a baseline to assess the progression contrasting with the contralateral normal side^61-64. For a handball athlete to RTS, an ideal functional performance of a minimum of 90%, compared with the contralateral side, has been recommended⁶⁵.

In general, athletes with ankle injuries may return to play depending on their signs and symptoms (Box 3).

The RTS in amateur and professional handball players after an acute ankle sprain has been reported between 7 and 15 - 19 days, respectively^18,66. Nevertheless, the time required depends on several factors, including the following:

1. The severity of the injury and associated bony injuries
2. Athlete’s compliance, cooperation, performance level, and baseline functional demands. Players with highly functional baseline demands may take longer to return to preinjury level⁶⁷.
3. Rehabilitation program

WHAT IS THE ROLE OF SURGERY IN ACUTE ANKLE SPRAINS TREATMENT?

The surgical repair of acute ankle sprains is controversial. Most of the studies have methodological flaws and, thus, should be interpreted carefully⁶⁸. Surgery can be done acutely or after failing conservative treatment because it does not seem to yield different outcomes⁶⁹. Although conservative and surgical therapies produce satisfactory results, subtle differences favoring surgery on pain and recurrent instability have been reported⁷⁰.

Surgical techniques can follow 2 principles⁷¹:

• Anatomic techniques: anatomical reinsertion of the ligament or reconstruction with a graft, for example, Brostrom technique.
• Functional crutch techniques: improving the healing response of the native ligament to its normal length and tensile conditions by using a functional crutch.

The Brostrom-Gould technique shares both principles and, similar to most techniques, can be performed in various approaches: open, percutaneous, and arthroscopically.

At present, arthroscopic techniques are preferred because they allow for assessing and potentially addressing concomitant injuries, which can be present ranging from 42% to 93% of athletes^72–74.

RTS typically ranges between 12 weeks and 4 months following surgery⁷⁵. In a case series including 42 professional athletes with an acute lateral ankle sprain, White and colleagues⁷⁶ reported a mean return to training time of 63 days (49–110) and an RTS of 77 days (56–127) with diagnostic ankle arthroscopy and open modified Brostrom repair. Similarly, Sanchez and colleagues⁷⁷, in their case series of 40 patients, reported more than 30 points of American Orthopaedic Foot & Ankle Society (AOFAS) improvement in function and pain control with an arthroscopy-assisted ATFL reconstruction.

Although all patients had a preoperative diagnosis of chronic lateral ankle instability, 2 acute instability cases were of high-performance athletes who required an early RTS.

Finally, a recent systematic review by Goru and colleagues⁷⁸, comprising 10 studies (343 athletes), showed that the modified Brostrom technique using an anchor provides satisfactory outcomes in athletes with lateral ankle instability. The technique is safe, and RTS can be expected at a mean of 16 weeks, with an 89% rate of return to preinjury performance. However, associated injuries are correlated with delayed RTS (Box 4)^75,76,78.

SUMMARY

The major cause of ligamentous ankle lesions in elite handball players involves plantarflexed and inversion ankle movements. Due to the decreased positional stability and taking into account the handball-specific cutting actions, significant inversion/ eversion ankle injuries can occur. Acute lateral ankle injury is initially managed with functional treatment. A short immobilization period is followed by neuro-motoric training to obtain full recovery of ankle function. When chronic lateral ankle instability occurs (following repeated episodes of ankle sprains) and/ or when functional rehabilitation fails, surgery can be indicated. Arthroscopic or Open ligament repair/reconstruction is currently considered the surgical option with the most successful outcome, especially considering the nature of an explosive impact sport such as elite handball.

Pieter d’Hooghe MD, PhD

Orthopaedic Surgeon

Aspetar CMO

Aspetar Orthopaedic and Sports Medicine Hospital

Doha, Qatar

Bruno Olory MD

Orthopaedic Surgeon

Aspetar Orthopaedic and Sports Medicine Hospital

Doha, Qatar

Gino Kerkhoffs MD, PhD

Academisch Medisch Centrum Universiteit van Amsterdam

Amsterdam, Netherlands

Theodorakys Marin Fermin MD

Orthopaedic Surgeon

Centro Medico Profesional Las Mercedes

Caracas, Venezuela

Contact: pieter.dhooghe@aspetar.com

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