Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings.

PURPOSE: To determine the diagnostic value of seven injury history variables, nine clinical tests (including the combination thereof) and overall clinical suspicion for complete discontinuity of the lateral ankle ligaments in the acute (0-2 days post-injury) and delayed setting (5-8 days post-injury). METHODS: All acute ankle injuries in adult athletes (≥18 years) presenting up to 2 days post-injury were assessed for eligibility. Athletes were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Using standardized history variables and clinical tests, acute clinical evaluation was performed within 2 days post-injury. Delayed clinical evaluation was performed 5-8 days post-injury. Overall, clinical suspicion was recorded after clinical evaluation. MRI was used as the reference standard. RESULTS: Between February 2018 and February 2020, a total of 117 acute ankle injuries were screened for eligibility, of which 43 were included in this study. Complete discontinuity of lateral ankle ligaments was observed in 23 (53%) acute ankle injuries. In the acute setting, lateral swelling had 100% (95% confidence interval [CI]: 82-100) sensitivity, haematoma had 85% (95% CI: 61-96) specificity and the anterior drawer test had 100% (95% CI: 77-100) specificity. In the delayed setting, sensitivity for the presence of haematoma improved from 43% (95% CI: 24-65) to 91% (95% CI: 70-98; p < 0.01) and the sensitivity of the anterior drawer test improved from 21% (95% CI: 7-46) to 61% (95% CI: 39-80; p = 0.02). Clinical suspicion had a positive likelihood ratio (LR) of 4.35 (95% CI: 0.55-34.17) in the acute setting and a positive LR of 6.09 (95% CI: 1.57-23.60) in the delayed setting. CONCLUSIONS: In the acute setting, clinical evaluation can exclude complete discontinuity (e.g., absent lateral swelling) and identify athletes with a high probability of complete discontinuity (e.g., positive anterior drawer test) of the lateral ankle ligaments. In the delayed setting, the sensitivity of common clinical findings increases resulting in an improved diagnostic accuracy. In clinical practice, this study underlines the importance of meticulous clinical evaluation in the acute setting. LEVEL OF EVIDENCE: Level III.

Management of radiology services during the 2022 FIFA football (soccer) World Cup.

Diagnostic imaging is the predominant medical service sought for the assessment and staging of musculoskeletal injuries in professional sports events. During the 2022 FIFA Football (soccer) World Cup, a centralized medical care infrastructure was established. This article provides a comprehensive account of the radiological services implemented during this event, encompassing the deployment of equipment and human resources, the structuring of workflows to uphold athlete confidentiality, and initiatives aimed at enhancing communication. Communication channels were refined through radiology consultations held with national teams' health care providers and the adoption of audiovisual reports available in multiple languages, which could be accessed remotely by team physicians. Our established framework can be replicated in international professional football events for seamless integration and efficacy.

Imaging-detected sports injuries and imaging-guided interventions in athletes during the 2022 FIFA football (soccer) World Cup.

OBJECTIVE: To describe imaging-detected musculoskeletal injuries and image-guided interventional procedures during the 2022 FIFA football (soccer) World Cup. MATERIALS AND METHODS: Retrospective analysis of all radiologic examinations performed in a central medical facility for athletes was performed by two board certified musculoskeletal radiologists. Data on muscle, tendon, ligament, cartilage, and bone injuries were collected according to imaging modality and body part. RESULTS: A total of 143 radiology examinations in 94 athletes were evaluated at the central medical facility. Magnetic resonance imaging (MRI) was the most utilized modality (67%), followed by radiography (12%), ultrasonography (9%), and computed tomography (4%). Image-guided interventions corresponded to 8% of all radiological examinations. There were 112 injuries described, affecting muscles and tendons (42%), ligaments (25%), cartilage (21%), and bone (12%). Most injured body parts were thigh (27%), foot and ankle (23%), knee (23%), and hip/groin (8%). Most injured players were within the age range of 24-35 years old (71%). CONCLUSION: Imaging was utilized in 11% of players who participated in the 2022 FIFA World Cup in Qatar. MRI was the most utilized modality, and acute muscle tears were the most diagnosed type of injury. Diagnostic imaging played an important role in diagnosing sports-related injuries during the 2022 FIFA World Cup.

Medical services at the FIFA world cup Qatar 2022.

OBJECTIVE: The Football World Cup is among the biggest sporting events in the world, but data to inform the requirements of medical care for such tournaments are limited. This study describes the athlete and team medical services at the FIFA World Cup Qatar 2022 . METHODS: Three different medical service entities were identified through a needs analysis based on expert advice, team physician interviews and questionnaires prior to the event: 'Team Services' to provide any workforce or equipment needs of the teams, a 'Polyclinic' to manage any acute medical demands, and a 'recovery centre' to improve game readiness throughout the tournament. All services had been set up prior to the tournament and thoroughly tested. RESULTS: Of a total of 832 athletes, ~1300 team delegation and ~130 match officials, 167 individuals including 129 (77%) athletes and 38 (23%) non-athletes were assessed in the polyclinic. For the 129 athletes (median 4 players per team), medical imaging was the most requested service, which peaked during the group phase of the tournament. Most requests were received during normal working hours despite many games finishing late at night. 30 of the 32 participating teams solicited medical services for their players at least once. Three teams made use of the recovery facilities, and 17 teams requested additional medical equipment or clinical assistance. CONCLUSION: Central imaging services was the most used medical resource at the FIFA World Cup Qatar 2022, and over half of teams required additional medical equipment or personnel. These data may inform planning of medical services for similar events in the future.

The injury mechanism correlation between MRI and video-analysis in professional football players with an acute ACL knee injury reveals consistent bone bruise patterns.

PURPOSE: To analyze the MRI features, in particular bone bruises pattern, of Anterior Cruciate Ligament (ACL) injured footballers, and to correlate them with the characteristics of injury mechanism and situation obtained from direct video footage. METHODS: Nineteen professional football (soccer) players that sustained ACL injury while playing during an official match of First League Championship were included in the study. The video of injury was obtained from the Television broadcast. Knee Magnetic Resonance (MRI) was obtained within 7 days from the injury. BB and meniscal lesions were analyzed on MRI, while a video-analysis of mechanisms of ACL injury and injury dynamic were assessed from the videos. RESULTS: The most commonly involved Bone Bruise areas in the knee were the Posterior Lateral Tibial Plateau (LTp) in 16 cases (84%) and the Central Lateral Femoral Condyle (LFc) in 11 cases (58%). Three patients (16%) had bone bruise in the Posterior Medial Tibial Plateau (MTp) while none (0%) had bone bruise in the Medial Femoral Condyle. Based on the bone bruise pattern, 11 (58%) had simultaneous LFc and LTp and were defined "Typical" while 8 (42%) had other locations or no bone bruise and were defined "Atypical". 9 out of 11 injuries (82%) of athletes with "Typical" pattern occurred with a "Pivoting" action", in contrast to only 1 case (12%) in those with "Atypical" bone bruise pattern (p = 0.0055). The most common situational mechanism pattern on video analysis was "pressing" (n = 7) accounting for the 47% of the "indirect" ACL injuries. In terms of movement pattern, ten injuries (52%) occurred during a "Pivoting" movement (7 pressing, 1 dribbling, 1 tackled, 1 goalkeeping), whereas the remaining were classified as "Planting" in four cases, "Direct Blow" in four cases and "Landing". CONCLUSION: A well-defined and consistent bone bruise pattern involving the posterior tibial plateau and central femoral condyle of lateral compartment is present in footballers that sustained non-contact and indirect ACL injuries during pivoting with sudden change of direction/deceleration, while heterogeneous patterns were present in those with direct contact or injury mechanisms involving high horizontal velocity. LEVEL OF EVIDENCE: Level IV.

Mechanisms of ACL injuries in men's football: A systematic video analysis over six seasons in the Qatari professional league.

To assess the mechanisms of ACL injury in male professional football players in Qatar across multiple seasons using systematic video analysis. 15 ACL injuries occurred in competition among the professional football teams that participated in an injury Surveillance Programme during 6 seasons (2013/2014 to 2018/2019). High-definition broadcast videos of these injuries were analyzed (49 views; 34 slow motion) by five analysts who independently described the injury mechanisms (situation, behavior, biomechanical characteristics) using validated observational tools. A knee valgus mechanism was observed in two-thirds of the cases (1 with direct contact to the knee, 3 with indirect contact (other body parts) and 6 with no contact). No visible valgus was reported in 2 of the direct knee contact injuries, while 3 cases of non-contact and indirect contact injuries were unclear. We observed 4 main categories of injury situation among those (n = 12) classified as non-contact/ indirect contact (multiple combinations were possible): pressing (n = 6), tackling or being tackled (n = 4), blocking (n = 3) and screening (n = 2). Direct contact injuries (n = 3) were suffered by 2 players during tackling and 1 whilst being tackled. Contact injuries represented only 20% of ACL injuries occurring during competition in Qatari professional soccer players. Independent of the playing situation, knee valgus was frequently observed (10/15 cases). Pressing was the most common situation (6/15 cases) leading to injury. Landing after heading was not reported in any of these ACL injuries.

Epidemiology of Achilles Tendon Rupture in Italian First Division Football (Soccer) Players and Their Performance After Return to Play.

OBJECTIVE: To evaluate the epidemiology, incidence rate, incidence proportion, and prevalence of Achilles tendon ruptures (ATRs) in professional footballers and their performance after the injury. DATA SOURCES: Professional male footballers participating in Serie A in 11 consecutive seasons (2008/2009-2018/2019) were screened to identify ATRs through the online football archive transfermarkt.com. Exposure in matches and training was calculated. The number of matches played in the 5 seasons before and after ATRs was obtained, when possible, together with transfers to a different team or participation in lower Divisions. MAIN RESULTS: Eleven ATRs were found in 11 footballers with a mean age of 29.8 ± 4.4 years; 72% of ATR involved the nondominant leg; 58% occurred during matches and 42% during training, with no peculiar distribution along the playing season. The overall incidence proportion was 0.17% (0.11% during matches and 0.06% during training). The overall incidence rate was 0.007 injuries per 1000 hours of play (0.051 during matches and 0.003during training; P < 0.0001). All players returned to play soccer after a mean of 170 ± 35 days after ATRs and participated in an official match after a mean of 274 ± 98 days. However, 2 seasons after ATRs, 3 footballers were playing in a lower Division; 1 played less than 10 matches (compared with >25 matches in the 5 seasons before an ATR) and 1 had retired. CONCLUSIONS: An overall ATR rate of 0.007 per 1000 hours of soccer play and an incidence proportion of 0.17% were reported. All footballers return to play; however, up to 40% players decreased the level of play by reducing the number of games or participating in a lower Division 2 seasons after an ATR.

Anterior ankle impingment syndrome is less frequent, but associated with a longer absence and higher re-injury rate compared to posterior syndrome: a prospective cohort study of 6754 male professional soccer players.

PURPOSE: To study the epidemiology and return to play characteristics of anterior and posterior ankle impingement syndromes (AAIS and PAIS) over 18 consecutive seasons in male professional soccer players. METHODS: Between the 2001-2002 and 2018-2019 seasons, 120 European soccer teams were followed prospectively for various seasons. Time loss injuries and player exposures were recorded individually in 6754 unique players. Injury incidence and burden were reported as the number of injuries and days absence per 1000 h with 95% confidence intervals (CIs). Injury severity was reported as median absence in days with the interquartile range (IQR). RESULTS: Out of 25,462 reported injuries, 93 (0.4%) were diagnosed as AAIS (38%) or PAIS (62%) in 77 players. AAIS and PAIS were similar regarding injury characteristics except for a greater proportion of AAIS having a gradual onset (69% vs.47%; P = 0.03) and being re-injuries (31% vs. 9%; P = 0.01). Impingement syndromes resulted in an overall incidence of 0.03 injuries (95% CI 0.02-0.03) per 1000 h and an injury burden of 0.4 absence days per 1000 h. PAIS incidence was significantly higher than that for AAIS [0.02 (95% CI 0.002-0.03) vs. 0.01 (95% CI 0.005-0.01) injuries per 1000 h (RR = 1.7). The absence was significantly longer in AAIS than in PAIS [10 (22) vs. 6 (11) days; P = 0.023]. Impingement syndromes that presented with a gradual onset had longer absences in comparison to impingement with an acute onset [8 (22) vs. 5 (11) days; P = 0.014]. Match play was associated with a higher incidence and greater injury burden than training: 0.08 vs. 0.02 injuries per 1000 h (RR 4.7), respectively, and 0.9 vs. 0.3 days absence per 1000 h (RR 2.5). CONCLUSION: Ankle injuries are frequent in men's professional soccer and ankle impingement is increasingly recognized as a common source of pain, limited range of motion, and potential time loss. In our study, ankle impingement was the cause of time loss in less than 0.5% of all injuries. PAIS was more frequently reported than AAIS, but AAIS was associated with more absence days and a higher re-injury rate than PAIS. The findings in this study can assist the physician in best practice management on ankle impingment syndromes in professional football. LEVEL OF EVIDENCE: II.

Acute clinical evaluation for syndesmosis injury has high diagnostic value.

PURPOSE: To determine the diagnostic value of injury history, physical examination, six syndesmosis tests and overall clinical suspicion for syndesmosis injury. METHODS: All athletes (> 18 yrs) with an acute ankle injury presenting within 7 days post-injury were assessed for eligibility. Acute ankle injuries were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Standardized injury history was recorded, and physical examination was performed by an Orthopaedic Surgeon or Sports Medicine Physician. Overall clinical suspicion was documented prior to MRI. Multivariate logistic regression was used to determine the association between independent predictors and syndesmosis injury. RESULTS: Between September 2016 and July 2019, a total of 150 acute ankle injuries were included. The median time from injury to acute clinical evaluation was 2 days (IQR 2). Prior to clinical evaluation, the median patient reported Visual Analog Scale for pain was 8/10 (IQR 2). Syndesmosis injury was present in 26 acute ankle injuries. An eversion mechanism of injury had a positive LR 3.47 (CI 95% 1.55-7.77). The squeeze tests had a positive LR of 2.20 (CI 95% 1.29-3.77) and a negative LR of 0.68 (CI 95% 0.48-0.98). Overall clinical suspicion had a sensitivity of 73% (CI 95% 52-88) and negative predictive value of 89% (CI 95% 78-95). Multivariate regression analyses demonstrated significant association for eversion mechanism of injury (OR 4.99; CI 95% 1.56-16.01) and a positive squeeze test (OR 3.25; CI 95% 1.24-8.51). CONCLUSIONS: In an acute clinical setting with patients reporting high levels of ankle pain, a negative overall clinical suspicion reduces the probability of syndesmosis injury. Eversion mechanism of injury and a positive squeeze test are associated with higher odds of syndesmosis injury. LEVEL OF EVIDENCE: Level III.

Current practice for safe return-to-play after lateral ankle sprain: A survey among French-speaking physicians.

BACKGROUND: Recommendations are available for assessment criteria for safe return-to-play (RTP) after a lateral ankle sprain. However, their current use among physicians is unknown. METHODS: French-speaking physicians in Belgium, France and Switzerland were asked to complete an online survey and report their clinical assessment of selected RTP criteria. RESULTS: The respondent sample (n=109) included physicians with and without Sports Medicine education, varied level of experience and proportion of athletes in their practice population. Pain was the most selected criterion for safe RTP (90% of physicians), followed by ability to engage in functional tasks (82%), functional instability (73%), range of motion (61%), proprioception (47%), mechanical instability (39%), strength (38%) and swelling (31%). A low proportion of physicians use quantitative measures to assess these criteria (between 4% and 53%). CONCLUSIONS: A large proportion of physicians consider the recommended criteria for RTP decisions. However, physicians do not frequently use quantitative measures.

Diagnostic value of ultrasonography in acute lateral and syndesmotic ligamentous ankle injuries.

OBJECTIVES: To determine the diagnostic value of ultrasonography for complete discontinuity of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the anterior inferior tibiofibular ligament (AITFL). METHODS: All acute ankle injuries in adult athletes (> 18 years old) presenting to the outpatient department of a specialised Orthopaedic and Sports Medicine Hospital within 7 days post-injury were assessed for eligibility. Using ultrasonography, one musculoskeletal radiologist assessed the ATFL, CFL and AITFL for complete discontinuity. Dynamic ultrasound measurements of the tibiofibular distance (mm) in both ankles (injured and contralateral) were acquired in the neutral position (N), during maximal external rotation (Max ER), and maximal internal rotation (Max IR). MR imaging was used as a reference standard. RESULTS: Between October 2017 and July 2019, 92 acute ankle injuries were included. Ultrasound diagnosed complete discontinuity of the ATFL with 87% (CI 74-95%) sensitivity and 69% (CI 53-82%) specificity. Discontinuity of the CFL was diagnosed with 29% (CI 10-56%) sensitivity and 92% (CI 83-97%) specificity. Ultrasound diagnosed discontinuity of the AITFL with 100% (CI 74-100%) sensitivity and 100% (CI 95-100%) specificity. Of the dynamic measurements, the side-to-side difference in external rotation had the highest diagnostic value for complete discontinuity of the AITFL (sensitivity 82%, specificity 86%; cut-off 0.93 mm). CONCLUSIONS: Ultrasound has a good to excellent diagnostic value for complete discontinuity of the ATFL and AITFL. Therefore, ultrasound can be used to screen for injury of the ATFL and AITFL. Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL. KEY POINTS: • Ultrasound has a good to excellent diagnostic value for complete discontinuity of the anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament (AITFL). • Ultrasound can be used to screen for injury of the ATFL and AITFL. • Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.

The ankle syndesmosis pivot shift "Are we reviving the ACL story?"

In recent literature, there is a growing interest for the high ankle sprain with emerging evidence on biomechanical behavior, function, injury, and treatment. Interpretation of emerging publications on the distal tibiofibular syndesmosis may raise questions about striking similarities with the anterior cruciate ligament function and pivot-shift mechanism of injury in the knee. This editorial note puts to question whether identical entities, a continuum or separate injuries are faced by contemplating on the mechanism of injury, diagnostics, treatment, and outcome.

Return to sport following navicular stress fracture: a systematic review and meta-analysis of three hundred and fifteen fractures.

PURPOSE: This meta-analysis aims to provide updated evidence on the success rate, return to play (RTP) rate, time to RTP, and complications of operatively and conservatively managed navicular stress fractures (NSFs) as well as delays in diagnosis while avoiding limitations of previous similar studies. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout February 2021 using the following keywords with their synonyms: "Navicular stress fracture," "return to play," and "athletes." The primary outcomes were (1) management success rate, (2) RTP rate, and (3) time to RTP. The secondary outcomes were (1) non-union, (2) time to diagnosis, (3) refracture, and (4) other complications. Inclusion criteria were clinical studies on NSFs reporting at least one of the desirable outcomes. Studies not reporting any of the outcomes of interest or the full text was not available in English, German, French, or Arabic were excluded. Case reports, case series with less than ten cases, and studies reporting exclusively on navicular non-union management were also excluded. The Newcastle-Ottawa scale was used for quality assessment while Review Manager (RevMan) Version 5.4 was used for the risk of bias assessment. Data were presented by type of treatment (surgical or conservative). If enough studies were present that were clinically and statistically homogeneous and data on them adequately reported, a meta-analysis was performed using a fixed-effects model. In case of statistical heterogeneity, a random-effects model was used. If meta-analysis was not possible, results were reported in a descriptive fashion. The need to explore for statistical heterogeneity was determined by an I2 greater than 40%. RESULTS: Eleven studies met the inclusion criteria with a total of 315 NSF. Out of those, 307 (97.46%) NSFs were in athletes. One hundred eight (34.29%) NSFs were managed operatively, while 207 (65.71%) NSFs were managed conservatively. Successful outcomes were reported in 104/108 (96.30%) NSF treated operatively with a mean success rate of 97.9% (CI: 95.4-100%, I2 = 0%). Successful outcomes were reported in 149/207 (71.98%) NSF treated conservatively, with a mean success rate of 78.1% (CI: 66.6-89.6%, I2 = 84.93%). Successful outcome differences were found to be significant in favor of operative management (OR = 5.52, CI: 1.74-17.48, p = 0.004, I2 = 4.6%). RTP was noted in 97/98 (98.98%) NSF treated operatively and in 152/207 (73.43%) NSF treated conservatively, with no significant difference between operative and conservative management (OR = 2.789, CI: 0.80-9.67, p = 0.142, I2 = 0%). The pooled mean time to RTP in NSF treated operatively was 4.17 months (CI: 3.06-5.28, I2 = 92.88%), while NSF treated conservatively returned to play at 4.67 months (CI: 0.97-8.37, I2 = 99.46%) postoperatively, with no significant difference between operative and conservative management (SMD = - 0.397, CI: - 1.869-1.075, p = 0.60, I2 = 92.24). The pooled mean duration of symptoms before diagnosis was 9.862 (3.3-123.6) months (CI: 6.45-13.28, I2 = 94.92%), reported in ten studies. Twenty (23.53%) refractures were reported after conservative management of 85 NSFs, while one (1.28%) refracture was reported after operative management of 78 NSFs, with a significant difference in favor of operative management (OR = 0.083, CI: 0.007-0.973, p = 0.047, I2 = 38.78%). CONCLUSION: Operative management of NSF provides a higher success rate, a lower refracture rate, and a lower non-union rate as compared to other non-operative management options. While not significant, there is a notable trend towards superior RTP rates and time to RTP following operative management. Therefore, we recommend operative fixation for all NSFs type I through III in athletes. Athletes continue to exhibit an alarmingly long duration of symptoms before diagnosis is made; a high index of suspicion must be maintained, therefore, and adjunct CT imaging is strongly recommended in the case of any work-up. Unfortunately, the published literature on NSFs remains of lower level of evidence and high-quality studies are needed.

The "Ankle Instability Instrument": Cross-cultural adaptation and validation in French.

BACKGROUND: Functional ankle instability affects 20-40% of individuals who have already suffered from a sprain. Such dysfunctions are difficult to diagnose. Therefore, the information provided by self-administered questionnaires is essential. Thus, the Ankle Instability Instrument (AII) was developed and initially validated in English. Our goal is to create a French version of the instrument, named AII-F, by scrupulously respecting the cultural adaptation phases and to make sure the new instrument has good psychometric properties. METHODS: International recommendations have been rigorously followed for the cultural adaptation and the French-translation phase. Six steps are recommended: I) two initial translations from English to French; II) synthesis of the two versions; III) back-translations from French to English; IV) comparisons between the back-translations and the original questionnaire by the expert committee; V) pretest; and VI) approval of the final French version of the AII. In order to validate this French-translation, 91 subjects suffering from ankle instability matched to 91 healthy subjects were asked to complete the AII-F. The Short Form Health Survey (SF-36) was used as a comparative questionnaire as well as the French Cumberland Ankle Instability Tool (CAIT-F). The psychometric properties of the questionnaire were evaluated by determining the test-retest reliability after a 10-14-day interval, the internal consistency, construct validity, and the floor/ceiling effects. RESULTS: The French-translation did not pose a problem and could be validated by the expert committee. The AII-F showed a very good test-retest reliability for the total score, with an Intra Class Coefficient of 0.983. The internal coherence is high with an alpha coefficient of Cronbach of 0.861. The association of the AII-F with the CAIT-F was high, for the summary of the physical component of the SF-36, meaning a great convergent validity. The other subscales of the SF-36 (mental health) were weakly correlated with the AII-F, reflecting good divergent validity. An optimal cut-off score was obtained to dissociate pathological patients from healthy subjects: when the subject responded to "yes" 5 times or more, he is considered, with a very high degree of confidence, to be pathological. CONCLUSION: The AII-F is reliable and valid for evaluating and measuring functional ankle instability.

Eighty-two per cent of male professional football (soccer) players return to play at the previous level two seasons after Achilles tendon rupture treated with surgical repair.

OBJECTIVE: To evaluate the time to return to playing following acute Achilles tendon rupture (ATR) and surgical repair in professional male football (soccer) players. METHODS: Professional male football (soccer) players who sustained an ATR and underwent surgical repair were identified through internet-based injury reports from January 2008 to August 2018. Only League 1 and 2 players with injuries who had at least 1 year of follow-up from the search date were included. Injury history and time to return to play were retrieved from the public platform transfermarkt.com. For athletes who competed for at least two seasons after returning to play, re-ruptures and number of matches played were reported. RESULTS: 118 athletes (mean age 27.2±7.2 years) were included. 113 (96%) returned to unrestricted practice after a mean of 199±53 days, with faster recovery in players involved in national teams. Return to competition was after a mean of 274±114 days. In the 76 athletes with at least two seasons of follow-up, 14 (18%) did not compete at the pre-injury level during the two seasons following the index injury. Six players (8%) sustained a re-rupture within the first two seasons after return to play; four re-ruptures were in footballers who returned to play <180 days after injury. Age >30 years and re-ruptures had higher odds ratios of not returning to the same level of play. CONCLUSIONS: 96% of professional male football players who underwent surgery to repair an ATR returned to unrestricted practice and then competition after an average time of 7 and 9 months, respectively. However, 18% did not return to the same level of play within the two seasons following their return, with a higher risk in those experiencing a re-rupture.

Return to play after surgery for isolated unstable syndesmotic ankle injuries (West Point grade IIB and III) in 110 male professional football players: a retrospective cohort study.

OBJECTIVES: To evaluate time to return to play following surgical stabilisation of isolated unstable syndesmosis injuries in a cohort of professional male football players. METHODS: All professional football players undergoing surgery for isolated unstable syndesmosis injury (West Point grade ≥IIB) at a specialised Orthopaedic and Sports Medicine Hospital were followed up until return to play (minimum ≥6 months). Players with a stable syndesmosis, injuries older than 6 weeks, concomitant medial or lateral malleolar fracture or previous ankle surgery were excluded. During rehabilitation, time required to return to sports-specific rehabilitation, team training and first match play, were recorded. RESULTS: Between January 2012 and December 2017, a total of 110 male professional football players were included. The mean time required to begin on field rehabilitation was 37±12 days, while the mean time to return to team training was 72±28 days. The first official match was played on average 103±28 days postoperatively. Multivariable analysis revealed that the severity of injury, the concomitant presence of talar cartilage injury and the age of the player were significantly associated (p<0.00001) with time to return to on field rehabilitation, team training and match play. CONCLUSION: In this cohort of professional football players, surgical stabilisation of isolated unstable syndesmosis injuries (West Point grade ≥IIB) allowed for relatively quick return to play. High grade injury (West Point grade III), concomitant cartilage injury and greater age were associated with longer return to play times. LEVEL OF EVIDENCE: Longitudinal observational cohort study (level II).

The CFL fails before the ATFL immediately after combined ligament repair in a biomechanical cadaveric model.

PURPOSE: To assess the impact on ankle stability after repairing the ATFL alone compared to repairing both the ATFL and CFL in a biomechanical cadaver model. METHODS: Ten matched pairs of intact, fresh frozen human cadaver ankles (normal) were mounted to a test machine in 20.0° plantar flexion and 15.0° of internal rotation. Each ankle was loaded to body weight and then tested from 0.0° to 20.0° of inversion. The data recorded were torque at 20.0° and stiffness, peak pressure and contact area in the ankle joint using a Tekscan sensor, rotation of the talus and calcaneus, and translation of the calcaneus using a three-dimensional motion capture system. Ankles then underwent sectioning of the ATFL and CFL (injured), retested, then randomly assigned to ATFL-only Broström repair or combined ATFL and CFL repair. Testing was repeated after repair then loaded in inversion to failure (LTF). RESULTS: The stiffness of the ankle was not significantly increased compared to the injured condition by repairing the ATFL only (n.s.) or the ATFL/CFL (n.s.). The calcaneus had significantly more rotation than the injured condition in the ATFL-only repair (p = 0.037) but not in the ATFL/CFL repair (n.s.). The ATFL failed at 40.3% higher torque than the CFL, at 17.4 ± 7.0 N m and 12.4 ± 4.1 N m, respectively, and 62.0% more rotation, at 43.9 ± 5.6° and 27.1 ± 6.8°, respectively. CONCLUSIONS: There was a greater increase in stiffness following combined ATFL/CFL repair compared to ATFL-only repair, although this did not reach statistical significance. The CFL fails before the ATFL, potentially indicating its vulnerability immediately following repair. LEVEL OF EVIDENCE: III, case-control therapeutic study.

Outcome of primary deltoid ligament repair in acute ankle fractures: a meta-analysis of comparative studies.

PURPOSE: The indications of deltoid ligament repair in ankle injuries with widened medial clear space in the absence of medial malleolus fracture remain controversial. Many authors reported no difference in long-term functional outcomes, while others stated that persistent medial clear space widening and malreduction are higher when deltoid ligaments went without repair. This meta-analysis aims to report the current published evidence about the outcomes of deltoid ligament repair in ankle fractures. METHODS: Several databases were searched through May 2018 for comparative studies. The primary outcome was the medial clear space correction, while secondary outcomes included maintenance of medial clear space reduction, pain scores, functional outcome, and total complications if any. Three comparative studies met the inclusion criteria for the meta-analysis. The analysis included a total of 192 patients, 81 in the deltoid ligament repair group and 111 in the non-repair group. RESULTS: The medial clear space correction and maintenance of the said correction on final follow-up radiographs were superior in the deltoid ligament repair group. Although the pain scores were better in the repair group at the final follow-up, this did not result in a better functional outcome, with similar total complication rates. CONCLUSION: In conclusion, those who had their deltoid ligament repaired had superior early and late radiological correction of the medial clear space, an indicator of the quality of ankle reduction with better pain scores. However, no differences in the functional outcome and complications rate were reported.

MRI of ankle sprain: the association between joint effusion and structural injury severity in a large cohort of athletes.

OBJECTIVE: To test the hypothesis if presence and amount of effusion in the tibiotalar and talocalcaneal joints are associated with an increased risk for severe structural injury in ankle sprains. METHODS: A total of 261 athletes sustaining acute ankle sprains were assessed on MRI for the presence and the amount of joint effusion in the tibiotalar and talocalcaneal joints, as well as for ligamentous and osteochondral injury. Specific patterns of injury severity were defined based on lateral collateral ligament, syndesmotic, and talar osteochondral involvement. The presence and the amount effusion (grades 1 and 2) were considered as risk factors for severe injury, while physiological amount of fluid (grade 0) was considered as the referent. Conditional logistic regression was used to assess the risk for associated severe injuries (syndesmotic ligament rupture and talar osteochondral lesions) based on the presence and amount of tibiotalar and talocalcaneal effusions. RESULTS: For ankles exhibiting large (grade 2) effusion in the tibiotalar joint (without concomitant grade 2 effusion in the talocalcaneal joint), the risk for partial or complete syndesmotic ligament rupture was increased more than eightfold (adjusted odds ratio 8.7 (95% confidence intervals 3.7-20.7); p < 0.001). The presence of any degree of effusion in any of the joints was associated with an increased risk for severe talar osteochondral involvement (several odds ratio values reported; p < 0.001), including large subchondral contusions and any acute osteochondral lesion. CONCLUSION: The presence of tibiotalar and talocalcaneal effusions is associated with an increased risk for severe concomitant structural injury in acute ankle sprains. KEY POINTS: • For ankles exhibiting severe (grade 2) effusion in the tibiotalar joint after sprain, the risk for partial or complete syndesmotic ligament rupture increases more than eightfold. • The presence of effusion in both tibiotalar and talocalcaneal joints is associated with an increased risk for severe ligament injury such as complete ATFL rupture as well as partial or complete syndesmotic ligament rupture. • The presence of effusion in the tibiotalar or talocalcaneal joints after sprain is associated with an increased risk for severe talar osteochondral involvement.

Epidemiology and return to play following isolated syndesmotic injuries of the ankle: a prospective cohort study of 3677 male professional footballers in the UEFA Elite Club Injury Study.

AIM: To determine the epidemiology of isolated syndesmotic injuries in professional football players. METHODS: Data from 15 consecutive seasons of European professional football between 2001 and 2016 contributed to the dataset of this study. Match play and training data from a total of 3677 players from 61 teams across 17 countries have been included. Team medical staff recorded player exposure and time loss injuries. Injury incidence was defined as the number of injuries per 1000 player-hours. Injury burden was defined as number of days absence per 1000 player-hours. Seasonal trends for isolated syndesmotic injury incidence, isolated syndesmotic injury proportion of ankle ligament injuries and isolated syndesmotic injury burden were analysed via linear regression. RESULTS: The isolated syndesmotic injury incidence was 0.05 injuries per 1000 hours of exposure (95% CI 0.04 to 0.06) or one injury per team every three seasons. The injury incidence during match play was 13 times higher compared with during training, 0.21 (95% CI 0.16 to 0.26) and 0.02 (95% CI 0.01 to 0.02), respectively. Out of the 1320 ankle ligament injuries registered during the 15 seasons, 94 (7%) were diagnosed as isolated syndesmotic injuries. An annual increase in injury incidence was observed (R2=0.495, b=0.003, 95% CI 0.001 to 0.004, P=0.003). However, no significant annual change of injury burden was observed (R2=0.033, b=0.032, 95% CI -0.073 to 0.138, P=0.520). Seventy-four per cent of the injuries were contact related, and the mean (±SD) absence following an isolated syndesmotic injury was 39 (±28) days. CONCLUSIONS: The incidence of isolated syndesmotic injuries in elite professional European football annually increased between 2001 and 2016.