From the Guidelines
Management of an ATFL tear with a nondisplaced cuboid fracture should prioritize functional treatment, including exercise and functional support, over immobilization, according to the most recent evidence. The initial approach should involve excluding any other fractures, using tools like the OAR, which has high sensitivity and specificity 1. Following this, a short period of immobilization may be beneficial in reducing pain and swelling, but this should be limited to allow for early mobilization and exercise therapy.
Key Components of Management
- Immobilization with a walking boot or short leg cast for a short period, typically 2-4 weeks, to allow initial healing of both the ligament tear and cuboid fracture.
- Early progression to partial weight-bearing as pain allows, with full weight-bearing usually achievable by 4-6 weeks, depending on the healing progress.
- Pain management using NSAIDs, such as ibuprofen or naproxen, for 7-10 days, supplemented with acetaminophen for breakthrough pain.
- Physical therapy focusing on ankle range of motion exercises, proprioception training, and progressive strengthening, typically lasting 6-12 weeks after the immobilization period.
- Consideration of ankle bracing or taping during the return to activities to provide additional support.
Role of Surgery
Surgery should be reserved for cases where conservative management fails, particularly for severe ATFL tears that do not respond to functional treatment and rehabilitation 1. The primary goal is to avoid unnecessary invasive treatment and its associated risks while ensuring proper healing and preventing chronic ankle instability.
Prevention of Future Injuries
Functional support, such as bracing or taping, and exercise therapy can be effective in preventing recurrent ankle sprains, although the evidence for first-time sprains is less clear 1. Maintaining a healthy BMI and avoiding excessive weight gain may also play a role in reducing the risk of persistent complaints and incomplete recovery following an ankle sprain.
From the Research
ATFL Tear with Cuboid Nondisplaced Fracture Management
- The management of an ATFL tear with a cuboid nondisplaced fracture involves a combination of non-surgical and surgical treatments, depending on the severity of the injury 2.
- Non-surgical treatment is the first choice for acute injury of the ATFL, and involves the "peace and love" principle, followed by personalized rehabilitation training programs 2.
- For cuboid fractures, non-displaced isolated fractures can be effectively treated conservatively by immobilization and avoiding weight bearing on the injured leg 3.
- However, if there is shortening of the lateral column > 3 mm or articular displacement > 1 mm, surgical management of the fracture is mandatory to avoid negative biomechanical and functional consequences for the foot 3.
- The treatment of ATFL injuries should also take into account the possibility of associated injuries, such as calcaneofibular ligament (CFL) injuries, deltoid ligament injuries, and osteochondral defects (OCDs) 4.
- Imaging examinations, such as magnetic resonance imaging (MRI) and ultrasonography (US), can be used to diagnose ATFL injuries and associated injuries 5.
Treatment Options
- Non-surgical treatment:
- Immobilization
- Avoiding weight bearing on the injured leg
- Personalized rehabilitation training programs
- Proprioception training
- Muscle training
- Functional exercise to restore limb coordination and muscle strength
- Surgical treatment:
- Arthroscopic anatomical repair or anatomical reconstruction surgery
- Open Broström surgery
- Internal fixation to restore the anatomy of the cuboid and/or restoration of the length of the columns with bridging constructs using internal or external fixation 6
Associated Injuries
- Calcaneofibular ligament (CFL) injuries
- Deltoid ligament injuries
- Osteochondral defects (OCDs)
- Peroneal tendon injuries 4