Damage to the ankle ligaments occurs as a result of injury - a twisted foot, often during sports or in winter, when there is ice. Pain may not occur immediately. After a short time or immediately after the injury, swelling of the ankle joint appears, its contours are smoothed out, and subcutaneous hematomas (bruises) appear. Sometimes patients o at the time of injury. Movement in the ankle joint causes acute pain; it is almost impossible to lean on the leg. You need to apply cold and immobilize the damaged joint, then go to a medical facility where you will have an x-ray of the ankle joint. Often this is not enough and a number of additional examinations may be required, such as ultrasound examination of the joint, magnetic resonance imaging (MRI) to assess the condition of the soft tissue structures (ligaments, tendons) of the ankle joint.
Symptoms of rupture/damage to the ligamentous apparatus of the fingers
Common signs of ligamentous injury include:
- Soreness.
- Limited swelling.
- Passive mobility of the joint in a non-standard direction.
In some cases, the fingers become spindle-shaped. This defect may persist for several months.
When the interphalangeal ligaments are damaged, patients complain of severe pain, weakness in the joint, discomfort when moving, and swelling. If the ligament is completely torn, the finger may become hyperextended. In case of injuries to the dorsum of the hand, the extension function of the fingers (one or more) is impaired. If the nerves are damaged, the fingers may become numb. Other sensory disturbances also occur. Hemorrhages may also occur.
Prevention of ligament damage
Athletes are now encouraged to warm up before performing exercises and stretch afterwards. Special exercises have also been developed to strengthen the ligaments of the knee joint.
Treatment of ligament injuries at home, unfortunately, is not possible. It must be remembered that a torn ligament injury can only be diagnosed by a professional doctor. They should also treat knee ligaments. It is unacceptable to self-medicate, as ligament damage is a serious problem.
Cost of cruciate ligament surgery
As mentioned above, the main factor leading to cruciate ligament injuries is injury to the knee joint. It is accompanied by severe acute pain and swelling of the knee. Usually, when a ligament ruptures, a cracking sound is heard and a feeling of dislocation appears, and if blood gets into the joint cavity during a rupture, then hemarthrosis occurs. The first days after injury are characterized by pronounced pain and a state of hemarthrosis, in which it is impossible to examine the knee joint by palpation (manual examination). Manual examination is performed after elimination of acute pain and symptoms of hemarthrosis. For comparison, a healthy leg is examined, a traumatologist checks the functionality of the knee joint using special tests (drawer, “Pivot Shift”, Lachman) and makes a diagnosis. To reduce pain and improve the quality of the examination, remove blood fluid from the joint cavity using a syringe. Magnetic resonance imaging (MRI), x-rays, and ultrasound are performed to rule out other possible injuries (fracture, meniscal or collateral ligament tears).
Diagnosis of rupture/damage to the ligamentous apparatus of the fingers in the clinic
Diagnosis of injuries to the ligamentous apparatus of the fingers begins with a simple examination and questioning of the patient. The doctor performs a visual inspection. He determines the type of damage by palpation (palpation of the hand). Additionally, instrumental examination methods are prescribed.
Our doctors have the necessary skills and knowledge for quick and high-quality diagnosis and diagnosis. We can conduct examinations using modern, high-precision, expert-class equipment from the world's leading brands. Diagnosis will take a minimum of time, and the doctor will be able to begin treatment immediately.
Examination methods
The main examination methods include:
- Ultrasound. An ultrasound examination allows you to assess the condition of the hand and determine the functionality of tendons and ligaments. Examining the hand, the doctor determines damage to the nerve threads, pinching, and small bone fractures that are not visualized on x-rays.
- X-ray examination in frontal and lateral projection. This examination is aimed at clarifying the type of injury. It also allows you to confirm or refute a bone fracture. Also, an x-ray can reveal the degree of injury to hard tissues that are located next to the ligamentous apparatus.
- MRI (magnetic resonance imaging). This survey is accurate and informative. It may be prescribed to clarify the diagnosis.
Examination methods are chosen by the doctor.
What are the differences between degenerative changes and lesions?
Degenerative processes in joints are not always dangerous. They are divided into changes and lesions:
- changes are a natural process of aging of joints, which does not have a serious impact on their functionality;
- lesions are a pathological condition that occurs at any age and leads to the development of arthrosis of the knee, shoulder or hip joint.
Degenerative lesions may have more than one cause, which overlap and reinforce each other. For example, the cartilage may be genetically defective, the joint may have anatomical defects or traumatic damage. The development of the disease is facilitated by overload, joint inflammation, and pathology of the endocrine system. One or more reasons trigger the mechanism of joint destruction from the inside.
Treatment of rupture/damage to the ligamentous apparatus of the fingers in the clinic
When the ligaments of the hand apparatus are torn, treatment can be either conservative or surgical.
Usually a plaster splint is placed on the arm for 2-3 weeks. It allows you to fix the hand in a functionally and anatomically correct position. The patient is then observed. If, after removal of the cast and rehabilitation therapy, instability of the joint remains, surgical treatment is prescribed. The operation can also be performed in fresh cases with severe instability of the joint. The intervention is aimed at applying a special suture to a ligament that is torn or torn with a bone plate.
If for some reason suturing is impossible, autoplasty of the ligament is performed. As part of the operation, channels of small diameter (2-3 mm) are formed in the bones in the direction from the back to the palm. A tendon graft is taken from the palmaris longus muscle. It is performed in a figure-of-eight pattern and tightened to eliminate lateral instability but preserve the ability of the fingers to flex and extend. The ends of the graft are sutured. Rehabilitation after such an operation lasts 2-3 weeks.
Important! If the damage is not detected promptly or treated, periarthritis may develop. At the same time, the fingers increase in volume, and the pain persists for a very long time. The patient loses the ability to move his fingers normally and is forced to change his usual lifestyle.
Treatment of anterior cruciate ligament injuries
Conservative treatment of the cruciate ligament of the knee joint
In the acute period, i.e. immediately after an injury, treatment should be aimed at relieving pain and swelling of the knee joint, and later at restoring normal mobility in the joint. Immediately after an injury, do not attempt to move without assistance. You must protect your knee from further damage that may occur without proper treatment. Conservative treatment includes ice packs, anti-inflammatory medications, and rest. If hemarthrosis is present, it is necessary to suction out the accumulated fluid. Physiotherapy and exercise therapy may also be prescribed.
Physical exercise will help quickly restore normal mobility in the joint and prevent muscle atrophy. Specific exercises focus on strengthening the hamstrings and quadriceps muscles, which help stabilize the knee. An important argument in favor of treatment is the fact that long-term instability of the joint leads to early arthritis of the knee joint.
Knee pads - bandages, orthoses and supports.
Bandages are knitted products that fit tightly around a joint and improve its stability. They may have special silicone inserts for better fixation of the patella - in the form of a ring or half ring. An orthosis is an orthopedic device whose main task is to compensate for impaired joint functions. Orthoses are usually called complex structures made of metal, plastic and fabric, which are used for more serious disorders and better stabilize the joint (Fig. 1). Sometimes it is difficult to draw a clear line between a bandage and an orthosis, since there are bandages with side iron inserts in the form of elastic springs or simple hinges, which are additionally secured with Velcro. The word "support" comes from the English word support, which is translated as "support" and is used as a general term. Calipers are often used for knee instability. If you do not lead an active lifestyle, you can completely do without surgical treatment. The caliper will provide the necessary stability.
However, there is no evidence that the use of knee supports prevents the development of arthrosis of the knee joint. Using a caliper can give a false sense of security when playing sports. Calipers will not always be able to protect your joint completely, especially during sudden movements, stops and jumps. Therefore, in case of severe instability of the joint, surgical treatment is recommended for people leading an active lifestyle and playing sports. Many doctors recommend using calipers for at least a year after surgery. So if you have an injured cruciate ligament, you will need supports in any case.
Surgical treatment of anterior cruciate ligament rupture of the knee
If, after a course of conservative treatment, the stability of the joint does not meet the requirements of physical activity and the calipers do not provide the necessary stability of the joint, then it is proposed to resort to surgical treatment. Even when it is obvious immediately after an injury that surgery is necessary, most doctors prescribe a course of physical therapy and exercise therapy to quickly relieve swelling and restore full mobility to the joint. Only after this is surgery possible.
Surgical treatment for a torn anterior cruciate ligament involves arthroscopic reconstruction of the anterior cruciate ligament. Arthroscopy is a method of endoscopic surgery on joints. Operations are performed using very thin instruments and special optics connected to a digital video camera (Fig. 2). During the operation, the surgeon looks at the monitor and sees everything that is happening at the moment in the joint, with high magnification - from 40 to 60 times. The use of modern instruments and highly sensitive optics makes it possible to perform the finest manipulations on the knee joint with minimal damage to surrounding structures and the joint itself (for example, suturing or removing part of the menisci, cartilage transplantation, ligament reconstruction) - and all this through 2-3 small incisions. After such an operation, the patient is usually discharged on the same day.
To reconstruct the anterior cruciate ligament, leading sports medicine clinics currently use grafts that are pieces of human tissue. In world practice, several sources of graft are used: autograft from the patellar ligament, autograft from the hamstrings, allografts.
- Reconstruction from the patellar ligament.
This ligament connects the patella to the tibia. The autograft is cut off from the tibia and patella with bone fragments. Using the bone fragment, the autograft is subsequently fixed in the bone canal. This technique not only increases the strength of attachment of the graft to the new bed, but also ensures its faster fusion with the latter, since the fusion of spongy bone in a canal, the walls of which are represented by a spongy structure, requires 2-3 weeks, which is significantly less than the period of fusion of such a ligament or tendon with bone. The edges of the cut ligament are sutured. Channels are drilled in the tibia and femur bones, leading into the cavity of the knee joint. The internal openings of these channels in the joint are located in the same place where the attachment points of the anterior cruciate ligament to the articular surfaces of the femur and tibia were located. The ligament graft is passed into the joint cavity through the bone canal of the tibia. The ends of the prosthesis are fixed in the bone canals using special metal or biopolymer absorbable screws. This is the method most often used in most clinics around the world.
- Autograft from hamstrings.
Tissue from the semitendinosus tendon can be used as graft material. There is still no consensus on which autograft is best. Reconstruction with an autograft from the patellar ligament is more traumatic and recovery after such an operation is more difficult due to injury to this ligament. But it is believed that such an operation is more reliable. The knee is then more stable and can withstand loads better. Although, if the surgeon has well mastered the technique of performing reconstruction from the tendons of the semitendinosus and gracilis muscles, comparable results are obtained. With the second method of surgery (from the tendon of the semitendinosus muscle), fewer incisions are made and in the future it is almost invisible that a knee operation was performed. With the first technique (from the patellar ligament), an additional 5-centimeter scar will remind you of the operation, which in reality is not very noticeable, especially in men. Recently, preference has been given to semitendinosus autografts or the quadriceps tendon, but this technique The operation is not applicable in all cases; the patellar ligament is no less rarely used. This issue is approached individually. Allografts are tissue obtained from a donor. After a person dies, tissue is removed from the body and sent to a tissue bank. There she is checked for all infections, sterilized and frozen. When surgery is necessary, the doctor sends a request to the tissue bank and receives the necessary allograft. The source of the allograft may be the patellar ligament, hamstrings, or Achilles tendon. The advantage of this method is that the surgeon does not have to cut the graft from the patient's body, disrupting its normal ligaments or tendons. This operation takes less time, because no time is wasted on isolating the graft. Considering the complex structure and biomechanics of the anterior cruciate ligament, during the development of the surgical technique, the term “cruciate ligament reconstruction or plastic surgery” was rejected. Performing only one stage of the operation, namely the location of the graft in the joint cavity is similar to the course of the normal cruciate ligament, does not give grounds to call this surgical intervention restoration of the cruciate ligaments, since the structure of the ligament is not completely recreated, each portion of which plays a significant role in its effective functioning. Therefore, the term “restoration of stability” or “stabilization of the knee joint in one way or another” would be correct and theoretically justified.
Prevention of rupture/damage to the ligamentous apparatus of the fingers and medical recommendations
To prevent damage you should:
- Try to reduce the risk of injury. To do this, you must always make all movements carefully. Before any physical activity, you should warm up the ligamentous apparatus and the joints themselves. It is very important to monitor the condition of your muscles.
- Visit a doctor regularly if your ligaments and joints are weak (especially if you have any chronic diseases of the musculoskeletal system). An experienced specialist will not only talk about preventive measures, but will also constantly monitor the health status of his patient.
- Pay attention to proper nutrition. You should definitely include foods that are good for your ligaments in your diet. These include fatty fish, ginger, garlic, broccoli, walnuts, fresh berries and fruits. On your doctor's recommendation, you can take complex vitamins regularly.
If you want to learn everything about preventing ligamentous injuries, contact our doctor. You can also make an appointment if you have an injury. Our doctor will prescribe the necessary diagnostics and then carry out treatment. Call us or leave a request on the website!
Inversion injuries of the capsular-ligamentous apparatus of the ankle joint in children and adolescents
Introduction. Injuries to the ankle joint account for up to 25% of the total number of musculoskeletal injuries in the general population [1]. In children, this percentage increases to 35% [2]. Among injuries to the soft tissue structures of the ankle joint, injuries to the lateral group of the capsular-ligamentous apparatus (inversion injuries), which account for 70-75% of ankle joint injuries, deserve special attention [3]. In the available literature, we found a few studies devoted to damage to the capsular-ligamentous apparatus of the ankle joint in children and adolescents [4-7].
A study of foreign publications showed that more than 40% of injuries to the lateral ligaments of the ankle joint lead to chronic instability and the development of degenerative processes in the joint [8, 9]. Loss of the supporting function of the ligaments predisposes the patient to repeated ligament ruptures or other injuries resulting from much lesser trauma, which has led to discussion and detailed study of this problem.
According to our observations, in most cases, when children come to the emergency room with damage to the ankle joint, an examination and radiographs are performed in standard projections. In the absence of bone damage, a diagnosis is made: ankle sprain. Such patients are recommended to fix the limb with an elastic bandage and apply warming ointments locally. However, with this treatment method, constant mobility in the joint leads to the formation of a stretched scar, which increases the risk of repeated injuries [10]. The term “sprain” makes doctors, patients and their parents less vigilant.
The problem of the pathogenesis of ankle ligament injuries has been studied for a long time. Early scientific papers described the possibility of stretching collagen fibers due to their folding. Research has shown that the extensibility of ligaments is their property [11]. A.A. Zavarzin experimentally measured the elastic modulus of collagen fibers, which amounted to 2.6-8.8 kg/mm² [18]. Therefore, with increasing load, one should expect ligament rupture rather than stretching. Based on this, the term “sprain” is incorrect. Therefore, for practical purposes, it is more appropriate to make a diagnosis of partial or complete ligament damage [12].
Among injuries to the external ligaments, 90% are injuries to the anterior talofibular ligament (65% of them are isolated, and 25% are combined with damage to the calcaneofibular ligament). The posterior talofibular ligament (or the third component of the external collateral ligament) is resistant to posterior displacement of the talus and is therefore rarely injured except in cases of complete foot dislocation [10].
In foreign guidelines, the “gold standard” in diagnosing ankle ligament injuries is the magnetic resonance imaging method with a sensitivity of 90% and a specificity of 83% [10]. However, the low prevalence of magnetic resonance imaging scanners and the high cost of the study significantly limit the use of this method when searching for injuries to the ankle joint. In addition, in young children this diagnosis can only be carried out under anesthesia.
The most accessible method for visualizing ankle ligament injuries is ultrasound. The sensitivity of the method according to the literature is 92%, specificity is 64% [13]. As a non-invasive, relatively cheap and widely available research method, it is of high value for visualizing the capsular ligamentous apparatus [14].
When studying and analyzing the information available in the literature, we noted many different methods of treating ankle ligament injuries. However, the tactics of treating ligamentous injuries remains controversial and this problem has not been solved to date. A number of authors recommend starting with conservative treatment methods in all cases of ankle ligament injuries [15]. In case of partial ligament damage, some authors recommend immobilization, while others oppose it [16].
Kannus P. writes in his publication that to understand the principles of treatment of ankle ligament injuries, it is necessary to know the stages of regeneration and the conditions that need to be created for the healing of the ligament [16]. The reparative process for damage to the ankle ligaments occurs in 3 phases:
1st phase. Inflammation (1-7 days). During this phase, capillary walls thicken, plasma and fibrin sweat, and inflammatory cells migrate to the site of damage. During this phase, it is necessary to ensure rest through immobilization and an elevated position. Cold has a beneficial effect. Lack of immobilization increases the inflammatory phase, which leads to the formation of large amounts of scar tissue.
Phase 2. Proliferative (7-21 days). During this phase, inflammatory cells carry out phagocytosis of damaged tissues. Fibroblasts produce type 1 collagen (mature collagen). In the middle of this phase, the formation of type III collagen (immature collagen) begins. At this stage of treatment, it is necessary to limit movement in the ankle joint to prevent excessive production of type III collagen, which contributes to the formation of a soft, stretched scar and chronic sprains.
Phase 3. Remodeling (21 days to 12 months). Collagen maturation. At this stage, controlled gradual loading will promote the correct orientation of the collagen fibers. Therapeutic exercise to develop movements in the ankle joint and strengthen weakened periarticular muscles in combination with a complex of physiotherapeutic treatment to improve blood supply, reduce swelling and pain will avoid the harmful effects of immobilization on muscles and articular cartilage. Treatment will continue until the collagen matrix matures so that full return to activity is possible 4 to 8 weeks after injury.
The purpose of the study is to develop a diagnostic algorithm and improve the results of treatment of children and adolescents with inversion injuries of the capsular-ligamentous apparatus of the ankle joint.
Materials and methods. An analysis of case histories and own clinical material of 53 patients with injuries to the lateral ligaments of the ankle joint was carried out. Depending on age, patients were divided into groups of preschool, primary school, senior school and youth. There were 23 girls with ankle ligament injuries, and 30 boys (Table 1).
Table 1. Distribution of patients by gender and age
The average time for patients to go to a medical facility after an injury is 1-7 days. Before admission to CITO, all patients were treated in medical institutions in Moscow. In 15% of patients the injury was recurrent.
We have developed an algorithm for examining patients with ankle joint injuries:
1. Taking an anamnesis.
2. Examination, including diagnostic stress tests (inversion, pronation, compression test, anterior drawer test).
3. X-ray of the ankle joint.
4. Ultrasonographic examination of the ankle joint.
The following anatomical structures were examined during ultrasound examination:
1. Anterior section: ligaments of the tibiofibular joint, tendons of the long extensor digitorum and the first finger.
2. Lateral section: tendons of the peroneal muscle group, joint capsule, anterior talofibular ligament, calcaneofibular ligament.
3. Medial section: tendons of the tibialis posterior muscle, flexor digitorum longus and flexor digitorum longus, deltoid ligament.
4. Posterior section: posterior talofibular ligament, Achilles tendon.
To assess the degree of damage to the capsular-ligamentous apparatus of the ankle joint, we used the classification developed by S. Trevino [17]
1st degree – fiber separation of the ligament.
2nd degree – partial damage to the ligament.
3rd degree – total damage to the ligament.
Ultrasound examination assessed the amount of effusion in the joint, the presence of intra-articular bodies, the thickness of the joint capsule, and determined the integrity and echogenicity of the capsule and joint ligaments.
Treatment of ankle ligament damage was carried out in 3 stages.
Stage 1 – plaster immobilization (or immobilization with modern rigid fixation orthoses) for up to 3 weeks. Loading on the injured limb was excluded. During immobilization, gymnastics was prescribed for the healthy limb, isometric gymnastics for the injured limb, and magnetic therapy.
Stage 2 - after the cessation of immobilization, active lightweight exercises are carried out to develop movements in the ankle joint, a special set of exercises to strengthen the periarticular muscles, special attention is paid to the peroneal muscle group, as the main stabilizers of the ankle joint. Exercises that cause trauma and stretching of the scar - adduction and supination - are excluded. An orthopedic regimen is prescribed - limiting the load on the injured leg for 1 week. To prevent scar trauma, we recommend that patients wear a special bandage or high lace-up boot that limits lateral movements of the foot and wear arch supports. The following physiotherapeutic measures are used: phonophoresis with hydrocortisone and lidase, magnetic therapy, warm foot baths with sea salt.
Stage 3 – consolidation. Therapeutic physical education according to the methodology of the final period. The procedures are performed in a sitting or standing position. Walking in place, on toes, on heels, in a straight line, sideways, with turns, going up and down ramps, stairs, etc. is used. During this period, exercises on leg exercise machines are prescribed. At the same time, we include running and jumping in the set of exercises.
Results and discussion. An examination of 7 patients with a referral diagnosis made at the emergency room: a closed fracture of the lateral malleolus revealed damage to the capsular-ligamentous apparatus of the ankle joint in the lateral part. The bone structures were intact. According to the examination, 45.3% of patients had damage to the capsular-ligamentous apparatus of grade I, 41.5% had grade II, and 13.2% had grade III (Table 2).
Table 2. Distribution depending on the severity of ankle ligament injuries
In accordance with the results obtained, damage to the anterior talofibular ligament was diagnosed in more than half of the cases (77.4%). The calcaneofibular ligament was in second place in terms of frequency of injuries (22.6%). No damage to the posterior talofibular ligament was detected in the examined patients. Analysis of the degree of damage showed a significant predominance of partial ligament damage (86.8%) over complete ligament rupture (13.2%) (Table 3).
Table 3. Distribution of inversion injuries to ankle ligaments
Objective assessment of the treatment effectiveness of patients was carried out after 3 weeks, 6 weeks, 6 and 12 months using the AOFAS questionnaire.
86.8% of patients had excellent treatment results, and 13.2% had good results.
Here is a clinical example. Patient K., 10 years old. During figure skating training, I sprained my right leg at the ankle joint. At the time of injury, she noted a click. When visiting the emergency room: examination, radiographs of the ankle joint. A diagnosis was made: sprain of the right ankle joint. Soft tissue immobilization of the ankle joint was performed using a figure-of-eight bandage, and local warming ointments were prescribed. The girl could not train due to severe pain in the joint. I contacted the CITO on the 3rd day after the injury. Examined. Ultrasound examination revealed partial damage to the anterior talofibular ligament, partial damage to the calcaneofibular ligament and joint capsule (Fig. 1). Plaster immobilization was performed for 3 weeks. After removing the plaster splint, physical therapy was carried out according to the proposed method, as well as a set of physiotherapeutic measures. Joint function was restored after 5 weeks. The girl returned to playing sports.
Rice. 1. Sonograms of the lateral ankle joint: 1a – the arrow indicates the anechoic area of the joint capsule, indicating a rupture of the joint capsule; 1b – the arrow indicates a hypoechoic area corresponding to partial damage to the anterior talofibular ligament; there is a partial tear of the ligament with a detached cortical layer from the lateral malleolus; 1c – a hypoechoic area is indicated, corresponding to partial damage to the calcaneofibular ligament.
conclusions
1. Considering the high frequency of relapses of inversion injuries of the capsular-ligamentous apparatus of the ankle joint in children and adolescents, examination and treatment of such patients requires a special approach.
2. The data obtained during the examination of patients indicate the need to introduce into everyday practice the ultrasonographic diagnostic method for traumatic injuries of the ankle joint in order to visualize damage to the capsular ligamentous apparatus in children and adolescents. The use of classical radiography alone as a visualization method in many cases leads to diagnostic errors and to the wrong choice of treatment method.
3. Ultrasonography, as a relatively cheap and widely available research method, is of high value both for visualizing the capsular-ligamentous apparatus and for assessing the degree of its damage. This is of great importance for the prognosis of the disease and determining further treatment tactics.
4. In case of damage to the ankle joint ligaments in children, in order to form a full-fledged scar, it is necessary to carry out short-term rigid immobilization of the joint (up to 3 weeks)
5. Comprehensive treatment of ankle ligament injuries helps prevent recurrence of injuries and the development of instability in the joint.