What is the treatment for a Grade 3 Anterior Talofibular Ligament (ATFL) injury?

From the Guidelines

Treatment for a grade 3 ATFL sprain should prioritize functional support and exercise therapy over immobilization and surgery, as it provides equal effects with less risk of complications, as evidenced by the most recent and highest quality study 1. The goal of treatment is to reduce pain and swelling, promote healing, and restore ankle function.

• Functional support, such as a brace, is preferred over immobilization to provide stability while allowing for early mobilization and exercise, as recommended by the British Journal of Sports Medicine study 1.
• Exercise therapy should be started as soon as possible to recover joint functionality, focusing on range of motion exercises, progressive strengthening, proprioception training, and balance exercises, as outlined in the study 1.
• NSAIDs, such as ibuprofen or naproxen, may be used to reduce pain and swelling, but their use should be limited to 1-2 weeks, as stated in the study 1.
• Surgery should be reserved for patients with chronic instability or those who have not responded to conservative treatment, as it may provide better outcomes in terms of recovery of ankle activity and instability, but also carries a higher risk of complications, as discussed in the study 1. Key considerations in treatment include:
• Early mobilization and exercise to promote healing and restore ankle function
• Use of functional support, such as a brace, to provide stability
• Limited use of NSAIDs to reduce pain and swelling
• Reservation of surgery for patients with chronic instability or those who have not responded to conservative treatment By prioritizing functional support and exercise therapy, patients with grade 3 ATFL sprains can achieve optimal outcomes and reduce the risk of chronic ankle problems, as supported by the evidence from the British Journal of Sports Medicine study 1.

From the Research

ATFL Grade 3 Treatment

• The treatment for ATFL grade 3 injury typically involves non-surgical methods as the first line of treatment 2.
• The standard treatment strategy involves the "peace and love" principle, followed by personalized rehabilitation training programs, which may include proprioception training, muscle training, and functional exercise to restore limb coordination and muscle strength 2.
• Static stretching and other techniques to loosen joints, acupuncture, moxibustion massage, and other traditional medical treatments can relieve pain, restore range of motion, and prevent joint stiffness 2.
• If non-surgical treatment is not ideal or fails, surgical treatment is feasible, with arthroscopic anatomical repair or anatomical reconstruction surgery being commonly used in clinical practice 2.
• Modified arthroscopic Broström surgery has many advantages, such as less trauma, rapid pain relief, rapid postoperative recovery, and fewer complications, making it a popular choice among patients 2.

Associated Injuries

• There is a high incidence of injuries associated with ATFL injury, with the calcaneofibular ligament (CFL) and deltoid ligament complex being the most commonly injured structures 3.
• Peroneal tendons are also injured in a significant number of patients, and osteochondral defects (OCDs) are found in about 20% of patients 3.
• The ATFL tends to be the only structure addressed during surgery, but repair of the ATFL only may lead to poorer outcomes and persistent pain if concurrent injuries are not addressed 3.

Chronic Lateral Ankle Instability

• Chronic lateral ankle instability may progress if nonoperative treatment is not successful, and apoptotic activity in the anterior talofibular ligament is higher in chronic injured ligaments than in acutely injured ligaments 4.
• Further research should focus on the timing of apoptotic progression and biological augmentation to reverse or prevent apoptosis within the anterior talofibular ligament 4.

Conservative Treatment

• The results of conservative treatment for acute lateral ligament injury of the ankle vary according to the severity of the injury, with excellent results in patients with isolated injury to the anterior talofibular ligament, but unsatisfactory results in those with combined injuries of the anterior talofibular and calcaneofibular ligaments 5.
• Stress radiography, ultrasonography, and MR imaging can be used to detect ATFL injury, with MR imaging being the most accurate 6.