What is the management of strain injuries to the Anterior Inferior Tibiofibular Ligament (AITFL), Anterior Talofibular Ligament (ATFL), and Calcaneofibular Ligament (CFL)?

From the Guidelines

Management of strain injuries to the anterior inferior tibiofibular ligament (AITFL), anterior talofibular ligament (ATFL), and calcaneofibular ligament (CFL) should prioritize functional treatment over immobilization, with a focus on early protected weight-bearing, exercise therapy, and proprioception training, as supported by the most recent evidence 1.

Key Principles of Management

• Exclude fractures using the OAR (Ottawa Ankle Rule) to determine the need for imaging studies 1
• Use functional support, such as a brace or tape, instead of immobilization to promote early mobility and reduce the risk of complications 1
• Implement exercise therapy as soon as possible to recover joint functionality, including proprioception training and strengthening exercises 1
• Consider NSAIDs for pain management, but avoid unnecessary invasive treatment and surgery unless absolutely necessary 1

Rehabilitation Approach

• Begin with gentle range of motion exercises after acute pain subsides, typically within 3-5 days
• Progress to proprioception training, strengthening exercises, and gradual return to functional activities
• Full rehabilitation typically takes 4-6 weeks for grade I sprains, 6-8 weeks for grade II, and 8-12 weeks for grade III injuries

Prevention of Recurrent Injuries

• Use functional support, such as a brace or tape, to prevent recurrent ankle sprains, especially in patients with a history of previous sprains 1
• Incorporate exercise therapy into regular training activities to reduce the risk of recurrent injuries 1

Important Considerations

• Surgery should be reserved for patients with chronic instability or those who have not responded to comprehensive exercise-based physiotherapy programs 1
• Be aware of the potential risks and complications associated with surgery, such as longer recovery times, higher incidences of ankle stiffness, and impaired ankle mobility 1

From the Research

Strain Injury Management

• The management of strain injuries to the anterior talofibular ligament (ATFL), anterior inferior tibiofibular ligament (AITFL), and calcaneofibular ligament (CFL) is crucial for proper recovery and rehabilitation 2, 3, 4.
• Non-surgical treatment is the first choice for acute injury of the ATFL, involving the "peace and love" principle, followed by personalized rehabilitation training programs 2.
• The rehabilitation programs 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.

Anatomical Considerations

• The distal fascicle of the AITFL has been found to be a constant structure in the lateral ankle and can be used as a potential landmark for lateral ankle ligament reconstruction 3.
• The distances from the most distal insertion of the AITFL's distal fascicle to the ligamentous footprint centers were found to be reliable and can be used to identify the origins of the ATFL and CFL for lateral ankle ligament reconstruction 3.
• The presence of the distal fascicle of the AITFL and its contact with the talus is a normal finding, but it may become pathological due to anatomical variations and/or instability of the ankle resulting from torn lateral ligaments 5.

Treatment Options

• For grade I and II ankle sprains, non-operative management with a "functional treatment" program is recommended, including immediate use of RICE, a short period of immobilization, and early range of motion, weight-bearing, and neuromuscular training exercises 4.
• For grade III injuries, treatment is more controversial, but early functional treatment has been shown to provide the fastest recovery of ankle mobility and earliest return to work and physical activity without affecting late mechanical stability 4.
• Surgical treatment may be necessary for chronic instability refractory to conservative measures, and subtalar instability should be carefully evaluated when considering surgery 4.